MtF sex reassignment surgery: Trombetta technique

Aim of the Study: To describe our surgical technique highliting several steps we experienced differently from the traditional Petrovich technique. Materials and Methods: Surgical equipe consists of two couples of surgeons working toghether at the beginning and at the end of surgery, separately at the central time. Patient position is lithotomic: two surgeons stand at the hips facing eachother, other two sit in front of perineum. Preoperative skin marking and penile lenght measuring is performed to obtain satisfacting results in terms of depth of neovagina and external genitalia reconstruction. Perifunicular fat is saved during orchifuniculectomy to add volume in labia majora construction. Spongious tissue of bulbar urethra and erectile tissue of corpora cavernosa is totally removed. Mucosa of neourethral meatus is everted using 3/0 resorbable suture. Neovaginal cavity is created by smooth dissection of Denovillier fascia. Anterior neovaginal wall consists of penile skin flap, posterior wall of scrotal skin flap. Scrotal and penile flaps are sutured along lateral borders forming a unique tubular flap, apex of neovaginal tubular flap is not sutured. Neoclitoris is proceeded from a piece of dorsal glans toghether with neurovascular penile bundle that is fixed above the symphysis by 4/0 suture. Neoclitoris/neourethral complex is lodged in a mucosal environment by a two-layered suture to connect both mucosal and spongiosal tissue. Lateral suture of labia majora is done with intradermal self-lock suture thread. Results: Contemporary surgical working allows shortening of operative time until 4 hours. Preoperative skin marking and measuring of penis lenght ensures simmetry and gives a preliminar aesthethic and function outcome. Perifunicular fat conferes natural aspect to labia majora. Total removal of erectile tissue prevents from dispareunia. Mucosal eversion of neourethral meatus prevents from stenosis. Leaving the apex of tubular neovaginal flap open allows the gain of lenght after surgery protecting from scar retraction. Adequate isolation of neurovascular bundle permits to reach orgasm by tactile stimulation and prevents from neoclitoral necrosis. Mucosal environment of neoclitoris/neourethral complex is fundamental for natural aesthetic outcome and lubrication. Intradermal lateral suture guarantees good wound healing and less infections. Discussion: The challenging of male-to-female sexual reassignment surgery requires good surgical technique and well-trained surgeons. The technique we reported has been developed after 30 years of experience and after more than 400 patients treated.