Cop+Ed+fisse 2006 Archivio Italiano di Urologia e Andrologia 2022; 94, 1118 LETTER TO EDITOR No conflict of interest declared. INTRODUCTION In recent years, the surgical techniques for sex reassignment surgery in male-to-female (MtoF) transsexualism have been standardized and improved with better functional and aesthetic results, therefore increasing patients’ satisfaction. Feminizing genital reconstruction is a complex surgical procedure that can be performed by using several skills such as penile skin inversion, penoscrotal flap, enterovaginoplasty. This challenging surgery is done by specific steps that could be related to other procedures in uro-andrological field, especially for benign conditions. In this context, MtoF reassign- ment surgery could represent a complete training model for future urologists. Here, we aim to describe all surgical steps of feminizing genital reconstruction as a core urological surgical training for young urologists. MTOF REASSIGNMENT SURGERY From November 2016 to December 2019, all resident doctors in urology training were involved in MtoF reassignment surgery. The basic steps of the feminizing genital reconstruction for gender dysphoria were described as follow: 1. Orchiectomy After anesthesia is induced, the patient is placed in the lithotomic position. An inverted U-shaped incision on the poste- rior surface of the scrotum is performed, the incision is extended through subcutaneous tissue so that the urethral cor- pus spongiosum and corpora cavernosa are bilaterally exposed (Figure 1). Subsequently, bilateral orchiectomy is per- formed by dissecting and suturing both spermatic cords at the level of external inguinal rings (Figure 2). Once this is done, the proximal end of these structures will retract into the inguinal canal, in order to close bilaterally external inguinal ring to avoid future weakness that can lead to inguinal hernia (1). 2. Penile degloving A circumferential subcoronal incision is made, allowing outwards folding of the penile skin downward to the base in order to expose the corpora. The penile skin is transected from the corpus spongiosum and the corpora cavernosa. A cylindri- cal penile skin flap is created and dissected from the albuginea, being careful to preserve the vitality of the skin, this flap will provide the anterior wall of the neovagina (Figure 3). 3. Penectomy The corpus spongiosum is isolated starting from the crura up to the penile glans. Through a bilateral incision of the Buck’s fascia, a plane is created between the tunica albuginea and the dorsal neurovascular bundle, whose connection to the glans is meticulously preserved. The glans is detached from the corpora cavernosa without danger and neurovascular bundle isolation is held in a retrograde fashion (Figure 4). The corpora are then excised as proximally as possible (1). 4. Creation of a prostatorectal space Fibers of bulbocavernosus muscles are divaricated on the midline and the bulbar urethra is completely freed. The central tendon of the perineum is incised, and an accurate, blunt dissection is performed in order to create a wide space between Core urological surgical training: The pivotal role of feminizing genital reconstruction for gender dysphoria Gianmartin Cito 1*, Elena Rovero 1*, Francesco Sessa 1, Simone Sforza 1, Girolamo Morelli 2, Arturo Lo Giudice 3, Lorenzo Masieri 1, Andrea Minervini 1, Riccardo Bartoletti 2, Giorgio Ivan Russo 3, Andrea Cocci 1 1 Department of Urology, Careggi Hospital, University of Florence, Florence, Italy; 2 Department of Urology, Cisanello Hospital, University of Pisa, Pisa, Italy; 3 Department of Urology, University of Catania, Catania, Italy. * These authors contributed equally to the work. KEY WORDS: Sex reassignment; Male to female; Surgery; Urology; Gender. Submitted 25 November 2021; Accepted 3 December 2021 DOI: 10.4081/aiua.2022.1.118 119Archivio Italiano di Urologia e Andrologia 2022; 94, 1 Sex reassignment training surgical model the rectum and the prostate, where the neovagina will be placed. The Denonvillier’s fascia is identified, and the blunt dissection con- tinues through this avascular plane, transecting the medial fibers of the elevator ani muscles (Figure 5). The penile-scrotal cylinder of skin is placed into the neo-cavity, forming the neovagina and sutured to the Denonvillier’s fascia (1). 5. Creation of the neourethra After the bulb of penis is completely excised, the distal urethra is reduced at the pubic symphysis and passed through a second inci- sion, more ventrally, so as to obtain a Y-shaped. The distal part of the urethral stump is spatulated and the urethro-cutaneous anas- tomosis is performed, with the apex fixed to the anterior portion of pubis. This becomes the reference point for positioning the neo- clitoris, which will be framed by urethral mucosa. The urethral bulb is carefully removed in order to avoid its bulging during sex- ual arousal and dyspareunia (Figure 6). The creation of the ure- thra-clitoris complex gives to the neoclitoris a mucosal environ- ment providing adequate lubrication; furthermore, the two layers suture permits a reciprocal vascular support, useful in case of ure- thral or clitoral ischemia (2). MAIN FINDINGS We analyzed how the learning curve of MtoF reassignment surgery could influence the skills of the same resident in practicing simpler andrological procedures as lead surgeon, assisted by his tutor. After performing 10 feminizing genital reconstructions as assistant surgeon, the resident performed 64 andrological procedures as lead surgeon, at the end of his training period with the tutor in the operating room (Table 1). No postoperative complications occurred. Operating times, as well as hospitalization times were comparable to those performed by the tutor. After the first 10 procedures, the mean operating time decreased of 20 minutes (SD ± 5; p < 0.05) and the mean blood loss decreased of 80 ml (SD ± 15; p < 0.05). The perineal approach using the inverted U-shaped incision on the posterior surface of the scrotum, the dissection and suture of sper- matic cords at the external inguinal rings and the bilateral orchiec- tomy helped the learning curve of the resident for the radical orchiectomy to treat testicular torsion (n = 5). Likewise, it helped to practice bilateral orchiopexy for testicular retraction (n = 10), that is generally performed with vertical perineal incision or homo- lateral transversal incision; by the way it was possible to facilitate to learn the inguinal approach, the exteriorization and asportation of the spermatic cord and testicle, that must be preferred in case of testicular cancer. The acquired expertise in gonadic surgery helped also to learn the procedure of hydrocelectomy in case of tense and large hydrocele (n = 5). Once a scrotal median incision is performed, the fluid is aspirated, the testicle exposed, and the sac everted to avoid a recurrence. The process of penile degloving in MtoF reassignment surgery facilitated the performance for the treatment of congenital or acquired penile curvature (Nesbit’s corporoplasty, n = 2). In this Table 1. Andrological procedures performed by resident, as lead surgeon, at the end of his training period with the tutor in the operating room. Figure 1. Inverted U-shape incision on the posterior aspect of the scrotum, centrally prolonged on the penis. Figure 2. Isolation of the testis and spermatic cord, before the ligature at the external inguinal ring. Figure 3. Penile degloving. Figure 4. Asportation of corpora cavernosa after isolation of neurovascular bundle. Figure 5. Creation of a prostatorectal space or neovaginal cavity, we can appreciate the prostate with Denonvillier’s fascia. Figure 6. Conservation of bulbar urethra and reduction urethral bulb. Procedure Total Circumcision 25 Orchiopexy 10 Varicocelectomy 10 Radical orchifunicolectomy 5 Hydrocelectomy 5 Corporoplasty 2 Penile prosthesis implantation 3 Meatoplasty 2 Radical or partial penectomy 2 Archivio Italiano di Urologia e Andrologia 2022; 94, 1 G. Cito, E. Rovero, F. Sessa, S. Sforza, G. Morelli, A. Lo Giudice, L. Masieri, A. Minervini, R. Bartoletti, G.I. Russo, A. Cocci 120 case, the best approach for penile skin degloving is a circumcisional incision 0,5-1 cm below the coronal sulcus deep- ened until the whitish Buck’s fascia, continued by blunt and sharp dissection (3). Circumcision and dissection with Dartos fascia preservation, to obtain a complete penile degloving, is normally per- formed during feminizing genital reconstruction for gender dysphoria. This training simplifies the learning ability of other surgical steps such as circumcision (n = 25), in case of severe phimosis or the preservation of the dorsal neurovas- cular bundle, required during corporoplasty. Moreover, the penoscrotal approach is widely used to implant penile prosthesis for the treatment of erectile dysfunction (n = 3) (4). The feminizing genital reconstruction helped also to get skills concerning functional anatomy of the penis, that allowed the resident to practice in radical penectomy for penile cancer (n = 2) (5). The preparation of the urethral stump before the urethrocutaneous anastomosis for the creation of the neourethra in fem- inizing genital reconstruction was useful to learn procedures of meatoplasty, performed in case of urethral strictures (n = 2) (6). Lastly, sex reassignment surgery requires expertise of the inguinal canal anatomy, that is conductive in varicocele treatment (n = 10). The inguinal approach involves a 3-5 cm incision over the inguinal canal, the opening of the external oblique aponeurosis and the delivery of the spermatic cord. All internal spermatic veins are identified and dissected under microscopy and then ligated with sutures or surgical clips. The vas deferens, vasal vessels, testicular artery and as many lymphatic channels as possible are preserved. In conclusion, assisting to complex andrological procedures, as MtoF reassignment surgery, seems to have a positive influence in facilitating the learning curve of other simpler procedures in young urologists. Thus, the challenging steps of feminizing genital reconstruction could be a core urological training in performing surgery for andrology conditions. REFERENCES 1. Mirone V, Imbimbo C, Verze P, Arcaniolo D. Transgender rencostructive surgery. In: Austoni E (ed). Atlas of reconstructive penile surgery. 1st edn. (Pacini Editore Medicina, 2010) pp.419-432. 2. Trombetta C, Liguori G, Bertolotto M (eds). Management of Gender Dysphoria: A Multidisciplinary Approach. (Springer, Milan, Heidelberg, New York, Dordrecht London, 2015). 3. Fabiani A, Fioretti F, Pavia MP, et al. Buccal mucosa graft in surgical management of Peyronie's disease: Ultrasound features and clinical out- comes. Arch Ital Urol Androl. 2021;93:107-110. 4. Bayrak O, Erturhan S, Seckiner I, et al. Comparison of the patient's satisfaction underwent penile prosthesis; Malleable versus Ambicor: Single center experience. Arch Ital Urol Androl. 2020; 92:25-29. 5. Moulavasilis N, Yiannopoulou K, Frangoulis M, et al. A surgical approach to squamous cell carcinoma of penis that also resolved the psycho- logical dysfunction of the patient. Arch Ital Urol Androl. 2020; 92:58-60. 6. Gentile G, Martino A, Nadalin D, et al. Penile-scrotal flap vaginoplasty versus inverted penile skin flap expanded with spatulated urethra: A multidisciplinary single-centre analysis. Arch Ital Urol Androl. 2020; 92:186-191. Correspondence Gianmartin Cito, MD gianmartin.cito@gmail.com Elena Rovero, MD elena.rovero@stud.unifi.it Francesco Sessa, MD francesco_sessa@hotmail.it Simone Sforza, MD simone.sforza1988@gmail.com Lorenzo Masieri, MD lorenzo.masieri@meyer.it Andrea Minervini, MD andreamine@libero.it Andrea Cocci, MD, PhD (Corresponding Author) cocci.andrea@gmail.com Department of Urology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134, Florence (Italy) Girolamo Morelli, MD girolamomorelli@gmail.com Riccardo Bartoletti, MD riccardo.bartoletti@hotmail.com Department of Urology, Cisanello Hospital, University of Pisa, Via Piero Trivella, 56124, Pisa (Italy) Arturo Lo Giudice, MD arturologiudice@gmail.com Giorgio Ivan Russo, MD giorgioivan1987@gmail.com Department of Urology, University of Catania, Via Plebiscito, 628, 95124, Catania (Italy)