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Anatomic study of vaginal wildth in MtF surgery.


RONG-Hwan Fang, M.D., Tzyy-Jiin Chen, M.D., and Tien-Hua Chen, M.D.(Taipei)


Despite the recent improvement in the design of MtF sex réassignent opérations to enlarge the vaginal vault and depth, the size of the neovagina remains somewhat limited and the exterior of the neovgina may be compressed by the bony structure of pubic rami. The purpose of this study was to determine by anatomic study the possible cause of this limitation. Eighteen male and 10 female cadavers were dissected to
measure the distance between the bilatéral bony pubic rami (interramic distance) at a level that corresponds to the same level in the vaginal canal of females. At the same level of the vaginal canal in the female, which corresponds to the lower border of the prostate in the male , empirically 3 cm below the bony symphysis pubis, the mean value of the interramic distance was 3,95 +/- 0,25 cm in the male and 5,20 +/-
0,36 cm in the female (p = 0,000). The interramic distance in the male and the female is significantly different. In those who have undergone the MtF opération, the newly structured vagina may be ventrolaterally limited. Several factors cause narrowing of vaginal orifice in MtF. On the basis of this study, it seems that the bony structure of the pubic rami compresses the vagina ventrolaterrally. This finding may suggest
raffinements of the structural design of the neo-vagina and prompt procédural changes in MtF reassignement opérations. Future investigation should be directed toward modifying vaginoplasty so that neo-vaginal widch can be increased to the patient’s satisfaction ( plast. Recoins. Surg. 112: 511, 2003.)

Males and females have many anatomic structural différentes. In addition to the externat génitalia in the périneum, the male reproductive system includes the corpora cavernosa, corpus spongiosium, prostate, and séminal vesicles, which are deeply seated in the pelvic cavity in front of the rectum. The female reproductive system includes the ovaries, utérus, cervix, and vaginal tissue in the rectovesical space, which lies between the urinary bladder and the rectum. Vaginoplasty for MtF reassignment is
designed to create a canal lined with épithélium in the rectovesical space. Futher, the neourethral canal is created 2,5 cm below the point of the neoclitoris, and the neovagina is created immédiately posterior to the neourethra to give it a nearly normal female apparence (fig 1).
However despote recent developments in the surgi cal tecnique to enlarge the vaginal diameter and depth (1-7) the neovaginal orifice is still somewhat narrow (unpublished data). It is well known that the bony pubic angle of the male is less than that of the female.(8). Whether the pubic rami cause direct external compression of the rami of pubic bone ventrolaterally has yet to be determined. We dissected cadavers in this study to determine how the bony structure of pubic rami affects the shape of the vaginal canal.

MATERIALS AND METHODS

Eighteen male and 10 femelles cadavers, which were available from. TheDept of biologie and Anatomy of the……Médical Center, were dissected to determine the interramic distance of the pubic bone at the level of vagina canal, which is empirically 3 cm from. the lower border of the bony symphysis pubis.The periosteum of pubic rami bone was elevated in both sexes to enable the measurement of the interramic distance. We used the Mann-Whitney U test to compare the significance of interramic distance différence at the level of normal vaginal canal between males and females. The value of interramic distance is presented as the mean +/- SD, and statistical significance was defined as p < 0,05.

RESULTS

At the empiric level of the vaginal canal, which is 3 cm below the lower border of bony structure of the symphysis pubis, the mean interramic distance was 3,95 +/- 0,25 cm in the male and 5,2 +/- 0,36 cm in the female ( p = 0,000). Thus, there is asignificant différence in the interramic distance of the pubic bone between males and females. In the MtF, there is a tendency for the newly structured vagina to become
significantly narrower ventrolaterally.



DISCUSSION

Since the first use of amniotic membrane for la reconstructing the aplastic vagina by Brindeau en 1934 (9) several procédural developments for reconstructing tissue to create a neovagina have been adopted such as the use of the split-thickness skin graft, (10-12) full-thickness skin graft (13-14) périnéal pedicted local flap (1,6, 15-18) peritoneum, (19), dura, (20) intestine,(21) rectosigmoid, (4,7, 22-24) penile skin flap. (5, 25, 26) and combined penile and scrotal skin flap,(2, 10, 27, 28). In the male transsexual opération, besides adéquate excision of érectile tissue,(29), the most frequently used tissue for constructing the vagina is the abdominally pedicted penile flap, followed by the combined penile and scrotal skin flap,(25, 27, 30); The advantages of both penile and scrotal flap inversion for neovagina reconstruction in the male were discussed by van Noort and Nicolai (30) en 1993.Compared with the penile skin flap designed by Bouman (25) in 1988both the penile and scrotal skin flap inversion can be used to create a wider and deeper vagina withtout the necessity of making a circular vaginal incision; this technique can prevent circumferential scar contracture, vaginal stricture, and even stenosis (7, 30). After long-term follow-up of MtF after surgery, 6 to 36 % of patients were found to have a narrowing of the vaginal canal (8, 27, 30-33) which may be due to inadéquate dilatation, scarring, or complications such as fistula and hematoma (2, 7, 10, 30-32) and may also de related to the périnéal diaphragmatic muscle. (3). However, the patient’s satisfaction is directly related to vaginal width and depth in addition to good cosmesis and sensory function (30) In our expérience, many patients complain at low-up about the narrowing of the vaginal canal (unpublished data) that occurs over time, despite the use of the combined penile and scrotal skin flap technique to create a wider and deeper vaginal canal. Presumably, the bony structure of pubic arch may compress the exterior of the vaginal canal ventrolaterally. From our study, we conclude that the significant narrowing and shortening of the inter-ramic distance at the level of the vaginal canal in MtF is related to the narrower male pubic angle, which may cause mechanical compression of the newly reconstructed vagina ventrolaterally. Future modification and refinement of vaginoplasty procédures to ensure the maintenance of néovaginal width and the patient’s satisfaction is a worth-while pursuit.

Rong-Huang Fang, M.D.
Division of Plastic and Reconstructive Surgery
Dept of Surgey
Taipei, Taiwan.

ACKNOWLEDGMENTS

The authors express their great gratitude to Ms. Hui-Chen Lee from. The Division of Experimental Surgery Taipei for her assistance in performing the statistical analysis.


REFERENCES

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2. Karim R.B, Hage J.J, Bouman F G, de Ruyter R, and van Kesteren J P.Refinements of pre-, intra-, and postoposive care to privent complications of vaginoplastie mtF.1995
3. Karim R.B., Hage J.J., and Mulder J.W. Neovaginoplasty in MtF.1996
4. Mass S.M., Eijsbouts Q.A., Hage J.J., and Cuesta M.A. Laparoscopie rectosisgmoid
Does it benefit our ts patients. 1999.
5. Perovic S.V., Stanojevic D.S., and Djoedjevic M.L. Vaginoplasty in man ts using penile skin and a urétral flap. 2000.
6. Monstrey S, Blondeel P, van Landuyt K, Verpaele A, Tonnard P, and Matton G. The versatility of the prudential thigh fasciocutaneous flap used as an Island flap. 2001.
7. Stanojevic D, Perovic S, Djordjevic M, Nejkovic L and Pibic N. Creation of a new vagina using a part of the rectosigmoide colon. 2001.
8. Siemssen P.A., and Matzen S.H. Neovaginal construction in vaginal aplasia ans sex-reasignment surgery. 1997.
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10. Chrichton D. Gender reassignment surgery for man primary transsexuals. 1993.
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13. Fogh-Anderson P, Transvestism and transsexulism: Surgical treatment in a case of atocastration. 1956.
14. Hage JJ and Karim RB. Abdominoplastic secondary full-thickness skin graft vaginoplastie for MtF. 1998.
15. Edgerton MT and Bull J. Surgical constrction of the vagina and labia in MtF. 1970
16. Pandya NJ, and Stuteville OH. Aone-stage tehnique for constructing female external genitalia in male TS. 1973.
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18. Cairns TS and de Villiers W. Vaginoplasty. 1980.
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20. Beller FK and Wagner H. Kunstliche scheide miels lyodura (dura mater cerebri) 1982.
21. Goligher JC. The use of pedigree transplants of sigmoid of oser parts of the intestine for vaginal contrusttion. 1983.
22. Laub DR and Laub DR II. Rectosigmoid vaginoplastie. 1989.
23. Hage JJ, Karim RB, Asscheman H, Bloemena E, and Cuesta MA. Unfavorable long-term results of rectosigmoïd neocolpopiesis. 1995.
24. Toolenaar TA, Freundt I, Huikeshoven FJ, Drogendijk AC, Jeekel H, and Chadha-Ajwani S. The occurrence of diversion colitis in patients wich a sigmoïd neovagina. 1995.
25. Bouman FG. Sex reassignment surgery in MtF. 1988.
26. Meyer R and Kesselring UK. One-stage reconstructrion of the vagina with penile skin as an Island flap in MtF. 1980.
27. Small MP. Penile and scrotal inversion vaginoplastie for MtF. 1987.
28. Hage JJ and Karim RB. Sensate pedigree neoclitoroplasty for MtF. 60 patients. 1996.
29. Karim RB, Hage JJ, Bouman FG and Dekker JJ. The importance of near total résection of the corpus spongiosité and total reseter of the corpora cavernosa in the surgery MtF. 1991.
30. Van Noors DE and Nicolaï JP. Comparison of two methods of vagina contrustion in MtF. 1993.
31. Bouman FG. Operatief aangebrachte veranderingen bij transsexuelen.1986.
32. Stein M, Tiefer L and Melman A. Follow-up observations of operating MtF 1990.
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(fig 1) a suivre

_________________
Meme si je ne parviens pas à décrocher la Lune,
Je resterais toujours parmi les Etoiles.

(les smiley sont indépendants de ma volonté )

Jeanne

_________________
Meme si je ne parviens pas à décrocher la Lune,
Je resterais toujours parmi les Etoiles.

On pourrait pas avoir un résumé traduit s'il vous plait ? ^^"

NiNi452

J'ai essayé de traduire (je nai plus qu un neurone)avec lexique médical
mais comment traduire un "jargon chirurgien chinois"
Avec un peu de bonne volnté, on peut lire l'ensemble avec figure a l'appui mais la modératrice fera le necessaire.

Bises

Jeanne

_________________
Meme si je ne parviens pas à décrocher la Lune,
Je resterais toujours parmi les Etoiles.

En quelques mots: recherche du point d'incision et l'angle du néo-vagin, en sachant que la structure pelvienne est diférente entre H e F. d'ou études sur des defunts. Risque de compression.....Un échange de données pour les différentes procédures pour que les patientes aient une entière satisfaction...à long terme sachant que 6 à 36% ont des complications. Les études se poursuivent pour abaisser ce %. Voir les références.

Bises

Jeanne

_________________
Meme si je ne parviens pas à décrocher la Lune,
Je resterais toujours parmi les Etoiles.

Oki merci !