Sexual reassignment surgery ( male to female) penile skin invertion

Service inclusions

• Doctor fee
• Clinical interview/ surgery consultation
• General anesthetic fee
• 4 nights in hospital
• All medications supplies
• Surgical not include medical diseases treatment such as diabetes mellitus, heart disease, hypertension

Pre op preparation

• Inform us about any allergies , underlying medical illness, medications taken
• Avoid aspirin ibuprofen , anticoagulant , vitamin E before surgery at least 2 weeks
• Hypertension within controlled
• Smoking should be refrained at least 10 days before and after surgery
• Plan to be in Bangkok at least 10- 14 days after surgery

Criteria of approval

• Patient must be at least 18 years of age and require permission (with signature on the consent) from parents if under 20 years old
• Patient must be diagnosed with at least one of the following disorders : gender identity disorder , gender dysphoria , or associated conditions
• Patient must have undergone at least one year of antiandrogen and/or female hormone.
• Patients are required to have full-time living as a cross gender role for at least 1 year( supported by identification document)
• Patients must have approval from psychiatrist ( MD )
• By Thailand legally rule patient have to be approved or diagnosed for gender identity disorder by at least another one of Thai psychiatrist. ( we can refer to an appropriated one for our patient )

Preparation before operation

Following the HBIGDA criteria you should have

One letter recommended the SRS from : 1: therapist , 2: psychiatrist , 3: endocrinologist or your general practitioner
Discontinue hormone treatment at least 14 days before surgery ; to reduce risk of thrombosis ( blood clot ) ; oral tablet should be halted two weeks prior to surgery and injectables should be halted four weeks prior to surgery ; oral antiandrogen should be halted three days prior to surgery ( and four weeks for the injectables)
Have your private doctor performed preoperative physical check up within three months prior to SRS and be confirmed by the private physician that patient is free from serious medical diseases that have high risk for major surgery and must pass the following blood tests :
CBC , anti HIV , electrolytes , blood sugar , bun , creatinine

Alkaline phosphatase , chest X-ray , ECG , SGOT , LDH

And email us the results

Reduced smoking , no aspirin , anticoagulants , ibuprofen and vitamin E at least 10-14 days prior to surgery
HIV patient can be done with an extra cost 30 % due to necessity of disposable instrument usage
Information documentation should send the FAX or email for appointment 1 month prior to surgery
Fact about the procedure

I am one of Thai plastic surgeons who was trained by Dr. Preecha Tiewtranon for the SRS operation and all the details of technique for the neovaginal cavity lining with penile skin inversion ; sensational clitoris and labiaplasty ( major and minor ) . All are done in one stage with 3 different considerations

Long penis : (> 6 inches) = penile skin inversion
Medium penis ( 2-6 inches ) = penile skin inversion with scrotal skin graft (SSG)
Short penis ( <2 inches) = penile skin inversion + sigmoid colon flap (SCF)

Surgery schedule

Day 1 : Arrived Bangkok

Day 2 : Meet with surgeon for clinical interview and consultation ; and also with psychiatrist if necessary

: check for all the medical documentations

: be admitted in the hospital and operation time will be scheduled

Then : complete enema for cleaning the rectum by nurse

: take a nice shower and clean up your perineum area

: preoperative intravenous fluid

Surgery will take about 3-4 hours

Day 3-5 : The day after surgery you will be able to have meal and move freely on bed. You will have the urine catheter and blood drainage bag don’t be worried . May you feel like about to urinate all the time because the bladder irritation by the urine catheter so don’t mention it , that’s normal. Pain is maximum on the first 24-48 hours and will gradually subside and suitable pain killer medication will be given along with you. The packing gauze dressing and sticky plaster will be removed on the 4th or 5th day and also all the catheters then you can take a nice shower and urinate by yourself like a woman. The nurse will help you.

Day 6 ( 4th day post –op ) : Doctor will removed all the packing bandages and catheters and check the immediate result . You may leave the hospital and take a rest at the hotel you had chosen

Day 7 – 10 : should be time for rest

Day 11 : You may go out for sight seeing or shopping

Day 12 : come back to hospital or clinic to be stitches off on the labia and do the final examaination

Day 13 : Transferred to the Bangkok international airport and back home safely

Surgical procedure

Create the vaginal cavity in the space between urethra , prostate , bladder and the rectum
Bilateral orchiectomy
Degloved the penile skin out of penile shaft
Separate urethra out of penile shaft
Isolate glans penis with two dorsal nerves and vessels
Penile skin inversion for vaginal wall lining with or without scrotal skin graft
Create space and setting the position of the sensate clitoris
Urethroplasty
Labiaplasty ( major and minor)
Note : the excess erectile tissue around the urethra will be removed in order to avoid engorged during sexual arousal.

Wound packing with the gauze bandage and blood drainage and urine catheter retaining.

Possible risk and complications

1.Infection : usually only minor wound infection which is subsided by wound care and antibiotics

2.Wound disruption : may happen at the base of labias deu to high tension but will require only wound care and spontaneous healing by 1 month

3.short vagina : normally you should get the depth about 5-6 inches and must do the dilatation by yourself to keep it deeper after 6-12 months after maturation of scar occur; if dilatation is not appropriated you may get the contracted and shorten vagina.

: in case of short vagina occur second operation can be done after 6 months by sigmoid colon procedure.

Rectovaginal fistula : when there is connection between rectum and vagina ( occur < 1 %) and correction can be done.
Bleeding : this can occur with any kind of major operations but bleeding point must be precisely stop in the operating room .

Side effects

1.Unable to urinate : happen sometime after urine catheter removed due to swollen and may need for more couple of days for urine catheter retaining

2.bleeding : normal bleeding can occur at the area of gauze dressing removal but if there is true bleeding (usually at the urethral stump or other area ) .Repacking or suturing may required.

After care

Before discharged the nurse will teach you how to take care of your vagina and stitches will be removed within 7-10 days

Recovery time

You should stay in Bangkok for at least 10-14 days and take time at home about 4-6 weeks before go back to work

Hospital admissions

5 nights

Post operative care

Dilatation is the most important thing if the patient does not dilate responsibly it may cause the shorten and contracted vagina and dilatation must do in the correct direction which will be taught by us so the injury will not occur.

After each dilating section wound should be wash gently and follow by douching in the toilette ( 5-10 cc of betadine solution with 1 L of water ) ( insert the douche in full depth squeeze and hold it tight while extracting the douche )

Keep the wound dry and betadine dressing outside and apply kemicitin ointment on the external wound if there is any bleeding just press and apply pressure with a cotton for 5-15 minutes

Feminine napkins should be changed several times a day for good hygiene

After one month you should apply the Premarin cream to your vagina two times a day

Patient can be return to hormonal treatment as before surgery after 2 months and you should consult your endocrinologist to adjust the appropriated dose

Sexual reassignment surgery ( male to female) sigmoid colon/ rectosigmoid vaginoplasty

All the inclusions and criteria of approval are same as sexual reassignment ( male to female ) surgery penile skin invertion technique

But there are some extra information about what is different between penile skin inversion and sigmoid colonal flap

One stage of operation with 3 different technique

Penile skin inversion ( PSI) only for long penis ( > 6 inches)
Penile skin inversion (PSI ) with scrotal skin graft ( SSG) for medium size penis ( 2-6 inches )
Penile skin inversion (PSI) with sigmoid colon flap ( SCF ) for tiny or small penis (< 2 inches)
That means criterias of approval are

Vaginal stenosis ; shorten after SRS call secondary operation
Very short penile skin ; call primary rectosigmoid vaginoplasty
The patient is healthy and not overweight
Preparation before surgery

Need to prepared bowel cleansing for one week before by daily enema , laxative

Liquid diet 3 days before surgery

Antibiotics 48 hours before surgery

Inform us about any allergies , medical illness and conditions and all the medications you are taking ( both prescription and non-prescription)

Avoid aspirin And all the supplements and hormones , ibuprofen ( motrin , advil , etc) and vitamin E for 2 weeks at least prior to operation

Refrain from smoking 7-10 days before and after surgery

Plan to be in Bangkok at least 14 days after surgery

Have genital electrolysis completed to be clean at the base and center of scrotum

Laxative 2 pills before bed 3 days before surgery to clean your bowel

Expense

If you are HIV positive ; you are a risk to hospital personnel . For this reason you have to pay an extra 30 % of the original charge

Payment

The payment can be prepared by US dollars , Euro dollars , Japanese yen while you are here we will assist you in cashing out the money into Thai baht before surgery at the bank nearby

Airport immigration and customs

Please present the supporting documents comfirming the scheduled operation upon request.

Please do not carry any unnecessary drugs and dangerous objects in your luggage

Appointment

Consultation and operation can be arrange once you have all the required papers already

Patients are required to submit following documents before operation

Email scan , fax one piece of photo identification ( e.g. passport )
Email scan , fax of bank 10% wire transfers
Email scan , fax copy of flight reservation itenery
Original signed ( hard copy ) document of claimed diagnoses or referrals ; we will collect your hard documents during the consultation ( looking at the documents for SRS approval )
Once the applicant has been approved for sigmoid colon surgery , the patient can make the flight arrangement.

Surgery schedule details

Day1 : arrive Bangkok meet our staff and be escorted to the hospital hotel

Day 2 : meet your doctor for clinical interview and surgical consultation

: check medical documents

: doctor will prescribe antibiotics to clean the bowel for 2 days

Day 3 : continue taking liquid diet , laxative and antibiotics as prescribed

Day 4 : admitted to the hospital and you will be asked to sign the hospital consent forms

Operation time will be set up and inform to you

The nurse will do the complete enema to clean rectum

Take very nice shower

Pre-op intravenous fluid and sedation

Operation begins with general anesthesia

Day 5-7 : You still cannot have food or drink and will received intravenous fluid and antibiotics. You still urinate through the urine catheter which can irritate and make you feel like to urinate all the time but do not worry.

Day 8 : Your bandage will be removed . you will be allowed to start liquid diet progress to soft diet and discontinue intravenous fluid

: You will be discharged from the hospital after 5 day post-op

Day 9-12 : you need to stay in hotel for at least 5 days before planning to go home

Day 13 You may start the sight seeing , visit the hospital and surgeon do the stitches off from labias and do the final check.

You will received a medical certificate that authenticates the surgery

Day 14 : Transferred to the Bangkok international airport for departure

Surgical procedure

The bowel is prepared mechanically. The patient is placed in lithotomy position. The plastic surgeon and general surgeon will simultaneously operate together. The general surgeon will make a short low transverse incision on the lower abdomen as in cesarian ( abdominal delivery operation ) section. The sigmoid colon will isolated about 15-20 cm long with a vascular pedicle from the inferior mesenteric or superior hemorrhoidal system and the remaining colon will be anastomosted with continuous one layer closure. At the same time plastic surgeon start the perineal part operation as in the SRS operation after complete the vaginal cavity creation and all the external structures such as labia major and minor , clitoris and urethral opening lining then the rectosigmoid colonal part will be passed down through the lower peritoneal opening after been closing the proximal end and the anastomosis will be made with the perineal vaginal skin cuff about 1-2 inches from perineum using interrupted absorbable suture.

Results

Advantages :

• Self lubricated
• Early sexual intercourse
• Long length vaginal cavity
• Very rarely contracted or stenosis with well care

Disadvantages :

• Extra cost for the other operation
• Higher risk with the bowel operation
• Need more experienced surgeon
• Excessive discharge and can cause smelling

Duration of operation

Between 3-5 hours

Possible risks and complications

Abdominal surgical risk such as wound infection , intra abdominal complications ( infection , bleeding , peritonitis , obstruction , leakage of anastomosis ) : all of these are rarely occurred in an experienced surgeon
Perineal operation complications such as bleeding and infection
Mucous discharge can be excessive during the first 3 months then subsided and well tolerated
After care

Dilator used for 15 minutes twice daily for six months

Sexual intercourse is allowed after 3 weeks

Having to wear tampon all the time for the first three months

Vaginal douche daily

Recovery time

• You need to stay in Bangkok at least 14 days after surgery before back home
• You will required 4-6 weeks of recuperation before returning to work
• The neovagina will function after 4 weeks and sexual intercourse will be allowed after 3 weeks at least

Hospital admission

You will requested to sign in the hospital consent form and will be admitted for 4-5 nights and another 5-7 days in a hotel in Bangkok

Anesthesia

General anesthesia

Post operative care

Dilatation is the most important thing if the patient does not dilate responsibly it may cause the shorten and contracted vagina and dilatation must do in the correct direction which will be taught by us so the injury will not occur.

Dilatation can be painful for the first week but is essential for developing maximum depth and ensure functioning neovagina

After each dilating section wound should be wash gently and follow by douching in the toilette ( 5-10 cc of betadine solution with 1 L of water ) ( insert the douche in full depth squeeze and hold it tight while extracting the douche )

Keep the wound dry and betadine dressing outside and apply kemicitin ointment on the external wound if there is any bleeding just press and apply pressure with a cotton for 5-15 minutes

Feminine napkins should be changed several times a day for good hygiene