Department of Urology & Plastic and Reconstructive Surgery, Oregon Health and Sciences University, Portland, OR; Transgender Health Program, Oregon Health and Science University, Portland, OR.
Department of Urology & Plastic and Reconstructive Surgery, Oregon Health and Sciences University, Portland, OR; Transgender Health Program, Oregon Health and Science University, Portland, OR.
Urology. 2024 Jan;183:e320-e322. doi: 10.1016/j.urology.2023.10.009. Epub 2023 Oct 29.
To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty.
For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed.
We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm.
We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.
介绍两种阴蒂成形术技术——包皮皮瓣和尿道瓣，并描述我们使用每种技术构建性别肯定性阴道成形术中阴蒂-尿道复合体的原理。
对于未行包皮环切术的患者或行包皮环切术但包皮内有超过 2cm 皮肤且在包皮环切术瘢痕近端有至少 8cm 阴茎皮肤的患者，我们使用包皮皮瓣阴蒂成形术，这是根特式阴蒂成形术的一种改良。切除内侧龟头和尿道黏膜后，整个龟头被使用。龟头在中线 1cm 处并拢，形成可见的卵圆形阴蒂；剩余的冠状组织保留在阴蒂的外侧，作为阴蒂体的性感觉。阴蒂固定在近端白膜上，位于内收长肌腱的水平。折叠的神经血管束固定在耻骨上方。尿道被切开并接近阴蒂。根据张力情况，将包皮近端缝合。阴蒂-尿道复合体被插入阴茎皮瓣上形成的开口中。对于皮肤较少的患者，我们使用尿道瓣阴蒂成形术。由于尿道形成阴蒂帽，因此使用更多的海绵体组织，这在文献中有描述，并归因于 Pierre Brassard。在背侧尿道切开术后，将阴蒂插入，将一小圈包皮皮瓣缝合到海绵体和尿道黏膜上。尿道在远端约 1cm 处被切断。然后将尿道切开并完成尿道成形术。
我们更喜欢使用包皮皮瓣技术，因为它的冠状组织体积较大，具有性感觉，并且在我们看来，美学效果更好。行包皮环切术的患者，其包皮环切术瘢痕远端至少应有 2cm 的皮肤。为了避免使用皮肤移植物进行入口——这是入口狭窄的风险——包皮环切线近端的阴茎皮肤至少应为 8cm。
我们提出了两种阴蒂成形术技术和性别肯定性阴道成形术中阴蒂-尿道复合体的构建技术。
