Читать книгу Handbook of Clinical Gender Medicine - Группа авторов - Страница 81

Results of masculinization surgery are evaluated according to the cosmetic aspects of the reconstructed GT, and its function, in terms of both transurethral urinary flow and sexual performance. It therefore requires a very long follow-up, through childhood, puberty, and adulthood. It is actually very difficult to get an objective idea of the results of the surgery because patients’ views often differ from surgeons’ views. Urine flow studies are unreliable because the material used for replacing the deficient urethra is different from normal urethral walls and because patients who received urethral surgery, especially children, commonly have dys-synergic micturition for a long time postoperatively. The capacity of children to tolerate dysuria is remarkable, and it is enhanced by the fear of having to undergo another surgical operation. Absence of a urinary tract infection and complete bladder emptying, checked by ultrasound scans, with no deterioration of the whole urinary tract, are probably the most reassuring criteria to assess the outcome of these reconstructions. The reported results on sexual life after early surgery are scarce and subjective. Questions remain about the sensitivity of the glans after hypospadias or clitoral surgery [7]. The number of operations certainly affects the patient’s confidence to enter adult sexual life. Ejaculatory anomalies are variable between 6 and 37% of operated individuals. There is no convincing data on impaired fertility.

Virilization of the female genitalia may vary widely in severity. Simple clitoromegaly or very distal entrance of the vagina into the urogenital sinus may require no treatment. Issues of an appearance of gender typicality have been debated for parent and patient concerns, with the risk for genital sensory function weighed against cosmesis. Timing, staging, and separating clitoroplasty and vaginoplasty (allowing patient input and decreasing unwanted surgery and revisions) continue to be at issue. In more virilized forms (as the vagina enters the urogenital sinus more proximally and nearer the bladder neck), typical intercourse may be impossible. Reconstructive surgery may be necessary to establish sexual capability. Feminizing genitoplasty may require multiple revision surgeries; 50-79% of patients require a second procedure. Third and fourth procedures are not uncommon for adequate vaginal construction which allows intercourse. As the procedure is not assuredly successful, only 77% of those who had this surgery ultimately have an adequate vaginal introitus on long-term follow-up. Scarring at the introitus or of the entire vaginal segment has been a problem. This complication is most prevalent when local skin flaps and squamous epithelial grafts are used to create portions of the vagina and in some cases the entire vagina (neovagina) [5, 6].