DNVB dissection from the underlying tunica albuginea is performed starting from the sides of the urethra bilaterally
The glans penis is entirely dissected from the corpora cavernosa of the penis maintaining continuity with the DNVB
184.108.40.206 Urethral Dissection and Spatulation of the Urethral Plate with Removal of the Bulbs
The urethra is carefully dissected from the corpora cavernosa within Buck’s fascia and shortened approximately 7 cm distally from the bulbous urethra. It is then spatulated ventrally all down to the bulb where the neourethral meatus will be formed (Fig. 14.3a, b). The spongiosal tissue of the bulbous urethra is carefully removed, in order to prevent bulking sensation during sexual arousal and consequently difficult and painful penetration . For this step the utilisation of Ligasure or a similar surgical instrument is a good solution since profuse bleeding can be difficult to control. The urethral plate is further incised dorsally on the distal end following the median line to form a forking (Fig. 14.4a, b). It is very important to avoid damage of the urethral circulation which runs laterally on both sides of the urethral plate.
(a, b) The urethra is shortened approximately 7 cm distally from the bulbous urethral and it is spatulated ventrally
(a, b) The urethral plate is incised dorsally on the distal end following the median line to form a forking
220.127.116.11 Urethral Neomeatus Construction and Neourethroclitoral Complex with Neoclitoral Hood Assembly
The neoclitoris is unified with the urethral plate at the level of the bifurcation, between both urethral flaps. The neoclitoris is joined with urethral flaps in two layers: spongiosum tissue of the urethral flap is sutured with the spongiosal tissue of the neoclitoris and the urethral mucosa is sutured with the neoclitoris epithelium (Fig. 14.5a, b). Urethral flaps are fixed around the neoclitoris (Fig. 14.6a, b). At this point the newly created neourethroclitoris complex is transposed ventrally through the incision in the penile skin flap, which runs above it. The urethral plate with the urethra-clitoris complex is joined and sutured to the surrounding penile skin flap.
(a, b) The neoclitoris is unified with the urethral plate at the level of the bifurcation and sutured in two layers
(a, b) Urethral flaps are fixed around the neoclitoris
14.2.2 Neoclitoroplasty with the Preservation of the Tunica Albuginea: “Bologna Technique”
Here, the two longitudinal incisions are made directly onto the tunica albuginea, without the need of isolation of the DNVB. The albuginea is incised longitudinally parallel to the urethra, care being taken to reduce the width of its terminal by 2 cm. By this way, a strip of albuginea is prepared, running from the glans to the common portion of the corpora cavernosa, carrying the neurovascular bundle on it (Fig. 14.7). This surgical step is completed by the resection of the residual cavernous tissue from the ventral aspect of the albugineal strip.
Neoclitoroplasty with the preservation of the tunica albuginea; a strip of albuginea carrying the neurovascular bundle is prepared
The neurovascular bundle and the underlying albuginea is bended on itself and fixed in the suprapubic area in order to create the mons veneris. According to the technique proposed by Perovic, the neoclitoris is configured/built maintaining the inner foreskin (mucosal) attached to the glans . The urethra is divided 4–5 cm proximally from the meatus and the glans is opened ventrally. Glans reduction is done medially, leaving its sides intact, in order to preserve the vascular support of both the neoclitoris and the foreskin that will become the neolabia minora.
The neoclitoris and its preputial hood are then positioned and fixed in a proper distance from the new urethral meatus. The remaining subglandular urethral part is used for the creation of the epithelial lining between the neoclitoris and the urethral meatus (Fig. 14.2).
14.3 Postoperative Care
In the immediate postoperative period, intensive monitoring of the neourethroclitoris complex is of essential importance. In the absence of major bleeding, the dressing is removed and changed 48 h after surgery. After that the neourethra and neoclitoris area should be adequately medicated at least once a day to maintain adequate hygiene and avoid infections. It is recommended to use antiseptic dressing. The application of antibiotic ointments is not indicated routinely. Prompt discovery of necrotic or infected areas should be followed by surgical therapy with debridement and dressing.
The catheter should be frequently mobilised to avoid formation of decubitus ulcer on the neomeatus and neoclitoris. It should be left in place until the wound edges looked properly closed in order to avoid contact with urine that slows the healing process. Usually the catheter is left in place approximately until the 5th postoperative day.
Some patients may experience pain due to hypersensitivity of the neoclitoris. In that case, lidocaine ointments can be useful.
A psychosexological support is essential since the first postoperative day to start learning about new anatomy, function and appearance of the genitalia. In the past a group of patients have been evaluated by means of preoperative and postoperative biothesiometry .
Complications can be divided into intraoperative (lesion of the neuromuscular bundle, lesion of the urethra, haemorrhage), early postoperative (partial or total neoclitoris, urethral plate and skin flap necrosis) and late postoperative (urethral stenosis, neoclitoral atrophy, hyposensitivity or insensitivity).
14.4.1 Intraoperative Complications
Neoclitoris ischaemia is possible but avoidable with meticulous technique of dissection and in selected cases with partial microsurgical dissection of the DNVB. When ischaemia occurs, it is usually recognised early intraoperatively. A clitoris that becomes pale during the isolation of the neurovascular bundle or during the fixation means that probably there is an ischaemia. The most common sites of neurovascular bundle injuries are the site of insertion into the glans, the origin at the level of ligamentum suspensorium and between the crura of the corpora cavernosa. It is extremely important to maintain as much as possible the blood supply of the urethra while making the dissection between the urethra, bladder and rectum and also during the detachment of corpora cavernosa. At the same time, an accurate haemostasis of the potential sources of significant bleeding is mandatory. The surgeon may decide to put a soft drainage if considered necessary.