Gender Reassignment Surgery Questions Answered
The questions on this page were answered by the late Professor Sava Perovic MD and/or by Dr Rados Djinovic, Chairman of the Sava Perovic Foundation.
In March 2015 in Madrid at the 30th annual meeting of the 43-year-old European Association of Urology (EAU), the largest urology meeting in the world, the more than 12000 participants from 117 countries elected Dr Djinovic Chairman of EAU’s Genitourinary Reconstructive Surgeons Section (ESGURS).
EAU is the leading authority on urological practice, research and education in Europe and represents urology professionals worldwide. It’s mission is to raise the quality of urological care in Europe by promoting professionalism and competence among its members.
EAU is strong about reconstructive surgery — and substantially less influenced by medical device manufacturers (lobbyists) than the American Urology Association.
Questions answered directly by the surgeons are verbatim quotes in blue italics
Additional information is provided by International Case Manager & Patient Advocate Richard RothHaas. His information uses text like this.
I have been shown post-operative photos of patients who have had metoidioplasty several years ago. Immediately post-op, their penis was very small and short. After a few years, the penis actually appeared to have grow longer and thicker. I want to know from the surgeon: Is this true for all patients who undergo metoidioplasty?
The clitoris can grow to some degree, but not too much, and never enough for sexual penetration.
If: a) a patient has been on hormone replacement surgery in full compliance with WPATH Standards of Care regarding that; and b) has applied Andractim on his clitoris for a month or two before metoidioplasty surgery … will the penises of metoidioplasty patients grow longer and increase in girth during the years after surgery?
To some degree with vacuum therapy and hormones, but not too much.
What percentage of metoidioplasty patients experience their penis getting increasingly larger over time?
A small percentage.
Does allowing a metoidioplasty penis to grow for a few years after surgery improve the surgical outcome of Total Phalloplasty?
Would growing a longer and bigger metoidioplasty clitoris result in better erotic sensation and stronger orgasms too?
What link is there between a big clitoris and erotic sensation?
What percentage of patients can urinate standing after Total Phalloplasty Stage One and urethral advancement?
A small percentage, around 10%.
One Perovic Total Phalloplasty Stage 3 patient I know suffered implant protrusion and returned to Belgrade for the Sava Perovic Foundation to correct the problem. Why did that happen? What percentage of Total Phalloplasty Stage 3 patients experience implant protrusion?
Prosthesis infection is a complication well known to all transgender people. The rate is higher in a Total Phalloplasty neophallus than in normal penises. In radial forearm phalloplasty, it is about 15-30%. In a Perovic Total Phalloplasty neophallus it is less than 10% because the neophallus is bigger and has more space for placement of prosthesis without tension. The main causes of infection in a neophallus are:
- small space for placement of implants;
- less than ideal vascularity; and
- less than ideal quality of tissue.
It is very hard to predict despite all measures that we take before, during and after implantation. When the complication occurs, the usual scenario is infection starts first and after a few days protrusion also. They are most often coupled. All of these procedures regarding total phalloplasty are extremely complex and difficult and infections and protrusion are the most common complications. There is no surgery without complication. The most important thing is that all of our patients will eventually have good phalluses with a urethra and prosthesis inside.
If I get a mastectomy one month before getting Perovic Total Phalloplasty using the musculocutaneous latissimus dorsi flap (MLD flap), when should I start having the massage preparation of the donor sites?
Some time must past between these two surgeries — at least TWO months. Three or more months would be better. The massaging can start approximately two weeks after the mastectomy.
If buccal mucosa is used for urethroplasty, will it cause problems when I eat?
No. (As of 2012, it has been rarely used for urethroplasty in Total Phalloplasty patients.)
How soon after Total Phalloplasty Stage One will I be able to walk, work, drive and play sports?
After Total Phalloplasty Stage One (preceded by organ removal or not), it takes 2-3 days until the patient can walk unaided, 14 days until he will be able to drive and work and at least 28 days before he can resume playing sports.
How long after Perovic Metoidioplasty will I be able to drive a car, do sports, have sex and return to work?
You'll should be able to drive a car after one week, work after 10-14 days, play sports after two weeks, and have sex after one month. (The penis resulting from metoidioplasty is too short and too small for sexual intercourse but does enable a patient to urinate standing.)
If the orgasmic sensation is located at the base of the neophallus resulting from Total Phalloplasty, what kind of sensation does the head and shaft have?
The head and the shaft, with time (1-2 or more years), slowly develop normal sensitivity as we have elsewhere on the body such as the arms, legs, abdominal skin, etc.
If the entire vagina is removed during a vaginectomy, how is the bladder kept in place to avoid risk of prolapse and incontinence?
The bladder is kept in place by its natural connective tissue that holds it in that position. The risk of incontinence is minimal in our experienced hands. (In recent years, Dr Djinovic has performed a highly specialized and developed variation of vaginectomy that preserves all the positive benefits of the organ and removes the negative aspects.)
Have any patients experienced any urinary problems as a result of a vaginectomy?
What complications can possibly occur as a result of a vaginectomy?
Potential complications, I mentioned before, are: injury of bladder, urethra, rectum, and exaggerated bleeding. Until now, we haven't experienced any of those.
What are the advantages and disadvantages of using general anesthesia vs local anesthesia or an epidural during metoidioplasty?
Compared to local anesthesia (epidural), general anesthesia carries more serious potential complications, although extremely rare. Also, recovery is much easier after epidural anesthesia. Epidural anesthesia is mostly combined with sedation — with sleep.
Can I get Perovic Total Phalloplasty & still keep my vaginal canal with the ability to be penetrated?
We don’t do these irregular patients — only regular transsexuals with psychiatric approval. You can find more info about transsexuals on WPATH.org. (Read the WPATH Standards of Care For the Health of Transsexual, Transgender and Gender Nonconforming People Disorders. Any unique or unusual surgery must have explicit psychiatric approval in writing authorizing the non-standard procedure.) We do not perform any kind of transsexual surgery without psychiatric approval for that kind of surgery.
What is the average length and width of the penis after your metoidioplasty?
From 3-5 cm length (average 5 cm) with small width. Nobody ever measured it. I don’t know why.
I have a hormone condition. Can I get male breast reduction (gynecomastia) and nipple reduction at the same time I get penis enlargement surgery by Sava Perovic?
No problem, we can do it simultaneously. Nipple reduction can be done too.
Are there any Thai doctors who perform Dr Sava Perovic's FtM sex change surgery in Bangkok?
They are not experienced in FtM surgeries like us. Neither are their techniques close.
How does Dr. Perovic incorporate the clitoral nerves to the neophallus during his Total Phalloplasty?
We don't incorporate the clitoral nerves into the neophallus but rather the ilioinguinal nerve in order to provide tactile sensation. It rises from the first lumbar nerve, passes through the inguinal canal and superficial inguinal ring to supply the skin of the upper medial thigh, mons pubis, and scrotum or labia major. We preserve the clitoris. In the early years of Total Phalloplasty we covered it under the skin so the patient can have sexual arousal and orgasm. In time, we found it best for orgasms to leave it revealed and uncovered.
Is a scrotoplasty also included in the third stage of Perovic Total Phalloplasty surgery?
Yes, of course! ( … if it wasn't already done during Stage One or Stage Two of Perovic Total Phalloplasty. And sometimes scrotoplasty is done during Stage One but testicular protheses are not implanted until Stage Three.)
Is it necessary to have a vaginectomy before getting Perovic Total Phalloplasty?
It's not necessary, but it is highly recommended. We can also do a vaginectomy and one week later perform the Total Phalloplasty. (In practice, a vaginectomy is always done if it wasn't done previously. And ALL SRS is now performed during a single 9-hour surgical session as Total Phalloplasty Stage One.)
How long must a Perovic Total Phalloplasty patient stay in hospital?
For the first stage of Total Phalloplasty, the patient must stay approximately seven days in hospital and a few days more in his hotel — about 10-14 days in Belgrade before traveling back home. (Staying longer than the minimum is recommended.)
Where does Sava Perovic Foundation usually perform Total Phalloplasty in Belgrade?
Dr Djinovic performs surgery at a number of private medical facilities and hospitals in Belgrade.
The type and length of surgery influences the choice of the most appropriate medical facility but there is no charge to the patient whichever facility is used since all surgical fees quoted are package prices that include everything related to the surgery, including transport from the airport to your accommodations, nursing, medicine, hospital stay, and anesthesia (Global Fee).
What's a fistula?
A fistula, pronounced FISS-CHA-LA, is among the most common complications of hypospadias repair and FtM phalloplasty procedures that include re-routing of the urethra.
Sometimes called a “fistulotomy”, it can result from injury, surgery, infection or inflammation.
It is an unintentional passageway from a vessel, body structure or hollow organ (such as a penis or neophallus) which enables passage of bodily fluids to the outer surface of the person's body or to another organ or area of the body.
There are many types of fistula including: blind, complete and incomplete. A blind fistula connects two places but is open on only one end. An incomplete fistula opens on the skin but is closed on the internal end of the duct. A complete fistula is open on both ends and these kind result in fluid transfer.
Can Dr Djinovic do “glans sculpting” so the glans looks more natural and conspicuous? Can anything be done in that regard in addition to the de-epithelialized skin strip at the tip of the neophallus created during Total Phalloplasty?
Glansoplasty is a standard component of Total Phalloplasty Stage Three.
What is the actual complication rate for Perovic Metoidioplasty with the urethral lengthening procedure?
Fistulas in about 3-5% of patients. Of those, the majority of the complications resolve by themselves. Stenosis occurs in an even smaller percentage of patients. As far as I can remember, a testicular implant has protruded in only one patient (0.0025% of 400+ cases).
In what way is Perovic Metoidioplasty more advanced than in the past and better than what is offered by other doctors?
The technique is similar but there are some small 'tricks and tips' in order to avoid complications. (The ‘small tips and tricks’ have been developed by doing the procedure more than 400 times over more than a decade.)
Can tissue engineering with biodegradable scaffolds be used for the clitoris during metoidioplasty to gain more girth and possibly length?
NO, these are completely different things.
If I went to Belgrade to have FtM metoidioplasty surgery performed, where and at which hospital will it be performed?
The hospital is not important at all. We do surgeries at many places and all have good conditions for this kind of surgery.
Does the Sava Perovic Foundation's metoidioplasty surgical fee include full hysterectomy and vaginectomy?
Scrotoplasty and testicular implants are included. Multiple female organ removal can be done during the same surgery session as metoidioplasty but is not included in the price for only metoidioplasty. Specify exactly what organs need to be removed and the surgical package you want to get the exact cost.
If I choose to have my metoidioplasty done by the Sava Perovic Foundation in Belgrade, will someone organize accommodations and transport during my stay there?
Of course! Our driver waits for all patients and drives them directly to hospital. We also take care of all accommodations until departure. Hospital cost is included in the price, but not the cost of a hotel when it is needed. We arrange accommodations, the hospital, transfers, any help that the patient needs, but we do not pay the hotel bill. (That was in the mid-1990s. From the year 2000, airport pickup had to be requested and full arrival flight details provided far in advance. Very few patients go directly to the hospital. Most go to their private accommodations. We do not take visitors to the airport when they return home. Also from the year 2000, the extent of our arrangement of lodging was providing the information in our article about Belgrade accommodations listing tried and proven service providers.)
Will the Sava Perovic Foundation supply me with Andractim gel to put on my clitoris to make it bigger?
It is a registered product that can be bought in France, Germany, Italy and many other European countries. The active substance in Andractim gel is 2.5% Dihydrotestosterone. So any other product with the same substance could be used.
The required active ingredient is Dihydrotestosterone (DHT) also know as 5α-Dihydrotestosterone or abbreviated 5α-DHT.
Perovic Total Phalloplasty can provide a permanent 7" penis with tactile sensation that enables satisfying and successful sexual intercourse and an orgasm without the need for a drug to bulk-up the clitoris.
Can Sava Perovic Foundation write a letter for me stating that I've already had my sex reassignment surgery since I'm going to have it soon?
We will not do any false documents for any patient.
My psychiatrist is unwilling to forward a copy of my psychiatric approval letters as explained in the Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders (World Professional Association for Transgender Health) but I'm ready for my SRS. I have done very well without outside help. I have been doing fine without the help of doctors for psychiatric approval. This is not a rash decision. I have heard good things about your facility and I was hoping you would do my SRS because I am having it done and I do not want to go somewhere less qualified. Will you perform my sex change surgery?
We only do regular transsexuals with psychiatric approval. You NEED to have official psychiatric approval before surgery. That is mandatory. We need some report from a psychiatrist. Under NO CIRCUMSTANCES can you be operated on without psychiatric approval. Unfortunately, a request for surgery without psychiatric approval overcomes our professional ethics. For all patients who require any kind of genital modification surgery toward the opposite sex, it is mandatory to have psychiatric approval. We just do the technical part of the job.
Surgeons only execute what the mental health professionals have determined is RIGHT for YOU because there are more than 1,500 documented cases of persons who got gender reassignment surgery and later decided he or she had made a MISTAKE and it was NOT right for them. (none were our patients)
You can send us digital copies of the letters to schedule the surgery and mail the originals to the surgeon or give them to him by hand when you meet.
The Standards of Care (SOC) are guidelines to help you achieve a successful transition and prepare you for it as well as getting all your loved ones and significant others on board and supporting your decision.
The SOC are not obstacles to make your life difficult.
You should also provide documentation of your hormonal therapy and your ‘Real Life Experience’ as well as having fulfilled the minimum time requirements for both.
Does Djinovic correct any complications arising from the surgery he performs?