Surgical sexual reassignement: between dreams and reality

In recent years transsexualism has acquired much greater medical and media attention, and increasing numbers are opting for gender reassignment treatment. From an epidemiological point of view this would seem to be a ubiquitous condition despite being difficult to quantify. Data collected in Sweden, England and Wales show that there is an average prevalence of 1 in 12,000 biological men and 1 in 100,000 biological women. The term gender identity disorder (GID) is used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, or a sense of inappropriateness in the gender role of that sex, as manifested by a preoccupation with getting rid of one's sex characteristics or the belief of being born in the wrong sex. In the case of M-to-F surgical reassignment, the procedure consists of five phases: bilateral orchidectomy, penile amputation, creation of the neovaginal cavity, lining of this cavity and reconstruction of a urethral meatus and, finally, construction of the labia and clitoris. Surgical techniques available for sex reassignment surgery in M-to-F transsexualism may be classified into five categories: nongenital skin grafts, penile skin grafts, penile-scrotal skin flaps, nongenital skin flaps, and pedicled intestinal transplant. In case of F-to-M surgical reassignment, the first phase consists of bilateral salpingo-oophorectomy, hysterectomy and possibly vaginectomy. The second phase consists in the phallic fashion. There are currently three surgical procedures for the construction of the penis: metoidioplasty, pedicle flap phalloplasty and skin flap phalloplasty. As techniques in sex reassignment surgery become more refined, more emphasis is being placed on aesthetic and functional outcomes by both surgeons and patients. Even if the incidence of complications has been reduced, this kind of surgery still represents a great challenge for urologists and plastic surgeons and necessity of wider experience and confidence with it.