Beginnings of Sex Reassignment Surgery in Japan
By Takamatsu Ako, M.D., Harashina Takao, M.D., Inoue Yoshiharu, M.D., Kinoshita Katsuyuki, M.D.**, Ishihara Osamu, M.D.**, Uchijima Yutaka, M.D.* **Department of Plastic and Reconstructive Surgery, Gynecology*, Urology**, Saitama Medical Center, Saitama Medical School, Japan
Abstract
The first sex reassignment surgery (SRS) performed officially in Japan - for a female-to-male (FtM) person in 1998 and for a male-to-female (MtF) person in 1999 - are reported. For the FtM, two-stage conversion was applied. In the first operation, salpingo-oophorectomy, hysterectomy, colpectomy, metoidioplasty, and mastectomy were performed. A free flap phalloplasty with the deltoid flap is planned as the second stage. For the MtF, one-stage neovaginoplasty was performed by penile skin inversion technique with sensate pedicled neoclitoplasty.
Introduction
Japan, which is considered to be one of the world's most advanced countries in terms of its economy, technology, industry, and medicine, has long been in the dark ages regarding people who suffer from gender dysphoria. In July 1996, the Ethics Committee of Saitama Medical School submitted a report, at our request, on surgical treatment for transsexual patients. The report acknowledges that transsexualism exists and that treating transsexual patients can be regarded as a justifiable medical activity. The report was made public by mass media. In 1997, the medical guidelines for transgender persons were issued by the Japanese Society of Psychiatry and Neurology, with some modifications of the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. We organized a medical team composed of psychiatrists, a sexologist, endocrinologists, gynecologists, urologists, and plastic surgeons.
This is a report of the first sex reassignment surgeries (SRSs) officially performed in Japan: one for a FtM person in 1998 and one for a MtF person in 1999. Diagnosis, preparatory psychotherapy, and hormonal therapy were carried out according to the above-mentioned guidelines.
Methods
SRS for a Female-to-Male Transsexual
In the first operation, regarded as the first stage in the two-stage conversion, bilateral salpingo-oophorectomy, hysterectomy, colpectomy, metoidioplasty, and mastectomy were performed.
First, the gynecologists performed a trans abdominal oophoro-hysterectomy. Then they began to elevate the anterior vaginal flap through the abdominal approach. The elevation was completed trans vaginally, just to the dorsal part of the urethral orifice, by plastic surgeons. The vaginal mucosa was resected, and colpocleisis was accomplished. After the abdominal wall was closed, we performed a metoidioplasty, as advocated by Hage (1996). By resection of the chordee, the clitoral shaft was released and abdominally advanced. The neourethra was constructed by suturing the vestibular skin, the vaginal mucosal flap and the labial flap around the urethral catheter in a watertight fashion (Figures 1, 2). A suprapubic cystostomy was performed and the urethral catheter was removed.
Figure 1 Figure 2
For the bilateral mastectomy, we used a modification of the concentric-circle periareoral de-epithelization technique reported by Davidson (1979). Resection of the breast gland and reduction of the nipple were performed by the transareolar approach described by Pitanguy (1966) and Hage and Bloem (1995) (Figures 3, 4).
Figure 3 Figure 4
The estimated blood loss was 740 ml, and the total operating time was 6 hours. The postoperative course was completely uneventful. The suprapubic catheter was left in place for 7 days. The total hospital stay was 14 days.
We are planning a free-flap phalloplasty as the second stage of the conversion. The patient desires the phalloplasty but at this time cannot afford the necessary fee which will amount to 2,500,000 yen (US$25,000).
A one-stage operation was performed in June 1999. The operative technique involved the following procedures: bilateral orchiectomy and penectomy followed by vaginoplasty, clitoroplasty, and vulvoplasty.
For the vaginoplasty, we employed a modification of the abdominally pedicled penile-skin-inversion technique added by a triangular perineal skin flap (Karim, Hage and Mulder, 1996). A dorsally based triangular perineal flap measuring about 10 cm long and 4 cm wide was used to line the posterior wall of the neovagina and widen the introitus (Figure 5). The testes were isolated and then removed with a double ligation of the spermatic cord at the level of the external inguinal rings. The skin of the penile shaft was mobilized from the corpora up to the level of the corona. A circumcising skin incision was made at the corona, completely denuding the penis of its skin and leaving the glans penis attached to the corpora (Figure 6).
We are planning a free-flap phalloplasty as the second stage of the conversion. The patient desires the phalloplasty but at this time cannot afford the necessary fee which will amount to 2,500,000 yen (US$25,000).
SRS for a Male-to-Female Transsexual
A one-stage operation was performed in June 1999. The operative technique involved the following procedures: bilateral orchiectomy and penectomy followed by vaginoplasty, clitoroplasty, and vulvoplasty.
For the vaginoplasty, we employed a modification of the abdominally pedicled penile-skin-inversion technique added by a triangular perineal skin flap (Karim, Hage and Mulder, 1996). A dorsally based triangular perineal flap measuring about 10 cm long and 4 cm wide was used to line the posterior wall of the neovagina and widen the introitus (Figure 5). The testes were isolated and then removed with a double ligation of the spermatic cord at the level of the external inguinal rings. The skin of the penile shaft was mobilized from the corpora up to the level of the corona. A circumcising skin incision was made at the corona, completely denuding the penis of its skin and leaving the glans penis attached to the corpora (Figure 6).
Figure 5 Figure 6
The dorsal part of the glans penis was used as a clitoris. Sensate pedicled neoclitoplasty using the reduced glans, which remained attached to its dorsal penile neurovascular pedicle, was performed (Brown, 1976). The corpora cavernosa were resected to prevent postoperative pain due to erection of the remaining corpora tissues.
A neovaginal cavity was created by dissection between the two layers of Denonvillier's fascia using a laparoscope placed in the abdomen as a guide. The created neovaginal depth was approximately 10 cm.
The lower abdominal skin flap was dissected to about the level of the umbilicus, and this advancement of the flap in the inferior and posterior direction made it possible for the base of the penile skin tube to overlie the introitus of the neovagina. The perineal triangular flap was sutured to the posterior wall of the penile skin tube and the widened tube was then inverted to line the neovaginal cavity. The skin flap was incised in the middle and the urethra was brought out through the buttonhole and amputated at the urogenital diaphragm level. The urethral stump and neurovascular pedicled neoclitoris were sutured to the skin with interrupted sutures. A soft, individually selected urethane mold, placed in a condom, was inserted into the neovagina, and the mold was securely sutured to the perineum to prevent prolapse (Figure 7).
A neovaginal cavity was created by dissection between the two layers of Denonvillier's fascia using a laparoscope placed in the abdomen as a guide. The created neovaginal depth was approximately 10 cm.
The lower abdominal skin flap was dissected to about the level of the umbilicus, and this advancement of the flap in the inferior and posterior direction made it possible for the base of the penile skin tube to overlie the introitus of the neovagina. The perineal triangular flap was sutured to the posterior wall of the penile skin tube and the widened tube was then inverted to line the neovaginal cavity. The skin flap was incised in the middle and the urethra was brought out through the buttonhole and amputated at the urogenital diaphragm level. The urethral stump and neurovascular pedicled neoclitoris were sutured to the skin with interrupted sutures. A soft, individually selected urethane mold, placed in a condom, was inserted into the neovagina, and the mold was securely sutured to the perineum to prevent prolapse (Figure 7).
Figure 7 Figure 8
The estimated blood loss was 760 ml and no transfusion was necessary. The postoperative course was uneventful and the patient was discharged on the eighth postoperative day. She wore the dilating stent every day for 3 months postoperatively; nevertheless, the neovagina decreased in depth to 6 cm and in diameter to two fingers' width. The neoclitoris was found to have returned to a normal level of sensation (Figure 8). The patient has returned to her previous occupation.
Discussion
We believe that most FtM transsexuals desire closure of the vagina. However, we recognize the different view of some surgeons who consider the risk benefit to be rather high. Their reasoning is that most patients are not necessarily aware of the presence of the vagina because of decreased discharge after hysterectomy and atrophied mucosa due to long-term hormone therapy. We have found vaginectomy to be technically difficult and bloody and autotransfusion has a valuable place here. We have also found the vaginas of the Japanese FtM transsexuals we have examined to be very narrow compared with those we have observed elsewhere, so we have chosen to do transabdominal hysterectomies. The other advantage of the transabdominal approach is that the partial elevation of a sufficient size of the anterior vaginal flap and vaginectomy can be carried out from above, under direct vision (Figure 9).
Discussion
We believe that most FtM transsexuals desire closure of the vagina. However, we recognize the different view of some surgeons who consider the risk benefit to be rather high. Their reasoning is that most patients are not necessarily aware of the presence of the vagina because of decreased discharge after hysterectomy and atrophied mucosa due to long-term hormone therapy. We have found vaginectomy to be technically difficult and bloody and autotransfusion has a valuable place here. We have also found the vaginas of the Japanese FtM transsexuals we have examined to be very narrow compared with those we have observed elsewhere, so we have chosen to do transabdominal hysterectomies. The other advantage of the transabdominal approach is that the partial elevation of a sufficient size of the anterior vaginal flap and vaginectomy can be carried out from above, under direct vision (Figure 9).
Figure 9 Figure 10
Figure 11 We are planning a free-flap phalloplasty as the second stage of the FtM SRS (Figure 10). We have experienced 13 cases of deltoid flap and 5 cases of forearm-flap phalloplasties in non- transsexual patients during the past 15 years (Figure 11). These techniques always result in extensive scarring of the donor area. Our first choice of donor site for phallic construction is the deltoid flap (Harashina et al.,1990) because it results in less morbidity in the donor site, is a true sensory flap, has hairless skin, and is less likely to result in atrophy of the neophallus. However, this technique may be technically more difficult than that with the forearm flap, and it may be impossible to make a roll on obese patients. We think the deltoid flap is especially suitable for Japanese FtM patients because they generally are not obese. In fact, they usually try to reduce their weight so that they will not be regarded as females.
At the time of writing this paper, we have performed six SRSs: one for MtF and five for FtM. Four of the five FtM patients had already undergone mastectomies elsewhere. The SRSs were performed at the Gender Clinic of Saitama Medical Center, which was the only provider of transgender-specific health services in Japan as of March 2000. In total, over 400 clients have visited our clinic since the first patient arrived in 1992, and about 100 new gender dysphoric clients have been seen each year. Sixty percent of them seek SRS. While there are many candidates, we take our time before performing surgery because there are very few psychiatric specialists in this field in Japan and we must apply for permission from our ethics committee in each case.
Conclusion
The first SRS operation in Japan was affirmatively reported all over the country and there was actually no public criticism. The operation was an historic turning point for the proper understanding of Gender Identity Disorder in our country.
We are just on the starting line. Many issues remain to be resolved in promoting the welfare of our patients. Whereas public interest is steadily increasing and some acknowledgement of SRS seems to have become established, there is still no policy regarding health insurance and legislation for those who have undergone the procedure. SRS is not covered by National Health Insurance, and postoperative persons cannot yet change any of their documents. Our team is still the only practising gender surgery team in Japan, although two other teams are now being organized. Despite these difficulties, the role of SRS, performed justifiably, is becoming more prominent in the treatment of transsexualism in Japan.
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References
Brown, J. (1976) Creation of a functional clitoris and aesthetically pleasing introitus in sex conversion. In Marchac, D. (Ed.), Transactions of the 6th International Congress of Plastic and Reconstructive Surgery. Paris: Masson, pp. 654-655.
Davidson, B. A. (1979) Concentric circle operation for massive gynecomastia to excise the redundant skin. Plastic and Reconstructive Surgery, 63: 350-354.
Hage, J.J. (1996) Metoidioplasty: An alternative phalloplasty technique in transsexuals. Plastic and Reconstructive Surgery, 97: 161-167.
Hage, J. J., Bloem J.J.A.M. (1995) Chest wall contouring for female-to-male transsexuals: Amsterdam experience. Annals of Plastic Surgery, 34: 59-66.
Harashina T., Inoue T., et al. (1990) Reconstruction of penis with free deltoid flap. British Journal of Plastic Surgery, 43: 217-222.
Karim, R.B., Hage J. J., and Mulder J. W. (1996) Neovaginoplasty in male transsexuals: Review of surgical techniques and recommendations regarding their eligibility. Annals of Plastic Surgery, 37: 669-675.
Pitanguy, I. (1966) Transareolar incision for gynecomastia. Plastic and Reconstructive Surgery, 38: 414-419.
Acknowledgement
We are grateful to Doctor Joris J. Hage in the Netherlands for his valuable help in accomplishing this task.
