World J Urol DOI 10.1007/s00345-015-1562-z
ORIGINAL ARTICLE
Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female‑to‑male transsexuals? Ying‑Fan Zhang1 · Cai‑Yue Liu1 · Chuang‑Yu Qu2 · Li‑Xuan Lu1 · An‑Tang Liu1 · Lie Zhu1 · Hui Wang1 · Zi‑Hao Lin1 · Yao‑Zhong Zhao1 · Xiao‑Hai Zhu1 · Hua‑Jiang1
Received: 20 November 2014 / Accepted: 13 April 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the female-to-male (FTM) transsexual patients. We report our experience with prefabricated pars pendulans urethrae using vaginal mucosal graft for phalloplasty in FTM transsexuals. Materials and methods We retrospectively reviewed notes on the 22 FTM patients treated with pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft between January 2008 and December 2012. Surgical outcome, urological function, and complications were recorded. Histological difference between normal mucosa and skin, and pathological changes of vaginal mucosal graft were also observed. Results All the reconstructive penis survived, and patients could void in a standing position finally at a median follow-up of 25.4 ± 6.0 months. Urethral fistula and urethral stricture rates were 31.8 % (7/22 patients) and 4.5 % (1/22 patients), respectively. The occurrence of the urethral
stricture was remarkably low compared with previous reports. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethral epithelium more closely than the forearm skin. Following the free transfer, the vaginal mucosal graft also showed a good revascularization and the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after a 6-month prefabrication. Conclusion With prefabrication of vaginal mucosal graft, we reconstruct a competent phallic neourethra in these FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is the excellent substitute material for promising urethral reconstruction in FTM transsexuals. Keywords Female-to-male transsexual · Urethral reconstruction · Prefabrication · Vaginal mucosal graft · Urethral complication
Introduction Ying-Fan Zhang and Cai-Yue Liu have contributed equally to this work and share co-authorship. * Xiao‑Hai Zhu [email protected] * Hua‑Jiang [email protected]; [email protected] 1
Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003, China
2
Department of Urology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003, China
Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the femaleto-male (FTM) transsexual patients on account of the high incidence of urethral fistulas and stricture formation [1–4]. Apart from constructing the fixed perineal part of the neourethra, it is necessary to create a phallic pendulant part to be connected to the pars fixa urethrae. Traditionally, there are several techniques used to reconstruct the pars pendulans urethrae in females with gender dysphoria such as tube-within-a-tube design, prefabrication with free skin graft, bilateral ventral flaps, free microsurgical flaps, and tubular skin flaps [5, 6]. However, the results of these
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methods are mixed due to the complexity of the procedures and urethral complications. No method has become standardized. As we all know, buccal mucosal graft presents a gold standard for staged urethroplasty and has been used as one of the best substitute materials in many urethral reconstructive surgeries over the past two decades [7–9]. However, so far there has not been any relevant reference reporting the application of oral mucosa in total phalloplasty due to its inadequate sources. Since both histological and structural similarities have already been found between human vaginal and buccal mucosa [10], vaginal mucosa had been successfully applied in partial or total urethral reconstruction of female patients [11–13]. In this study, we herein report our experience in pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft for 22 FTM transsexuals in our department.
World J Urol Table 1 Complications in female-to-male transsexuals No
VMG (abdominal 14, thigh 8)
Patients Flap-related following penile reconstruction Complete flap loss Marginal partial necrosis Urologic after urinary tract reconstruction Total fistula Total strictures Combination of both fistula and strictures Early fistula (closing spontaneously) Strictures treated conservatively Fistula require urethroplasty Strictures require urethroplasty
22 0 0 0 7 (31.8 %) 7 (31.8 %) 1 (4.5 %) 1 (4.5 %) 2 (9.1 %) 0 4 (18.2 %) 0
Patient satisfaction of aesthetic results
18 (81.8 %)
Materials and methods Patients From January 1, 2008, to December 31, 2012, 22 FTM transsexual patients received at least a two-stage sex reassignment surgery in our department. All these patients (mean age 27.8 ± 4.4, range 19–34 years) had been diagnosed with gender dysphoria by psychiatrists in mental health centers and assessed as suitable candidates for surgical treatment. Prefabrication of the pars pendulans neourethra with tubed vaginal mucosal graft in lower abdomen (14 cases) or anterolateral thigh region (8 cases) was performed in the first-stage operation. During the secondstage, lower abdominal pedicled fascia flap [14] or the anterolateral thigh (AT) flap containing prefabricated urethra was employed to construct the new phallus (Table 1). Operative techniques Before the operation, the axial arteries [arteria epigastrica superficialis (SIEA) and arteria circumflexa ilium superficialis (SCIA) in lower abdominal flap; the first and second perforators from descending branch of lateral circumflex femoral artery in anterolateral thigh (AT) flap] were traced by Doppler ultrasound, and their suprafascial courses were marked. In the first-stage operation, mastectomy, hysterectomy, salpingo-oophorectomy, and vaginectomy were firstly performed with the assistance of gynecologists. After the uterus and adnexa were freed from the pelvic attachments endoscopically, an experienced gynecologist began to elevate the mucosa from the vagina, leaving the urethral orifice–vaginal junction intact as the mucosa pedicle. Then, the mucosa together with the uterus and adnexa
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were cut and removed from the vaginal tunnel, as en bloc as possible (Fig. 1a). Then the vaginal mucosa would be utilized for two sections of urethral reconstruction, pedicled and free. The pedicled section was tailored to a size of 5 cm × 2.5 cm, and sutured mucosa-inward around the urethral catheter and tunneled to open at the anterior point of the pubic symphysis for elongation of the pars fixa urethrae [6, 15] (Fig. 1b). The catheter was removed in 2 weeks. Then the rest of full-thickness vaginal mucosa, as a single piece or in multiple pieces, was sutured and wrapped around a drainage tube (1.5 cm in diameter) to form a tube (12–14 cm in length, average 13 cm) for prefabrication of the pars pendulans urethrae (Fig. 1c–e). A 12–14 cm (length) × 2 cm (width) subcutaneous tunnel was created closely to reticular dermis in the lower abdomen or in the anterolateral region of the thigh depending on the selected flap for penis reconstruction. In the process of tunneling, the axial vessels were supposed to be avoided to prevent injury (Fig. 3b). Then the tubed graft was introduced into the tunnel and fixed in place. The drainage tube was used to support the prefabricated urethrae for 3 months (three patients) or 6 months (19 patients) until the second-stage operation (Figs. 2a, 3c). The patients were instructed to irrigate the neourethra with saline from one side of the stent tube to the other side twice a day themselves. When they returned to hospital once a month, the old stent tube was replaced with a new one by our doctors. In the second-stage operation, the pedicled abdominal flap or anterolateral thigh flap together with the prefabricated neourethra was raised and transposed to the pubic region. Eventually, the prefabricated urethrae were connected to the already extant pars fixa. The abdominal donor-site was sutured directly, while the anterolateral thigh donor-site was covered with skin graft taken from the
World J Urol Fig. 1 a Mucosa, together with the uterus and adnexa, were cut and removed from the vaginal tunnel. b The pars fixa neourethra was elongated using the anterior vaginal flap which was indicated by the right part of the black line, while the left part of the mucosa would be cut to preconstruct the pars pendulans neourethra. The upper black arrow indicated the location of the new urethral orifice. The lower black arrow indicated that the clitoris was freed and would be denuded and buried subcutaneously. c A single piece of fullthickness vaginal mucosa would be sutured mucosa-inward around a drainage tube to form the pars pendulans urethra. d Multiple pieces of the mucosa would be sutured together to form the pars pendulans urethra. e The average length of the mucosal tube graft was 13 cm (12–14 cm)
other thigh (Figs. 2b–c, 3c–e). After the second-stage operation, patients were followed up for 25.4 ± 6.0 months. Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient, respectively, to compare their histological pattern during the firststage operation (Fig. 4a–d). In addition, biopsies of the vaginal mucosal grafts were taken concomitantly in different period (3 or 6 months following the first-stage operation) from the patients. Hematoxylin- and eosin-stained sections were examined by light microscopy. Masson’s trichrome was used to examine the extent of fibrosis (Fig. 5a–f).
second-stage phalloplasty during the follow-up period, and its parameters (Qmax, mean flow rate, voiding time, voided volume) were recorded.
Results All of the reconstructed penises survived completely. No flap loss or necrosis occurred in these 22 patients. Urinary function and urological complications following urinary tract reconstruction
Uroflowmetry test Uroflowmetry test was conducted for 22 patients to make a postoperative checking of urethroplasty 1 year after the
All the patients were ultimately able to void in a standing position through the newly reconstructed penis. The uroflowmetry test result did not show abnormal findings, and
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Fig. 2 24-year-old patient. a Frontal view following the first-stage operation. The prefabricated pars pendulans urethra located at left lower abdomen with a drainage tube in it. The blue lines indicated the superficial courses of the superficial iliac and epigastric arteries. b Preoperative designs of phalloplasty. A rectangular-shape 13 × 11 cm flap was designed for phallus shaft. The prefabricated urethra was located in the inner one-third part of the flap, and a
4 × 4 cm round flap was designed on the distal part of the urethra to fabricate the glans. The black arrows indicated the prefabricated urethral orifices. c The pedicled flap was transposed to the pubic region, and the prefabricated urethra was anastomosed with the advanced urethral orifice. The abdominal donor-site was sutured directly. d Lateral view during voiding 24 months following the second-stage operation
Fig. 3 22-year-old patient. a A pinch thickness of skin tissues was 3 cm in thigh. b The tubed vaginal mucosal graft was introduced into the tunnel in the right anterolateral region of thigh. The black arrows indicated the penetrating points of the two skin perforators. c Preoperative design of phalloplasty. A rectangular-shape 12 × 10 cm flap was designed for the phallus shaft, and a 7 × 5 cm flap was designed on the distal part of the urethra to fabricate the glans. The black
crosses indicate the penetrating points of the two skin perforators. d The anterolateral thigh flap passed through the tunnel under the rectus femoris and sartorius muscles on its vessel pedicle. e The pedicled flap was transposed to the pubic region, and the prefabricated urethra was anastomosed with the advanced urethral orifice. f Lateral view during voiding 18 months following the second-stage operation
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Fig. 4 Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient to compare their histological pattern during the first-stage operation. a The forearm skin showed keratinized squamous epithelium, thin epithelium (6–9 layers), and a thick subdermal layer with dense collagen fibers which are in bright red dyeing. b The normal urethral mucosa has thick
epithelium without keratinized layer. A pronounced similarity was found between vaginal (c) and buccal mucosa (d). They were both non-keratinized epithelium which have similar thickness of epithelium (20–30 layers), cell structural composition, loose and thin submucosal layer, and abundant vasculature. They resembled urethral epithelium more than the forearm skin
the parameters of our patients (Qmax, ml/s: 15.5 ± 5.6, Table 3) were consistent with previous reports (Qmax, ml/s: 14.0 ± 9.7) by Hoebeke et al. [16]. Mild incontinence was reported in 13 patients (59.1 %): for 10 (45.5 %) occurred post-voiding only while other three patients (13.6 %) had this problem all the time. A total of 16 patients (72.7 %) reported post-voiding dribbling. Since these symptoms were not considered as a problem by all affected patients, no further medical therapy was performed in this study. Similarly, Hoebeke et al. [16] also reported that, other symptoms, like post-void dribbling and mild incontinence, were commonly reported, with no need for medical help. However, in this study, each patient was instructed to perform appropriate maneuver: compressing the reconstructed urethrae from the pas fixa to the pars pendulans, especially during the last part of voiding in order to empty the
residual urine in the reconstructed urethrae and improve their symptoms. Seven fistulas (31.8 %, 7 of 22) and one stricture (4.5 %, 1 of 22) occurred in seven patients (31.8 %, 7 of 22). Six urethral fistulas were observed at the anastomosis between phallic urethra and bulbar urethra in six cases. A stricture developed at the anastomosis between the phallic urethra and the bulbar urethra with a fistula in pars fixa part in one patient. Spontaneous closure of the fistula was observed in three patients. In other three patients, a simple excision of the fistula tract was successfully performed at least 3 months after the second-stage operation. Stricture resection and an end-to-end anastomosis were performed in that patient with stricture 6 months after the second-stage operation. Meanwhile the fistula tract in the pars fixa part was also excised (Tables 1, 2, 3).
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Fig. 5 Histological changes of the vaginal mucosal grafts. The histology of a, d the normal vaginal mucosa had the thick non-keratinization stratified squamous epithelium showing a high similarity to the normal urethra. b, e The mucosal graft in the abdominal flap after a 3-month prefabrication verified a good “take” and the epithelium showed irregular thickness with areas of epithelial proliferation.
There were obvious inflammatory cell infiltrations and fibroblastic reactions in the lamina propria. c, f The neourethra mucosa grafting for 6 months, the epithelium showed more regular thickness and the inflammation and fibrosis decreased significantly to the normal level (a, b, c Hematoxylin and eosin, ×100; d, e, f Masson’s trichrome, ×100)
Table 2 Details and treatment of urologic complications Patient number Prefabrication duration (months) Urologic complications Revision procedure 1 3
3 3
Fistula Stricture and fistula
7 11 12 15
6 6 6 6
Fistula Fistula Fistula Fistula
Excision of the fistula tract Stricture resection and an end-to-end anastomosis, excision of fistula Healed spontaneous Excision of the fistula tract Healed spontaneous Healed spontaneous
19
6
Fistula
Excision of the fistula tract
Histological findings
Table 3 Uroflowmetry parameter analysis Uroflowmetry parameters
X ± SD VMG (n = 22)
Qmax (ml/s)
15.5 ± 5.6
Mean flow rate (ml/s) Voiding time (s)
9.9 ± 2.3 34.5 ± 13.2
Voided volume (ml)
340.6 ± 45.4
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Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient, respectively, to compare their histological pattern during the first-stage operation. Histological examinations showed a pronounced similarity between vaginal (Fig. 4c) and buccal mucosa (Fig. 4d). They were both non-keratinized epithelium
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which have similar thickness of epithelium (20–30 layers), cell structural composition, loose and thin submucosal layer, and abundant vasculature. Morphologically, they resembled urethral epithelium more closely than the forearm skin. The former also had a thick epithelium without keratinized layer (Fig. 4b). In contrast, the forearm skin was keratinized squamous epithelium which had thinner epithelial layers (6–9 layers) and thicker subdermal layer with dense collagen fibers which are in bright red dyeing (Fig. 4a). Vaginal mucosa, non-keratinized stratified squamous epithelium, had a high similarity to the normal urethra (Fig. 5a, d). After a 3-month prefabrication, the vaginal mucosal graft showed a good “take.” The thickness of the epithelium was relatively irregular, and epithelial proliferation could be observed in some areas. The inflammatory reaction and fibroblastic proliferation could also be obviously seen in the lamina propria (Fig. 5b, e). Following a 6-month prefabrication after the first-stage operation, the epithelium of the prefabricated mucosal graft showed a more regular thickness. The number of inflammatory cells and the extent of fibrosis both decreased to a relatively normal level (Fig. 5c, f).
Discussion The ability to urinate while standing has priority for most of the FTM patients, a complete and competent urethra should be created [5]. Although the radial artery-based forearm free flap (RAFFF) is by far the most frequently used flap and universally considered as the standard technique in penile reconstruction in these patients, the problems with the neourethra, reconstructed by tube-within-tube method, are very common, with a fistula rate of around 20–35 % in most series while the rate of urethral stricture formation, especially at the anastomosis of the mucosal tissue with the inner skin tube of the neophallus, is sizeable (18 %) [3, 17]. Other reports also showed relatively high rates of urethral stricture (14 % (3/22) [18], 16.3 % (47/287) [17], 20 % (1/5) [19], 36 % (9/25) [20], 40 % (4/10) [21]). Reasons may be insufficient vascular supply of the local flaps and the inappropriate width of the phallic urethra, the latter being responsible for relative obstruction of the urinary stream and increased force on the “bulbar urethra” and anastomotic sites [20]. Scientific progress in reconstructive urethroplasty of total phalloplasty is slow. In our study, we have made good use of the “waste tissues”-vaginal mucosa and reconstructed a competent neourethra, especially the phallic part with prefabrication technique. All the patients could void in a standing position and the rate of urethral strictures while not fistula was remarkably low (4.5 %, 1/22 patients) for a follow-up of 25.4 ± 6.0 months. Generally
speaking, dealing with strictures is more troublesome and complicated than fistulas since the majority of the fistulas could close spontaneously [17]. The probable reasons were as follows: First of all, reduced urethral stricture rate was related to the graft material. Most importantly, a prerequisite for reconstructive surgery is a close homology between the replaced tissue and the material used for reconstruction [22]. To our knowledge, this was also the important reason why the oral mucosa has been used as one of the best substitute materials in many urethral reconstructive surgeries over the past two decades [7–9]. However, no reference has reported the application of oral mucosa in total phalloplasty. Many publications have reported that the vaginal and oral mucosa are histologically similar. They are wet mucosal epithelium, smooth, and hairless. They also have similar thickness of epithelial layers, cell structural composition, and a dense submucosal plexus [22, 23]. Moreover, Thompson et al. [10] have found that the ultrastructure and distribution of keratin filaments between the vaginal and buccal epithelia were similar, as is their permeability to water, and the distribution and appearance of the lipid lamellae in the intercellular spaces were also similar. Therefore, it was reasonable that vaginal epithelium could be used as a substitute for buccal epithelium in certain in vitro or in vivo study [10]. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethra epithelium more closely than the forearm skin. Indeed, both of them are the same type of mucosal epithelium-predominantly nonkeratinized stratified squamous epithelium, while the forearm skin is keratinized squamous epithelium. The bladder mucosa, which was also chosen to reconstruct the urethra, is the transitional epithelium with thin epithelial layer [22]. The thicker epithelial layer of vaginal mucosa means the better stability, barrier function, and self-renewing of the graft material [22]. Additionally, the thin and loose submucosal layer and abundant vasculature rendering the vaginal mucosa are more prone to obtain a blood supply from the graft site, which might be an advantage for early revascularization, and thus to healing [22–24]. Based on these, we have reasons to believe that vaginal mucosa could be much more suitable and reasonable than other tissues to reconstruct a new urethra. Besides, low occurrence of urethral strictures could also be partly explained by less formation of scar tissues. Scar contracture and wound healing around the urethral anastomosis were considered to be the reasons for urethral stricture in phalloplasty in traditional RAFFF method [18, 25]. It has been reported when using mucosal tissues for urethroplasty, the wound of both recipe-site and donorsite healed very well [7, 8]. In our study, it is the vaginal mucosa connected with the extended urethral mucosa
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(mucosa connected with mucosa) to form a neourethra. It has been reported, compared with the skin and dermal wound healing, the wounds of the oral mucosa tend to heal in an accelerated fashion and display no or minimal scar formation [26]. Possible mechanisms involved in the difference between scar-forming dermal versus scarless oral mucosal wound healing could be their architectural and environmental differences. Keratinocyte reactions and expression of extracellular matrix (ECM) components like procollagen I and tenascin-C are different in dermal and oral wound healing. Furthermore, a favorable effect on oral healing has been attributed to salivary components [26]. Based on these, we herein hypothesized that vaginal mucosa has a similar advantage to oral mucosa. In addition, unlike buccal mucosa, the vaginal mucosa could provide enough material for reconstruction of a urethra. Using this “waste tissues,” which were originally discarded in vaginectomy in FTM patients, could avoid extra injury of donor-site for constructing the neourethra and was more easily accepted by these patients. Furthermore, in our method, an approximate 5-cm-wide (1.5 cm in diameter) vaginal mucosa was formed for preconstruction of the phallic neourethra compared with a 3-cm-wide skin strip used in RAFFF method [20]. A larger caliber neourethral may also reduce potential chances of contracture, which in theory reduce the rate of potential urethral strictures. Secondly, prefabrication procedure was beneficial to low occurrence of urethral strictures. In the traditional “tube-within-a-tube” method of the RAFFF, presumably these strictures could form as a result of relative ischemia at the anastomosis of tissues of native urethra to the free forearm tube-flap, which was exacerbated by kinking at the neophallus base [25], while the vaginal mucosal grafts could establish sufficient blood supply within a 6-month delay following the prefabrication. For this aforementioned reason, we did not tube to form a total male urethra with the harvested vaginal mucosa in a one-stage operation, although it is technically feasible [12, 13]. In this study, we performed a two-stage operation because the entire prefabricated urethra, especially its two end points, could effectively inhibit the primary cicatricial contracture after a long-standing support with a drainage tube [27]. Further histological studies also showed, in prefabricated vaginal mucosa, the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after 6-month prefabrication, which suggested that a 6-month prefabrication could be a more appropriate and reasonable interval than 3 months’ prefabrication between the firststage and second-stage operations (Fig. 5). At last, pedicled-flap phalloplasty with prefabricated urethra made the second-stage operation much more simple and convenient without microsurgical techniques.
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Conclusion With prefabrication of vaginal mucosal graft, we reconstructed a competent phallic neourethra in FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is one of the best substitute materials for promising urethral reconstruction in total phalloplasty. Although longer follow-up is needed, in this preliminary report, pedicled-flap phalloplasty combined with vaginal mucosal graft to prefabricate the phallic neourethra represents a simple and effective surgical option in FTM transsexuals. Acknowledgments Thanks to Benjamin G. Huey from Medical School of Emory University for his careful reading on grammar and expression of English, Dr. Yueju Su from Department of Mathematics & Statistics in Georgia State University for her statistical assistance. This work was supported by Grant Nos. 10ZR1439200, 2006079 of the Natural Science Foundation of Shanghai and 81100950 of Natural Science Foundation. Conflict of interest The authors declare that they have no conflict of interest. Ethical standard All human have been approved by the Ethics Committee of Second Military Medical University and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study have been omitted.
References 1. Gilbert DA, Horton CE, Terzis JK et al (1987) New concept in phallic reconstruction. Ann Plast Surg 18:128–136 2. Selvaggi G, Elander A (2008) Penile reconstruction/formation. Curr Opin Urol 18:589–597 3. Selvaggi G, Bellringer J (2011) Gender reassignment surgery: an overview. Nat Rev Urol 8:274–282 4. Wroblewski P, Gustafsson J, Selvaggi G (2013) Sex reassignment surgery for transsexuals. Curr Opin Endocrinol Diabetes Obes 20:570–574 5. Hage JJ, Bloem JJ (1993) Review of the literature on construction of a neourethra in female-to-male transsexuals. Ann Plast Surg 30:278–286 6. Hage JJ, Bouman FG, Bloem JJ (1993) Preconstruction of the pars pendulans urethrae for phalloplasty in female-to-male transsexuals. Plast Reconstr Surg 91:1303–1307 7. Mckillop C (2007) Interview with Dr Guido Barbagli. Substitution urethroplasty: which tissues and techniques are optimal for urethral replacement? Eur Urol 52(3):602–604 8. Bhargava S, Chapple CR (2004) Buccal mucosal urethroplasty: is it the new gold standard? BJU Int 93(9):1191–1193 9. Patterson JM, Chapple CR (2008) Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol 53(6):1162–1171 10. Thompson IO, van der Bijl P, van Wyk CW et al (2001) A comparative light-microscopic, electron-microscopic and chemical
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study of human vaginal and buccal epithelium. Arch Oral Biol 46(12):1091–1098 Blaivas JG (1989) Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol 141(3):542–545 Blaivas JG, Heritz DM (1996) Vaginal flap reconstruction of the urethra and vesical neck in women: a report of 49 cases. J Urol 155(3):1014–1017 Hendren WH (1998) Construction of a female urethra using the vaginal wall and a buttock flap: experience with 40 cases. J Pediatr Surg 33(2):180–187 Hu ZQ, Hyakusoku H, Gao JH, Aoki R, Ogawa R, Yan X (2005) Penis reconstruction using three different operative methods. Br J Plast Surg 58(4):487–492 Hage JJ, de Graaf FH (1993) Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery 14:592–598 Hoebeke P, Selvaggi G, Ceulemans P, De Cuypere G, T’Sjoen G, Weyers S, Decaestecker K, Monstrey S (2005) Impact of sex reassignment surgery on lower urinary tract function. Eur Urol 47:398–402 Monstrey S, Hoebeke P, Selvaggi G et al (2009) Penile reconstruction: is the radial forearm forearm flap really the standard technique? Plast Reconstr Surg 124(2):510–518 Fang RH, Kao YS, Ma S et al (1999) Phalloplasty in female-tomale transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg 52:217–222
19. Byun JS, Cho BC, Baik BS (1994) Results of one-stage penile reconstruction using an innervated radial osteocutaneous flap. J Reconstr Microsurg 10:321–331 20. Rohrmann D, Jakse G (2003) Urethroplasty in female-to-male transsexuals. Eur Urol 44(5):611–614 21. Biemer E (1998) Penile construction by the radial arm flap. Clin Plast Surg 15(3):425–430 22. Filipas D, Fisch M, Fichtner J et al (1999) The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine. BJU Int 84(1):108–111 23. Zaino RJ, Robboy SJ, Bentley R et al (2004) Diseases of the vagina. In: Kurman R (ed) Blaustein’s pathology of the female genital tract, 4th edn. Springer, New York, pp 131–136 24. El-Sherbiny MT, Abol-Enein H, Dawaba MS et al (2002) Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol 167(5):2225–2258 25. Levine LA, Elterman L (1998) Urethroplasty following total phallic reconstruction. J Urol 160(2):378–382 26. Glim JE, van Egmond M, Niessen FB et al (2013) Detrimental dermal wound healing: what can we learn from the oral mucosa? Wound Repair Regen 21(5):648–660 27. Zhang Y, Lu L, Zhang W et al (2010) A simple and effective method for phalloplasty in female-to-male transsexuals. Plast Reconstr Surg 126(5):264e–265e
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ORIGINAL ARTICLE
Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female‑to‑male transsexuals? Ying‑Fan Zhang1 · Cai‑Yue Liu1 · Chuang‑Yu Qu2 · Li‑Xuan Lu1 · An‑Tang Liu1 · Lie Zhu1 · Hui Wang1 · Zi‑Hao Lin1 · Yao‑Zhong Zhao1 · Xiao‑Hai Zhu1 · Hua‑Jiang1
Received: 20 November 2014 / Accepted: 13 April 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the female-to-male (FTM) transsexual patients. We report our experience with prefabricated pars pendulans urethrae using vaginal mucosal graft for phalloplasty in FTM transsexuals. Materials and methods We retrospectively reviewed notes on the 22 FTM patients treated with pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft between January 2008 and December 2012. Surgical outcome, urological function, and complications were recorded. Histological difference between normal mucosa and skin, and pathological changes of vaginal mucosal graft were also observed. Results All the reconstructive penis survived, and patients could void in a standing position finally at a median follow-up of 25.4 ± 6.0 months. Urethral fistula and urethral stricture rates were 31.8 % (7/22 patients) and 4.5 % (1/22 patients), respectively. The occurrence of the urethral
stricture was remarkably low compared with previous reports. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethral epithelium more closely than the forearm skin. Following the free transfer, the vaginal mucosal graft also showed a good revascularization and the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after a 6-month prefabrication. Conclusion With prefabrication of vaginal mucosal graft, we reconstruct a competent phallic neourethra in these FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is the excellent substitute material for promising urethral reconstruction in FTM transsexuals. Keywords Female-to-male transsexual · Urethral reconstruction · Prefabrication · Vaginal mucosal graft · Urethral complication
Introduction Ying-Fan Zhang and Cai-Yue Liu have contributed equally to this work and share co-authorship. * Xiao‑Hai Zhu [email protected] * Hua‑Jiang [email protected]; [email protected] 1
Department of Plastic and Reconstructive Surgery, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003, China
2
Department of Urology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Huangpu District, Shanghai 200003, China
Construction of a neourethra is always considered to be a difficult part in phalloplasty, especially for the femaleto-male (FTM) transsexual patients on account of the high incidence of urethral fistulas and stricture formation [1–4]. Apart from constructing the fixed perineal part of the neourethra, it is necessary to create a phallic pendulant part to be connected to the pars fixa urethrae. Traditionally, there are several techniques used to reconstruct the pars pendulans urethrae in females with gender dysphoria such as tube-within-a-tube design, prefabrication with free skin graft, bilateral ventral flaps, free microsurgical flaps, and tubular skin flaps [5, 6]. However, the results of these
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methods are mixed due to the complexity of the procedures and urethral complications. No method has become standardized. As we all know, buccal mucosal graft presents a gold standard for staged urethroplasty and has been used as one of the best substitute materials in many urethral reconstructive surgeries over the past two decades [7–9]. However, so far there has not been any relevant reference reporting the application of oral mucosa in total phalloplasty due to its inadequate sources. Since both histological and structural similarities have already been found between human vaginal and buccal mucosa [10], vaginal mucosa had been successfully applied in partial or total urethral reconstruction of female patients [11–13]. In this study, we herein report our experience in pedicled-flap phalloplasty with prefabricated pars pendulans urethrae using vaginal mucosal graft for 22 FTM transsexuals in our department.
World J Urol Table 1 Complications in female-to-male transsexuals No
VMG (abdominal 14, thigh 8)
Patients Flap-related following penile reconstruction Complete flap loss Marginal partial necrosis Urologic after urinary tract reconstruction Total fistula Total strictures Combination of both fistula and strictures Early fistula (closing spontaneously) Strictures treated conservatively Fistula require urethroplasty Strictures require urethroplasty
22 0 0 0 7 (31.8 %) 7 (31.8 %) 1 (4.5 %) 1 (4.5 %) 2 (9.1 %) 0 4 (18.2 %) 0
Patient satisfaction of aesthetic results
18 (81.8 %)
Materials and methods Patients From January 1, 2008, to December 31, 2012, 22 FTM transsexual patients received at least a two-stage sex reassignment surgery in our department. All these patients (mean age 27.8 ± 4.4, range 19–34 years) had been diagnosed with gender dysphoria by psychiatrists in mental health centers and assessed as suitable candidates for surgical treatment. Prefabrication of the pars pendulans neourethra with tubed vaginal mucosal graft in lower abdomen (14 cases) or anterolateral thigh region (8 cases) was performed in the first-stage operation. During the secondstage, lower abdominal pedicled fascia flap [14] or the anterolateral thigh (AT) flap containing prefabricated urethra was employed to construct the new phallus (Table 1). Operative techniques Before the operation, the axial arteries [arteria epigastrica superficialis (SIEA) and arteria circumflexa ilium superficialis (SCIA) in lower abdominal flap; the first and second perforators from descending branch of lateral circumflex femoral artery in anterolateral thigh (AT) flap] were traced by Doppler ultrasound, and their suprafascial courses were marked. In the first-stage operation, mastectomy, hysterectomy, salpingo-oophorectomy, and vaginectomy were firstly performed with the assistance of gynecologists. After the uterus and adnexa were freed from the pelvic attachments endoscopically, an experienced gynecologist began to elevate the mucosa from the vagina, leaving the urethral orifice–vaginal junction intact as the mucosa pedicle. Then, the mucosa together with the uterus and adnexa
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were cut and removed from the vaginal tunnel, as en bloc as possible (Fig. 1a). Then the vaginal mucosa would be utilized for two sections of urethral reconstruction, pedicled and free. The pedicled section was tailored to a size of 5 cm × 2.5 cm, and sutured mucosa-inward around the urethral catheter and tunneled to open at the anterior point of the pubic symphysis for elongation of the pars fixa urethrae [6, 15] (Fig. 1b). The catheter was removed in 2 weeks. Then the rest of full-thickness vaginal mucosa, as a single piece or in multiple pieces, was sutured and wrapped around a drainage tube (1.5 cm in diameter) to form a tube (12–14 cm in length, average 13 cm) for prefabrication of the pars pendulans urethrae (Fig. 1c–e). A 12–14 cm (length) × 2 cm (width) subcutaneous tunnel was created closely to reticular dermis in the lower abdomen or in the anterolateral region of the thigh depending on the selected flap for penis reconstruction. In the process of tunneling, the axial vessels were supposed to be avoided to prevent injury (Fig. 3b). Then the tubed graft was introduced into the tunnel and fixed in place. The drainage tube was used to support the prefabricated urethrae for 3 months (three patients) or 6 months (19 patients) until the second-stage operation (Figs. 2a, 3c). The patients were instructed to irrigate the neourethra with saline from one side of the stent tube to the other side twice a day themselves. When they returned to hospital once a month, the old stent tube was replaced with a new one by our doctors. In the second-stage operation, the pedicled abdominal flap or anterolateral thigh flap together with the prefabricated neourethra was raised and transposed to the pubic region. Eventually, the prefabricated urethrae were connected to the already extant pars fixa. The abdominal donor-site was sutured directly, while the anterolateral thigh donor-site was covered with skin graft taken from the
World J Urol Fig. 1 a Mucosa, together with the uterus and adnexa, were cut and removed from the vaginal tunnel. b The pars fixa neourethra was elongated using the anterior vaginal flap which was indicated by the right part of the black line, while the left part of the mucosa would be cut to preconstruct the pars pendulans neourethra. The upper black arrow indicated the location of the new urethral orifice. The lower black arrow indicated that the clitoris was freed and would be denuded and buried subcutaneously. c A single piece of fullthickness vaginal mucosa would be sutured mucosa-inward around a drainage tube to form the pars pendulans urethra. d Multiple pieces of the mucosa would be sutured together to form the pars pendulans urethra. e The average length of the mucosal tube graft was 13 cm (12–14 cm)
other thigh (Figs. 2b–c, 3c–e). After the second-stage operation, patients were followed up for 25.4 ± 6.0 months. Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient, respectively, to compare their histological pattern during the firststage operation (Fig. 4a–d). In addition, biopsies of the vaginal mucosal grafts were taken concomitantly in different period (3 or 6 months following the first-stage operation) from the patients. Hematoxylin- and eosin-stained sections were examined by light microscopy. Masson’s trichrome was used to examine the extent of fibrosis (Fig. 5a–f).
second-stage phalloplasty during the follow-up period, and its parameters (Qmax, mean flow rate, voiding time, voided volume) were recorded.
Results All of the reconstructed penises survived completely. No flap loss or necrosis occurred in these 22 patients. Urinary function and urological complications following urinary tract reconstruction
Uroflowmetry test Uroflowmetry test was conducted for 22 patients to make a postoperative checking of urethroplasty 1 year after the
All the patients were ultimately able to void in a standing position through the newly reconstructed penis. The uroflowmetry test result did not show abnormal findings, and
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Fig. 2 24-year-old patient. a Frontal view following the first-stage operation. The prefabricated pars pendulans urethra located at left lower abdomen with a drainage tube in it. The blue lines indicated the superficial courses of the superficial iliac and epigastric arteries. b Preoperative designs of phalloplasty. A rectangular-shape 13 × 11 cm flap was designed for phallus shaft. The prefabricated urethra was located in the inner one-third part of the flap, and a
4 × 4 cm round flap was designed on the distal part of the urethra to fabricate the glans. The black arrows indicated the prefabricated urethral orifices. c The pedicled flap was transposed to the pubic region, and the prefabricated urethra was anastomosed with the advanced urethral orifice. The abdominal donor-site was sutured directly. d Lateral view during voiding 24 months following the second-stage operation
Fig. 3 22-year-old patient. a A pinch thickness of skin tissues was 3 cm in thigh. b The tubed vaginal mucosal graft was introduced into the tunnel in the right anterolateral region of thigh. The black arrows indicated the penetrating points of the two skin perforators. c Preoperative design of phalloplasty. A rectangular-shape 12 × 10 cm flap was designed for the phallus shaft, and a 7 × 5 cm flap was designed on the distal part of the urethra to fabricate the glans. The black
crosses indicate the penetrating points of the two skin perforators. d The anterolateral thigh flap passed through the tunnel under the rectus femoris and sartorius muscles on its vessel pedicle. e The pedicled flap was transposed to the pubic region, and the prefabricated urethra was anastomosed with the advanced urethral orifice. f Lateral view during voiding 18 months following the second-stage operation
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Fig. 4 Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient to compare their histological pattern during the first-stage operation. a The forearm skin showed keratinized squamous epithelium, thin epithelium (6–9 layers), and a thick subdermal layer with dense collagen fibers which are in bright red dyeing. b The normal urethral mucosa has thick
epithelium without keratinized layer. A pronounced similarity was found between vaginal (c) and buccal mucosa (d). They were both non-keratinized epithelium which have similar thickness of epithelium (20–30 layers), cell structural composition, loose and thin submucosal layer, and abundant vasculature. They resembled urethral epithelium more than the forearm skin
the parameters of our patients (Qmax, ml/s: 15.5 ± 5.6, Table 3) were consistent with previous reports (Qmax, ml/s: 14.0 ± 9.7) by Hoebeke et al. [16]. Mild incontinence was reported in 13 patients (59.1 %): for 10 (45.5 %) occurred post-voiding only while other three patients (13.6 %) had this problem all the time. A total of 16 patients (72.7 %) reported post-voiding dribbling. Since these symptoms were not considered as a problem by all affected patients, no further medical therapy was performed in this study. Similarly, Hoebeke et al. [16] also reported that, other symptoms, like post-void dribbling and mild incontinence, were commonly reported, with no need for medical help. However, in this study, each patient was instructed to perform appropriate maneuver: compressing the reconstructed urethrae from the pas fixa to the pars pendulans, especially during the last part of voiding in order to empty the
residual urine in the reconstructed urethrae and improve their symptoms. Seven fistulas (31.8 %, 7 of 22) and one stricture (4.5 %, 1 of 22) occurred in seven patients (31.8 %, 7 of 22). Six urethral fistulas were observed at the anastomosis between phallic urethra and bulbar urethra in six cases. A stricture developed at the anastomosis between the phallic urethra and the bulbar urethra with a fistula in pars fixa part in one patient. Spontaneous closure of the fistula was observed in three patients. In other three patients, a simple excision of the fistula tract was successfully performed at least 3 months after the second-stage operation. Stricture resection and an end-to-end anastomosis were performed in that patient with stricture 6 months after the second-stage operation. Meanwhile the fistula tract in the pars fixa part was also excised (Tables 1, 2, 3).
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Fig. 5 Histological changes of the vaginal mucosal grafts. The histology of a, d the normal vaginal mucosa had the thick non-keratinization stratified squamous epithelium showing a high similarity to the normal urethra. b, e The mucosal graft in the abdominal flap after a 3-month prefabrication verified a good “take” and the epithelium showed irregular thickness with areas of epithelial proliferation.
There were obvious inflammatory cell infiltrations and fibroblastic reactions in the lamina propria. c, f The neourethra mucosa grafting for 6 months, the epithelium showed more regular thickness and the inflammation and fibrosis decreased significantly to the normal level (a, b, c Hematoxylin and eosin, ×100; d, e, f Masson’s trichrome, ×100)
Table 2 Details and treatment of urologic complications Patient number Prefabrication duration (months) Urologic complications Revision procedure 1 3
3 3
Fistula Stricture and fistula
7 11 12 15
6 6 6 6
Fistula Fistula Fistula Fistula
Excision of the fistula tract Stricture resection and an end-to-end anastomosis, excision of fistula Healed spontaneous Excision of the fistula tract Healed spontaneous Healed spontaneous
19
6
Fistula
Excision of the fistula tract
Histological findings
Table 3 Uroflowmetry parameter analysis Uroflowmetry parameters
X ± SD VMG (n = 22)
Qmax (ml/s)
15.5 ± 5.6
Mean flow rate (ml/s) Voiding time (s)
9.9 ± 2.3 34.5 ± 13.2
Voided volume (ml)
340.6 ± 45.4
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Biopsies of normal forearm skin, vaginal, buccal, and distal urethral mucosa were taken from one patient, respectively, to compare their histological pattern during the first-stage operation. Histological examinations showed a pronounced similarity between vaginal (Fig. 4c) and buccal mucosa (Fig. 4d). They were both non-keratinized epithelium
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which have similar thickness of epithelium (20–30 layers), cell structural composition, loose and thin submucosal layer, and abundant vasculature. Morphologically, they resembled urethral epithelium more closely than the forearm skin. The former also had a thick epithelium without keratinized layer (Fig. 4b). In contrast, the forearm skin was keratinized squamous epithelium which had thinner epithelial layers (6–9 layers) and thicker subdermal layer with dense collagen fibers which are in bright red dyeing (Fig. 4a). Vaginal mucosa, non-keratinized stratified squamous epithelium, had a high similarity to the normal urethra (Fig. 5a, d). After a 3-month prefabrication, the vaginal mucosal graft showed a good “take.” The thickness of the epithelium was relatively irregular, and epithelial proliferation could be observed in some areas. The inflammatory reaction and fibroblastic proliferation could also be obviously seen in the lamina propria (Fig. 5b, e). Following a 6-month prefabrication after the first-stage operation, the epithelium of the prefabricated mucosal graft showed a more regular thickness. The number of inflammatory cells and the extent of fibrosis both decreased to a relatively normal level (Fig. 5c, f).
Discussion The ability to urinate while standing has priority for most of the FTM patients, a complete and competent urethra should be created [5]. Although the radial artery-based forearm free flap (RAFFF) is by far the most frequently used flap and universally considered as the standard technique in penile reconstruction in these patients, the problems with the neourethra, reconstructed by tube-within-tube method, are very common, with a fistula rate of around 20–35 % in most series while the rate of urethral stricture formation, especially at the anastomosis of the mucosal tissue with the inner skin tube of the neophallus, is sizeable (18 %) [3, 17]. Other reports also showed relatively high rates of urethral stricture (14 % (3/22) [18], 16.3 % (47/287) [17], 20 % (1/5) [19], 36 % (9/25) [20], 40 % (4/10) [21]). Reasons may be insufficient vascular supply of the local flaps and the inappropriate width of the phallic urethra, the latter being responsible for relative obstruction of the urinary stream and increased force on the “bulbar urethra” and anastomotic sites [20]. Scientific progress in reconstructive urethroplasty of total phalloplasty is slow. In our study, we have made good use of the “waste tissues”-vaginal mucosa and reconstructed a competent neourethra, especially the phallic part with prefabrication technique. All the patients could void in a standing position and the rate of urethral strictures while not fistula was remarkably low (4.5 %, 1/22 patients) for a follow-up of 25.4 ± 6.0 months. Generally
speaking, dealing with strictures is more troublesome and complicated than fistulas since the majority of the fistulas could close spontaneously [17]. The probable reasons were as follows: First of all, reduced urethral stricture rate was related to the graft material. Most importantly, a prerequisite for reconstructive surgery is a close homology between the replaced tissue and the material used for reconstruction [22]. To our knowledge, this was also the important reason why the oral mucosa has been used as one of the best substitute materials in many urethral reconstructive surgeries over the past two decades [7–9]. However, no reference has reported the application of oral mucosa in total phalloplasty. Many publications have reported that the vaginal and oral mucosa are histologically similar. They are wet mucosal epithelium, smooth, and hairless. They also have similar thickness of epithelial layers, cell structural composition, and a dense submucosal plexus [22, 23]. Moreover, Thompson et al. [10] have found that the ultrastructure and distribution of keratin filaments between the vaginal and buccal epithelia were similar, as is their permeability to water, and the distribution and appearance of the lipid lamellae in the intercellular spaces were also similar. Therefore, it was reasonable that vaginal epithelium could be used as a substitute for buccal epithelium in certain in vitro or in vivo study [10]. Our histological results also showed a pronounced similarity between vaginal and buccal mucosa. Morphologically, they resembled urethra epithelium more closely than the forearm skin. Indeed, both of them are the same type of mucosal epithelium-predominantly nonkeratinized stratified squamous epithelium, while the forearm skin is keratinized squamous epithelium. The bladder mucosa, which was also chosen to reconstruct the urethra, is the transitional epithelium with thin epithelial layer [22]. The thicker epithelial layer of vaginal mucosa means the better stability, barrier function, and self-renewing of the graft material [22]. Additionally, the thin and loose submucosal layer and abundant vasculature rendering the vaginal mucosa are more prone to obtain a blood supply from the graft site, which might be an advantage for early revascularization, and thus to healing [22–24]. Based on these, we have reasons to believe that vaginal mucosa could be much more suitable and reasonable than other tissues to reconstruct a new urethra. Besides, low occurrence of urethral strictures could also be partly explained by less formation of scar tissues. Scar contracture and wound healing around the urethral anastomosis were considered to be the reasons for urethral stricture in phalloplasty in traditional RAFFF method [18, 25]. It has been reported when using mucosal tissues for urethroplasty, the wound of both recipe-site and donorsite healed very well [7, 8]. In our study, it is the vaginal mucosa connected with the extended urethral mucosa
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(mucosa connected with mucosa) to form a neourethra. It has been reported, compared with the skin and dermal wound healing, the wounds of the oral mucosa tend to heal in an accelerated fashion and display no or minimal scar formation [26]. Possible mechanisms involved in the difference between scar-forming dermal versus scarless oral mucosal wound healing could be their architectural and environmental differences. Keratinocyte reactions and expression of extracellular matrix (ECM) components like procollagen I and tenascin-C are different in dermal and oral wound healing. Furthermore, a favorable effect on oral healing has been attributed to salivary components [26]. Based on these, we herein hypothesized that vaginal mucosa has a similar advantage to oral mucosa. In addition, unlike buccal mucosa, the vaginal mucosa could provide enough material for reconstruction of a urethra. Using this “waste tissues,” which were originally discarded in vaginectomy in FTM patients, could avoid extra injury of donor-site for constructing the neourethra and was more easily accepted by these patients. Furthermore, in our method, an approximate 5-cm-wide (1.5 cm in diameter) vaginal mucosa was formed for preconstruction of the phallic neourethra compared with a 3-cm-wide skin strip used in RAFFF method [20]. A larger caliber neourethral may also reduce potential chances of contracture, which in theory reduce the rate of potential urethral strictures. Secondly, prefabrication procedure was beneficial to low occurrence of urethral strictures. In the traditional “tube-within-a-tube” method of the RAFFF, presumably these strictures could form as a result of relative ischemia at the anastomosis of tissues of native urethra to the free forearm tube-flap, which was exacerbated by kinking at the neophallus base [25], while the vaginal mucosal grafts could establish sufficient blood supply within a 6-month delay following the prefabrication. For this aforementioned reason, we did not tube to form a total male urethra with the harvested vaginal mucosa in a one-stage operation, although it is technically feasible [12, 13]. In this study, we performed a two-stage operation because the entire prefabricated urethra, especially its two end points, could effectively inhibit the primary cicatricial contracture after a long-standing support with a drainage tube [27]. Further histological studies also showed, in prefabricated vaginal mucosa, the inflammatory reaction and the extent of fibrosis of the mucosa decreased to the normal level after 6-month prefabrication, which suggested that a 6-month prefabrication could be a more appropriate and reasonable interval than 3 months’ prefabrication between the firststage and second-stage operations (Fig. 5). At last, pedicled-flap phalloplasty with prefabricated urethra made the second-stage operation much more simple and convenient without microsurgical techniques.
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Conclusion With prefabrication of vaginal mucosal graft, we reconstructed a competent phallic neourethra in FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is one of the best substitute materials for promising urethral reconstruction in total phalloplasty. Although longer follow-up is needed, in this preliminary report, pedicled-flap phalloplasty combined with vaginal mucosal graft to prefabricate the phallic neourethra represents a simple and effective surgical option in FTM transsexuals. Acknowledgments Thanks to Benjamin G. Huey from Medical School of Emory University for his careful reading on grammar and expression of English, Dr. Yueju Su from Department of Mathematics & Statistics in Georgia State University for her statistical assistance. This work was supported by Grant Nos. 10ZR1439200, 2006079 of the Natural Science Foundation of Shanghai and 81100950 of Natural Science Foundation. Conflict of interest The authors declare that they have no conflict of interest. Ethical standard All human have been approved by the Ethics Committee of Second Military Medical University and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in the study. Details that might disclose the identity of the subjects under study have been omitted.
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19. Byun JS, Cho BC, Baik BS (1994) Results of one-stage penile reconstruction using an innervated radial osteocutaneous flap. J Reconstr Microsurg 10:321–331 20. Rohrmann D, Jakse G (2003) Urethroplasty in female-to-male transsexuals. Eur Urol 44(5):611–614 21. Biemer E (1998) Penile construction by the radial arm flap. Clin Plast Surg 15(3):425–430 22. Filipas D, Fisch M, Fichtner J et al (1999) The histology and immunohistochemistry of free buccal mucosa and full-skin grafts after exposure to urine. BJU Int 84(1):108–111 23. Zaino RJ, Robboy SJ, Bentley R et al (2004) Diseases of the vagina. In: Kurman R (ed) Blaustein’s pathology of the female genital tract, 4th edn. Springer, New York, pp 131–136 24. El-Sherbiny MT, Abol-Enein H, Dawaba MS et al (2002) Treatment of urethral defects: skin, buccal or bladder mucosa, tube or patch? An experimental study in dogs. J Urol 167(5):2225–2258 25. Levine LA, Elterman L (1998) Urethroplasty following total phallic reconstruction. J Urol 160(2):378–382 26. Glim JE, van Egmond M, Niessen FB et al (2013) Detrimental dermal wound healing: what can we learn from the oral mucosa? Wound Repair Regen 21(5):648–660 27. Zhang Y, Lu L, Zhang W et al (2010) A simple and effective method for phalloplasty in female-to-male transsexuals. Plast Reconstr Surg 126(5):264e–265e
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