Room 517-C | Clinical Care of Intersexuality - Emerging Solutions of the Controversy Monday, July 11, 2005 Time: 8:30 AM-10:30 AM |
Genital Surgery: Techniques, Outcomes, and Prospects.
Schober, Justine*,1, 1 Hamot Medical Center, Erie, PA, USA
ABSTRACT- Genitoplasty, the surgical aspect of the clinical management of intersexuality, has been modified repeatedly over the last four decades. Initially, goals were simplistic and limited to feminizing by removal of clitorophallic tissue with the addition of a vaginal space to facilitate passive sexual function. Feminizing external appearance only, without the preservation of sexual sensitivity was predictably easy. Creating a well positioned, functionally patent vagina was less successful. A variety of methods with the use of many different tissues have been employed, hinting at the reality that none produced the stable, well functioning vaginal cavity. Eventually, surgical demands were expanded by the expectation that good surgical outcomes for sexual function should include sexual sensitivity, natural genital appearance without excessive scarring and vaginal construction that led to intercourse without pain and that did not require repeated modification. The endpoint of reliable, successful genitoplasty technique has not yet been achieved. These are demanding repairs and reconstructions with significant complications. There has been significant advancement of technique in the last ten years. Skin flap vaginoplasty has proven unsuccessful. Bowel vaginaoplasty, though still used may have undesirable side effects that limit patient satisfaction. Pull through techniques have changed, with progress beginning on exposure positions (posterior approaches), mobilizing the total urogenital sinus. And now, with better understanding of innervation, limitations at certain points in mobilization may continue to improve sensitivity outcomes. Baskin has elucidated innervation of not only the clitoris, but now also of the female lower urogenital tract. Particular attention to the urethral sphincter complex and nerve direction beneath the pubic symphysis is now recognized as crucial to ongoing reconstructive surgical design modifications. Outcomes analysis has become much more demanding. Patient feedback has made this necessary. The development of testing tools that give detailed patient feedback about genital sensitivity progress but include only data for normals at this point. Post operative testing of genital sensitivity after older versions of surgery assure us that surgical sites have lessened hot, cold, and vibratory sensation on external surfaces objectively. Post operative analysis also shows the need for repeated modification of the vaginal introitus because of stenosis and the clitoris because of continued growth and unsightly appearnace. The beginnings of outcomes analysis to include sexuality quality of life studies have increased the comprehensiveness of knowledge about patient experience in daily life situations. Prospects for betterment of outcomes may require study outside the modification of surgical technique. A crucial factor may be the estrogen environment. A surgical window has been debated in more recent years. However, maintenance of an estrogen zed environment may be crucial for surgical healing, limitation of scarring and stenos and ongoing support of genital tissue integrity. It may also have impact on genital sensation. We look ot the localization of estrogen receptors in tissue, estrogen impact on other hormones such as relaxing, and estrogen impact on intercellular proteins that mediate communication (connexins), for furtue improvements.
Key words: intersexuality, genital surgery, genitoplasty