Miroslav Djordjevic

Transsexualism in Serbia: A Twenty-Year Follow-Up Study

INTRODUCTIONnGender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment.nnnAIMnTo describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia.nnnMETHODSnData, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively.nnnMAIN OUTCOME MEASURESnAge at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated.nnnRESULTSnApplicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision.nnnCONCLUSIONSnAlthough transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Total phalloplasty using a musculocutaneous latissimus dorsi flap

Authors from Serbia describe their experience of total phalloplasty in children and adults using a musculocutaneous latissimus dorsi free flap, finding that this method successfully allowed the creation of a neophallus, facilitating subsequent urethroplasty and the safe insertion of a penile prosthesis.

Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair.

There are three different topics covered in the paediatric urology section in this issue. Authors from Belgrade describe how a dorsal dartos flap can be used to prevent fistula in the Snodgrass hypospadias repair. The use of extracorporeal pelvic floor magnetic stimulation in children with voiding dysfunction is described by authors from Seoul. And finally, authors from Antalya write about the impact of the location of the ureteric orifice on the efficacy of endoscopic injection to correct VUR.

A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE

PURPOSEnTechniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair.nnnMATERIALS AND METHODSnFrom November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis.nnnRESULTSnMean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients.nnnCONCLUSIONSnOur penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.

Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children.

OBJECTIVEnTotal phalloplasty is rarely performed in children due to the mutilation involved and the dilemma concerning neophallic size in children. We present a musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children with difficult psychological problems.nnnMATERIALS AND METHODSnTotal phalloplasty was performed in eight boys aged between 10 and 15 years. Indications were small penis after failed epispadias repair (4), micropenis (3) and intersexuality (1). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethroplasty was performed in five patients using buccal mucosa, while in the remaining three a Mitrofanoff channel had been created previously. An inflatable penile prosthesis was implanted in two cases after puberty.nnnRESULTSnFollow-up was from 6 to 53 months (mean: 29 months). Penile size varied from 13 to 16 cm in length and from 10 to 12 cm in circumference. No flap necrosis, either partial or total, was noted. The donor site healed acceptably in four cases while in the remaining four moderate scarring occurred. Function of the penile prostheses is satisfactory. Psychological status is significantly improved in all children.nnnCONCLUSIONnPhalloplasty in childhood is indicated to prevent profound psychological problems related to body dysmorphia. The musculocutaneous latissimus dorsi flap is a possible choice for phalloplasty in children that enables good neophallic size as in adults. We recommend this surgery to be performed before puberty to ensure optimal psychosexual pubertal development.

PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR: VARIANTS OF TECHNIQUE

PURPOSEnWe present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee.nnnMATERIALS AND METHODSnBetween 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1.nnnRESULTSnMean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each.nnnCONCLUSIONSnOur variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

BLADDER AUTOAUGMENTATION WITH RECTUS MUSCLE BACKING

PURPOSEnBladder autoaugmentation is a procedure which includes detrusoromyotomy or detrusorectomy to release intact urothelium which than prolapses and increases bladder capacity and compliance. The prolapsed urothelium is usually covered with de-epithelialized pedicled colonic or gastric patch. We present our initial experience with bladder autoaugmentation using rectus muscle backing.nnnMATERIALS AND METHODSnBetween August 1999 and December 2000 autoaugmentation was performed in 4 girls and 3 boys 4 to 11 years old (median age 8). All patients had neurogenic bladder with small capacity and poor compliance. The technique is performed using an extraperitoneal approach through either an inferior midline longitudinal or transverse incision. The procedure is started with a semi-filled bladder to find the right plane and then continues with an almost empty bladder to avoid severe injury of the prolapsed urothelium. Both rectus muscles are dissected from the anterior and posterior sheaths and sutured to detrusor edges. Urothelium is sutured to the muscle at several places to prevent its retraction and shrinkage. Thus, the bladder is fixed and hangs on rectus muscles, that is the anterior abdominal wall.nnnRESULTSnFollowup was 10 to 25 months (median 16). Bladder capacity at 6 months postoperatively increased in all patients, and ranged from 162 to 368 ml. (median 266). All patients had clinical improvement, decreased hydronephrosis, no vesicoureteral reflux and better compliance.nnnCONCLUSIONSnBladder autoaugmentation with rectus muscle backing is a safe and simple procedure. Rectus muscle is a good alternative to other backing materials.

ORIGINAL RESEARCH–INTERSEX AND GENDER IDENTITY DISORDERS: Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience

INTRODUCTIONnMetoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses.nnnAIMnOur aim is to describe our technique and highlight its advantages.nnnMETHODSnBetween September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed.nnnMAIN OUTCOME MEASURESnPatients personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data.nnnRESULTSnThe median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients.nnnCONCLUSIONSnMetoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

‘Pseudospongioplasty’ in the repair of a urethral diverticulum

To describe a technique for repairing urethral diverticula which includes neourethral reconstruction and increasing the mechanical support of the neourethra.

The penile disassembly technique in the surgical treatment of Peyronie's disease

Objective To present an approach for treating Peyronies disease, using the penile disassembly technique for reconstructive surgery.