Cop+Ed+fisse 2006 Archivio Italiano di Urologia e Andrologia 2020; 92, 3186 ORIGINAL PAPER No conflict of interest declared. DOI: 10.4081/aiua.2020.3.186 Penile-scrotal flap vaginoplasty versus inverted penile skin flap expanded with spatulated urethra: A multidisciplinary single-centre analysis Giorgio Gentile 1, Ardigò Martino 2, Daniela Nadalin 3, Martina Masetti 4, Brigida Lilia Marta 5, Franco Palmisano 1, Alessandro Franceschelli 1, Patrizia Stella 3, Anna Paola Sanfelici 3, Eugenio Brunocilla 4, Fulvio Colombo 1 1 Andrology Unit, University Hospital S.Orsola-Malpighi, Bologna, Italy; 2 Institute for Integrated Health, Federal University of Mato Grosso Do Sul, Campo Grande MS, Brazil; 3 Health Centre Gender Dysphoria at Movement for Transsexual Identity – Agreement with Local Health care Unit, City of Bologna, Italy; 4 Department of Urology, University of Bologna, Bologna, Italy; 5 Department of Anthropology, Medical Anthropology Research Center, Rovira I Virgili University , Tarragona, Spain. This study is aimed to compare outcomes of penile-scrotal flap vaginoplasty to inverted penile skin flap expanded with spatulated urethra as a single- centre experience. Data regarding vaginoplasty performed between May 2003 and January 2014 were reviewed. Subjects were divided into two groups according to the surgical technique performed: per- ineal-scrotal flap vaginoplasty (Group A), and inverted penile skin flap expanded with spatulated urethra vaginoplasty (Group B). All patients underwent to psychological analysis before surgery. Functional follow-up was based on a modified validated Female Sexual Function Index. Overall, 67 patients with a mean (SD) age of 34 (±9.38) years underwent to sur- gery. 41 patients were included into the Group A and 26 into the Group B. Mean operative time among Groups A and B was 316 (±101.65) and 594 (±89.06) minutes, respectively (p<0.0001). Longer postoperative hospitalization was shown in Group B (14 days ± 4,51) than in Group A (10 days ± 2,49); (p<0.0001). Group B patients showed a higher anemization rate requiring blood transfusion (p=0.00014) as well as com- pressive neuropathy (p=0.038). In addition to this, necrosis of the skin flap was reported in 8 patients of Group B (p<0.0001). Comprehensive functional follow-up data was included; spontaneous vaginal lubrication was not reported in 82.4% of Group A vs 12.5% cases of Group B (p=0.0085). When compared to penile-scrotal flap vaginoplasty, inverted penile skin flap expanded with spatulated urethra technique shows an increased risk of complications with comparable sat- isfaction rates whereas a higher spontaneous vaginal lubrica- tion is reported. Sexological support is of utmost importance in this setting. KEY WORDS: Transgender; Penile inversion; Vaginoplasty; Techniques; Outcomes, Sexologist. Submitted 2 March 2020; Accepted 16 March 2020 Summary ture of one gender rather than other within a specific social and cultural background (2-3). The term GI disorder appeared in the DSM-IV in 1994 (4-5) and was renamed “gender dysphoria” (GD) in the 2013 DSM-V revised version (6), whereas biological sex ("feeling of being trapped in the wrong body") (7) is not per- ceived as wrong by patients but the gender assigned at birth. In the light of this, transsexualism treatment nec- essarily requires the change of the nominally assigned gender rather than sexual characters (6). Besides being of utmost importance the psychological evaluation in GD diagnosis, patient should be managed in a multidisciplinary setting taking into account hor- mone replacement therapy, psychological support and, if required, sex reassignment surgery (SRS) (8). Regarding the technical aspects of SRS, the principal sur- gical goal is the creation of aesthetically natural and func- tionally effective external female genitalia, with a suffi- ciently deep and compliant neovagina allowing normal sexual intercourse without anatomical hindrance (8). In the 1950s, pioneers of SRS used invagination of the inverted penile skin sheath to form the neovagina, in order to maintain optimal vascularization (9). Almost two decades later, Jones et al. described the prin- ciples of male-to-female (MTF) SRS using a double cuta- neous flap obtained from penile, perineal and scrotal skin for the configuration of the neovagina (10). This technique was the starting point for the develop- ment of several other procedures for MTF-SRS. Particularly, Perovic et al. proposed to use a cylinder sharped by inverted penile skin widened with spatulat- ed urethra for the neo-vaginal cavity’s lining allowing an increased vaginal sensitivity with urethral secretions- related autonomous lubrication (11-12). Since the comparison of the different techniques is still the subject of debate in relation to the different surgical outcomes particularly those related to complications and satisfaction rate, the aim to this study was to com- pare results of penile-scrotal flap vaginoplasty to invert- ed penile skin flap expanded with spatulated urethra as a single-centre experience. INTRODUCTION The concept of "gender identity" (GI) in Male-to-Female people refers to the individual's awareness of belonging to female rather than to male gender (1). In this context, Stoller postulated the existence of GI distinguishing it from the “role identity”, defined as the behavioral struc- 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 186 187Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Vaginoplasty: surgical-sexological comparison of two techniques PATIENTS AND METHODS In this retrospective cohort study we identified patients within the Department of Andrology of our Centre who underwent vaginoplasty between May 2003 and January 2014. Patients were divided into two groups according the surgical technique performed: perineal-scrotal flap vaginoplasty (Group A), and inverted penile skin flap expanded with spatulated urethra vaginoplasty (Group B). For both groups, we recorded intraoperative features including, if present, a modification of the technique pro- posed by our Center for the creation of the mons veneris and of the neoclitoris, introduced from May 2010. Before surgery, all patients underwent to psychological analysis performed by consultants working within the Transsexual Identity Movement (MIT), an Italian non-prof- it association that offers counselling assistance to trans- sexuals; this Service was created in 1994 acknowledging Emilia Romagna Government’s financial support. All patients were previously treated with estrogens and androgen antagonists and lived for at least two years in the role of a person belonging to the desired gender. Psychological aspects were recorded, such as the type of followed pathway, the observation of real-life experience, the examination of areas of the individual’s global func- tioning such as the emotional, social and working areas and her defense mechanisms. All patients underwent a detailed medical history intake, as well as a general physical and andrological examina- tion. The procedure was performed by the same experi- enced surgical team. Intraoperative and post-operative adverse events were recorded. Surgical complications were divided into three groups: intraoperative complications; short-term compli- cations, noticed during the post-operative hospital stay; and long-term complications, noticed during follow up after patient discharge. Long-term complications were further divided according their aesthetical and function- al concern. Functional follow-up based on a standard internal pro- tocol consisted of a modified validated Female Sexual Function Index (13-15), the questionnaire was adminis- tered through interviews during outpatient visits or by telephone to all the patients with at least 6 months of post-operative revaluation. This questionnaire was mod- ified according to psychoclinical/sexological indications (see also supplementary file). R software was used for statistical analysis (R: A language and environment for statistical computing; R Core Team, 2014; R Foundation for Statistical Computing, Vienna, Austria). Statistical significance for the tests was set at a < .05. Descriptive statistics and test statistics were used to com- pare the 2 groups in terms of clinical variables. One-way Kolmogorov-Smirnov statistical tests were applied to assess the normality of variables. Continuous variables were presented as mean ± standard deviation (SD) and compared using Chi squared, Fisher’s exact and Wilcoxon tests, where normality could not to be assumed. This retrospective study was conducted according to the guidelines and principles of the Declaration of Helsinki and standard ethical conduct for research involving humans; after approval of our Ethical Committee for Clinical Research, all patients signed an informed consent agreeing to supply their own anonymous data for this and future studies. Table 1. Surgical complications. Intra operative complications Group A Resolution Group B Resolution Rectum’s injuries 1 (2.4%) Simple suture 1 (3.9%) Protective stoma recanalized after two months Anemization (calo di hb > 2 g) 5 (12.2%) Transfusion 14 (53.8%) Transfusion Bulbar urethra’s injuries 2 (4.9%) Simple suture — — Short-term post operative complications Group A Resolution Group B Resolution Hyperpyrexia (T > 38°C after the 4th postoperative day) 11 (26.8%) Antibiotic therapy 13 (50%) Antibiotic therapy Anemization 12 (29.3%) Transfusion 20 (76.9%) Transfusion Compressive neuropathy 3 (7.3%) Physiotherapy 7 (26.9%) Physiotherapy Urethro-neovaginal fistula * 1 (2.4%) Urinary catheter kept for 3 weeks — — Prolonged urethral bleeding 1 (2.4%) Surgical revision — — Infection of the surgical wound associated with hyperpyrexia 3 (7.31%) 1 Antibiotic therapy and 1 surgical revision to remove necrotic material — — Clitoral ischemic necrosis — — 1 (3.9%) Loss of clitoris Necrosis of the skin flaps with dehiscence of the wound sutures — — 8 (30.8%) Courettage and sutures * Probably due to urethral necrosis. Long-term postoperative complications Group A Resolution Group B Resolution FUNCTIONAL COMPLICATIONS Stenosis of the neo- urethral meatus 5 (12.2%) Later meatoplasty 1 (3.9%) Urinary catheter placed and maintained for two weeks Neovaginal atresia (reduction in vaginal depth up to less than 5 cm) 4 (9.8%) Enteric vaginoplasty (1/4 patients) 2 (7.7%) Enteric vaginoplasty (1/2 patients) Vaginal prolapse 1 (2.4%) Colpopexy 1 (3.9%) — Recto-vaginal fistula ** — — 1 (3.9%) — ** The patient had previously undergone left hemicolectomy due to colorectal cancer followed by pelvic radiotherapy. AESTETHICAL COMPLICATIONS Group A Group B Reconfiguration of the labia majora due to asymmetries of them or to the presence of dog-ear residual. 2 (4.9%) _ Clitoroplasty for a clitoral hypertrophy 1 (2.4%) 2 (7.7%) Labia minora and/or clitoral hood’s reconfiguration 3 (7.3%) 1 (3.9%) Lower neo-vaginal commissure’s reconfiguration 3 (7.3%) 1 (3.9%) Scar tissues’ removal 2 (4.9%) _ 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 187 Archivio Italiano di Urologia e Andrologia 2020; 92, 3 G. Gentile, A. Martino, D. Nadalin, M. Masetti, B.L. Marta, F. Palmisano, A. Franceschelli, P. Stella, A.P. Sanfelici, E. Brunocilla, F. Colombo. 188 RESULTS Overall, 67 patients with a mean (SD) age of 34 (± 9.38) years underwent to surgery. According to the technique performed, 41 patients were included into the Group A and 26 into the Group B. Our modified technique was applied to 26 subjects of Group A whereas was per- formed in all patients of Group B. Mean (SD) operative time among Groups A and B was 316 (± 101.65) and 594 (± 89.06) minutes, respectively; this result was statistically significant (p < 0.0001). Similarly, postoperative hospitalization revealed longer in Group B (14 days ± 4.51) than in Group A (10 days ± 2.49); (p < 0.0001). Surgical complications are report- ed in Table 1; Group B patients showed a higher blood transfusion rate (p = 0.00014) as well as compressive neuropathy (p = 0.038). In addition to this, necrosis of the skin flap was reported in 8 patients of Group B (p < 0.0001). Functional questionnaire was administered in 19 sub- jects in Group A (46.3%) and 17 patients in Group B (65.4%); 46.3% of the whole cohort resulted unreach- able or refused the questionnaire administration. In terms of sexual orientation, 18 patients of Group A (94.7%) declared to be mainly attracted to men and 1 (5.3%) has defined herself as bisexual, while 14 (82.3%) cases of Group B were mainly attracted to men, 1 was mainly attracted to women (5.9%) and 2 were bisexual (11.8%). All patients with a stable partner, 12 (68.4%) in Group A and 4 (23.5%) in Group B, resulted to be attracted to men, and all their partners resulted to be attracted to women. Among Group A subjects with a stable relation- ship, 6 (46.1%) reported to have sex once or twice a month, 6 (46.1%) several times a week and 1 patient (7,8%) daily. Regarding Group B patients, 1 (25%) reported to have sexual intercourses once or twice per month while 3 hav- ing sex (75%) several times per week. Additionally, 61.5% of Group A (8) declared to be satisfied with their couple sexuality, 4 (30.8%) revealed moderately satisfied whilst 1 case (7.7%) demonstrated very dissatisfied with her couple sexuality. Among Group B, 1 patient (25%) declared to be very sat- isfied while 75% of cases (3) reported to be moderately satisfied with couple's sex life. In terms of emotional complicity with the partner during sexual intercourse, 10 patients of group A (76.9%) declared to be very satisfied and 3 patients (23.1%) showed themselves moderately satisfied, while all 4 cases in Group B declared to be very satisfied about the couple emotional complicity. Functional questionnaire results concerning autoero- tism, sexual intercourses and sex arousal are reported in Table 2. When asked how often they managed to have a spontaneous vaginal lubrication during sexual activity, 82.4% of Group A answered to be never or almost never able to lubricate; significantly higher than 2 (12.5%) cases of Group B (p = 0.0085). In addition to this, 62.5% of Group B patients claimed to be able to lubricate always or most of the time. Summarizing the overall sexual satisfaction in Group A and B, patients defined as very satisfied in 10 and 11 (52.6% vs. 64.7%; p > 0.05) cases. Moreover 6 (31.6%) patients of Group A declared to be moderately satisfied while 1 (5.3%) was really dissatisfied, whereas in Group B 3 (17.6%) patients were neither satisfied nor dissatis- Group A (n,%) Group B (n,%) How often do you masturbate? Never 12 (63.1) 5 (29.4) Less than once a month 1 (5.3) 2 (11.8) One or two times a month 2 (10.5) 4 (23.5) Several times a week 3 (15.8) 6 (35.3) Daily 1 (5.3) - How often do you have sexual intercourses? Never 3 (15.8) 2 (11.8) Less than once a month - 2 (11.8) One or two times a month 8 (42.1) 4 (23.5) Several times a week 7 (36.8) 9 (52.9) Daily 1 (5.3) - Over the last 4 weeks how often have you felt sexual desire or sexual interest? Always or almost always 2 (10.5) 3 (17.6) Often 3 (15.8) 7 (41.2) Sometimes 10 (52.6) 7 (41.2) Never or almost ever 4 (21.1) - Over the past 4 weeks, how would you rate your level of sexual desire or interest? Very high 5 (26.3) 4 (23.5) High 5 (26.3) 4 (23.5) Moderate 5 (26.3) 9 (53) Low 1 (5.3) - Very low or none at all - - Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse? No sexual activity 2 (10.5) 5 (29.4) Almost always or always 8 (47.1) 8 (66.7) Most times (more than half the time) 5 (29.4) 3 (25) Sometimes (about half the time) 3 (17.6) 1 (8.3) A few times (less than half the time) - - Almost never or never 1 (5.9) - How often did you reach orgasm through masturbation? I don’t masturbate 5 (26.3) 3 (17.6) Almost always or always 5 (26.3) 10 (71.4) Most times (more than half the time) 1 (7.1) 1 (7.1) Sometimes (about half the time) 3 (21.4) - A few times (less than half the time) 1 (7.1) - Almost never or never 4 (28.6) 3 (21.5) How often did you reach orgasm through sexual intercourses? I don’t have sexual intercourses 1 (5.3) 1 (5.9) Almost always or always - Most times (more than half the time) 7 (38.9) 7 (43.8) Sometimes (about half the time) 2 (11.1) 4 (25) A few times (less than half the time) 5 (28.7) 2 (12.5) Almost never or never 4 (22.2) 3 (18.8) Did you notice a change in the orgasmic feeling between before and after surgery? Yes 13 (81.3) 13 (92.9) No 3 (18.8) 1 (7.1) I haven’t had orgasm yet 3 (15.8) 3 (17.6) Over the past 4 weeks, how satisfied were you with your ability to reach orgasm during sexual activity or intercourse? No sexual activity 2 (10.5) 1 (5.9) Very satisfied 10 (58.8) 12 (75) Moderately satisfied 5 (29.4) 1 (6.3) Moderately dissatisfied 1 (5.9) 1 (6.3) Very dissatisfied 1 (5.9) 2 (12.5) Table 2. Functional questionnaire investigating desire and sexual interest, frequency of sexual intercourses and masturbation, sex arousal. 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 188 189Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Vaginoplasty: surgical-sexological comparison of two techniques fied and 2 (11.8%) declared to be moderately satisfied. Other post-operative problems revealed through ques- tionnaire are reported in Figure 1. DISCUSSION Vaginoplasty is often the final stage in the gender-con- firming process for transgender women. Being gender affirmation surgery paramount in the treatment of gen- der dysphoria, vaginoplasty offers the opportunity for removal of masculine-appearing genitalia and replace- ment with a gender-congruent appearance (16). The aim of our study was to compare two different tech- niques, from a surgical and functional point of view, in a cohort of transgender patients who underwent vagino- plasty, in the real-life setting. We found significant differ- ences in terms of short-term adverse events with good aesthetic and functional results. In decades of experience at our Center, an original technical modification which involves the preservation of tunica albuginea below the neurovascular bundle was introduced in 2007, allowing a faster and safer clitoroplasty and providing a more nat- ural aspect of mons veneris; this modification was adopt- ed by Jones and subsequently by Perovic (17). Outcomes of penile inversion vaginoplasty are generally in the form of large case series from high volume institutions. Buncamper et. Al reported a retrospective series of 475 patients who underwent penile inversion vaginoplasty, of whom 85% required additional full-thickness skin grafts (18). The most frequently observed intraoperative compli- cation was rectal injury (n = 11-2.3%) whereas short-term postoperative bleeding that required transfusion and/or reoperation was shown in 6.7% of the cohort. Among other vaginoplasty techniques, Salgado et al. reported a small case series of transwomen who underwent primary sigmoid vaginoplasty (19); among 12 patients, 2 major complications were reported (1 deep venous thrombosis, 1 suspected pulmonary embolism). From an aesthetical and functional point of view, it is important to emphasize that imperfections are extremely subjective: women with minor imperfections may suffer from issues in their sexual life to the point of requiring further surgery, whereas other patients with serious blemishes decide not to undergo re-intervention. Clitoral dimensions are inevitably related to original gland size, since the necessity of saving the marginal portion of the gland for vascularization and innervation of the neo-cli- toris (20-21). Moreover, depending on the surgical technique, the mor- phology of the lower commis- sure varies: Jones technique results in a u-shaped commis- sure while the Perovic strategy results in a v-shaped commis- sure, which has a more natural aspect and can allow hinder penetration (8). In our experi- ence, more patients within group A than group B were subjected to surgical reconfiguration of the lower com- missure (7% Group A - 3% Group B): this may be dependent to an interindividual variability. Concerning the sexual functionality and sensitivity eval- uation, a different time lapse between two Groups should be taken into account. In fact, follow-up of the patients of Group A is longer than that of Group B, whereas the type B procedure has been performed in our Center only since 2010. This may significantly influence the quality of sexual life reported by patients: in fact, the capability of re-balancing personal sexuality on a differ- ent reproductive system and of reaching orgasm fre- quently requires a long period (22). An important element which emerged from the ques- tionnaire relates to the high ability to reach an autonomous vaginal lubrication after appropriate sexual stimulation in the patients of group B, due to the mucous secretions of the urethral flap that forms the neovaginal roof, confirming the data in Literature (11-12). Stable partner was reported more commonly in Group A, this can be due to a longer follow-up, as well as by a quicker post-surgery recovery; in addition to this, the emerging trend in Group B concerning low sexual satis- faction may be related to the more challenging surgery and therefore to a longer process of integration of body parts with the symbolic expectations (23). The widely shared results within two cohorts about the high emotional complicity of the couples during inter- course are likely motivated by issues due to stigma and prejudice as experienced by transsexual couples that, once overcome, tend to favor emotional sharing and lead to an increase of intimacy (24). Concerning the sexual desire levels, higher scores reported in the patient of Group B may be hypothetically due to their more con- sistent effort in post-surgery recovery phase and their interest into the expression of a sexual activity. Neovaginal moisture is perceived by these patients as crucial, because it allows to be closer to a standard ideal of femininity, as it matches the symbolic component of Figure 1. Supplementary data about post-operative problems. 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 189 Archivio Italiano di Urologia e Andrologia 2020; 92, 3 G. Gentile, A. Martino, D. Nadalin, M. Masetti, B.L. Marta, F. Palmisano, A. Franceschelli, P. Stella, A.P. Sanfelici, E. Brunocilla, F. Colombo. 190 representation with anatomical reality also in its func- tioning (25). Independently of the well-known benefits of SRS on the patients general and sexual life-related quality of life, as well as on cosmesis and sexual func- tioning (26, 31), it is reasonable to offer sexologic con- sultation in order to favor the integration of physical and anatomical parts and to sustain and encourage the sub- ject undergoing surgery to achieve a satisfying sexuality. Several limitations to this study should be acknowledged, of which the single Institution design is probably the most evident. Another limitation of the present study lies in the fact that the two different types of intervention were per- formed by two different surgeons, and this may affect the data collected. On the other hand, this aspect is a good representation of a real-life situation in contrast to single surgeon series. In this context, regardless of the surgeon who performed surgery, it is important to consider that the longer duration of the surgical intervention, the longer post-surgery hospitalization and the higher rate of anemia and hyperpyrexia in the case of group B patients may be related to the greater technical complexity of this proce- dure, and to the fact that more vascularized tissues – such as the urethra – are handled. Moreover, the questionnaire used is not standardized; nevertheless, its essential pur- pose is to answer a purely surgical and clinical interest rather than to report objective measures of sexual satisfac- tion. In the light of this, there are more variables involved in sexual satisfaction compared to the biological subset, which is essentially linked to the type of surgery and its clinical consequences. Therefore, the impact of body transformation on sexuality should be evaluated by qualitative methods, rather than quantitative, involving couples and not only individuals since that may interfere with subjective evaluation of sur- gery outcomes. Lastly, it should be noted that this analysis focuses on an outdated case series; this is due to the fact that after 2014 the State funds destined for this setting were suspended; in this sense, we hope that this analysis will be a signal for the restoration of this public activity answering to a real need in the transgender community of our region. CONCLUSIONS When compared to penile-scrotal flap vaginoplasty, inverted penile skin flap expanded with spatulated ure- thra technique shows an increased risk of complications with a higher spontaneous vaginal lubrication and com- parable satisfaction rates. REFERENCES 1. Stoller RJ. Sex and gender. Vol.2: The transsexual experiment. London: Hogarth Press, 1975. 2. Stoller RJ. Presentations of gender. New Haven: Yale University Press, 1985. 3. Stoller RJ. The gender disorders. In: Rosen I, ed. Sexual devia- tions. Third Edition. Oxford: Oxford University Press, 1997. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: APA, 1965. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text revision (DSM-IV- TR). Washington, 2000. 6. American Psychiatric Association, Diagnostic and statistical man- ual of mental disorders (5th ed.) Arlington, 2013 VA: American Psychiatric Publishing. 7. Prosser J. Second skins: The body narratives of transsexuality. New York: Columbia University Press, 1998. 8. Belgrano E, Fabbris B, Trombetta C. Il Transessualismo, Iden - tificazione di un Percorso Diagnostico e Terapeutico. Milano: ed. Kurtis 1999; 9-125. 9. Goddard JC, Vickery RM, Terry TR. Development of feminizing genitoplasty for gender dysphoria. J Sex Med. 2007; 4:981-9. 10. Jones HWJ, Schirmer HKA, Hoopes JE. A sex convention opera- tion for males with transsexualism. Am J Obstet Gynecol. 1968; 100:101-9. 11. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethra flap. BJU International. 2000; 86:843-850. 12. Perovic SV, Djinovic R. Genitoplasty in male-to-female trans- sexuals. Curr Opin Urol. 2009; 19:571-576. 13. Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000; 26:191-208. 14. Stephenson KR, Toorabally N, Lyons L, M Meston C. Further validation of the female sexual function index: specificity and asso- ciations with clinical interview data. J Sex Marital Ther. 2016; 42:448-61. 15. Roisin Worsley, Robin J. Bell, Pragya Gartoulla, and Susan R. Davis, Prevalence and predictors of low sexual desire, sexually relat- ed personal distress, and hypoactive sexual desire dysfunction in a community-based sample of midlife Women J Sex Med. 2017; 14:675-686. 16. Pariser JJ, Kim N. Transgender vaginoplasty: techniques and outcomes. Transl Androl Urol. 2019; 8:241-247. 17. Soli M, Brunocilla E. Male to female gender reassignment: Modified Surgical Technique for creating the clitoris and Mons Veneris. J Sex Med. 2008; 5:210-216. 18. Buncamper ME, van der Sluis WB, van der Pas RSD, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg. 2016; 138:999-1007. 19. Salgado CJ, Nugent A, Kuhn J, et al. Primary sigmoid vagino- plasty in transwomen: technique and outcomes. Biomed Res Int. 2018; 2018:4907208. 20. Giraldo F, Esteva I, Bergero T, et al. Corona glans clitoroplasty and urethropreputial vestibuloplasty in male-to-female transsexu- als: the vulval aesthetic refinement by the Andalusia Gender Team. Plast Reconstr Surg. 2004; 114:1543-50. 21. Cocci A, Rosi F, Frediani D, et al. Male-to-Female (MtoF) gen- der affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty). Arch Ital Urol Androl. 2019; 91:119-124. 22. Bockting WO, Miner M, Robinson BE, et al. Transgender Identity Survey. 2005 Minneapolis, MN: University of Minnesota, Program in Human Sexuality. 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 190 191Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Vaginoplasty: surgical-sexological comparison of two techniques 23. Feldman J, Safer J. Hormone therapy in adults: Suggested revi- sions to the sixth version of the standards of care. International Journal of Transgenderism. 2009; 11:146-182. 24. Van Trotsenburg MAA. Gynecological aspects of transgender healthcare. International Journal of Transgenderism. 2009; 11:238- 246. 25. Ruppin U, Pfäfflin F. Long-term follow-up of adults with gender identity disorder. Arch Sex Behav. 2015; 44:1321-1329. 26. De Cuypere G, T’Sjoen G, Beerten R, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005; 34:679-690. 27. Gijs L, Brewaeys A. Surgical treatment of gender dysphoria in adults and adolescents: recent developments, effectiveness, and chal- lenges. Annual review of sex research. 2007; 18:178-184. 28. Klein C, Gorzalka B. Sexual functioning in Transsexuals follow- ing hormone therapy and genital surgery: a review. J Sex Med. 2009; 6:2922-2939. 29. Marecek J, Crawford M, Popp D. On the construction of gender, sex, and sexualities. The psychology of gender. 2004; 2:192-216. 30. Bevan TE. The Psychobiology of Transsexualism and Transgenderism: A new view based on scientific evidence. Santa Barbara, CA: Praeger, 2015, p. 257 pp, ISBN-13: 978-1440831263. 31. Epstein S. A queer encounter: Sociology and the study of sexual- ity. Sociological Theory. 1994; 12:188-202. Correspondence Giorgio Gentile, MD Franco Palmisano, MD (Corresponding Author) franco.palmisano@hotmail.it Fulvio Colombo, MD Alessandro Franceschelli, MD Andrology Unit, University Hospital S.Orsola-Malpighi, via Pelagio Palagi 9, 40138 Bologna (Italy) Ardigò Martino, MD Institute for Integrated Health, Federal University of Mato Grosso Do Sul, Campo Grande MS (Brazil) Daniela Nadalin, MD Patrizia Stella, MD Anna Paola Sanfelici, MD Health Centre Gender Dysphoria at Movement for Transsexual Identity Agreement with Local Health care Unit, City of Bologna (Italy) Martina Masetti, MD Eugenio Brunocilla, MD Department of Urology, University of Bologna, Bologna (Italy) Brigida Lilia Marta, MD Department of Anthropology, Medical Anthropology Research Center, Rovira I Virgili University, Tarragona, (Spain) 06Gentile-Palmisano_Stesura Seveso 24/09/20 14:18 Pagina 191