General Anesthesia

Surgical option can be one out of three procedures provided.

( Penile Skin inversion, Penile skin+ Scrotal flap +/- Skin Graft, and sigmoid colon) depends on the size of the penis. Those who has long term hormonal intake often have a small size penile length, so the option goes to more technically demanding procedure.

The M to F, SRS surgery is as followed
1. Creation of vaginal space between urethra, prostate gland, bladder and rectum
2. Bilateral orchiectomy
3. Degloved penis shaft
4. Separation of urethra from the penis
5. Isolation glans penis with 2 dorsal nerves and vessels
6. Penile skin inversion to line vaginal cavity with or without scrotal skin graft or
sigmoid colon graft
7. Clitoroplasty (Sensate)
8. Urethroplasty
9. Labiaplasty, major and minor

A portion of the glans (head of the penis), with its nerves and vessels, is converted into a clitoris. In so do, the clitoris will be functional in sensation as well as in appearance.

The excess erectile tissue around the urethra should be removed in order to avoid
symptoms that stem from engorged erectile tissue during sexual arousal, that may
result in the narrowing of the vaginal opening.

• All vital sign as well as the new genital wound will be monitored for at least 3 hours in our

SRS recovery unit. After that, the nurses will send you to your room if you are fully conscious.

•  The pain control medication will normally given through the intravenous

line and the anti- vomiting drug will be administered intermittently.

•  In case my anesthesiologist use the epidural block technique for your surgery, the pain after surgery should be expected minimally and well controlled with the low dose of analgesic medication administered through the catheter.

• Ice pack will immediately applied to the surgical area and be changed every 1-2 hour for a couple of days.

•  Sufficient bed rest helps speed up your healing and prevent the wound complications.

You will not be allowed to get up until the proper healing has taken place around the fourth days.

•  You will lie on the provided alfa-bed, which can help prevent back pain and pressure sore.

•  You should drink plenty of water to promote urination. The foley's catheter will be taken off on either fourth or fifth day.

•  The vaginal gauze packing will normally be removed on the fourth day. Early ambulation is

recommended to prevent thromboembolism (abnormal blood clots in your vessels).

•  The inverted and scrotal skin graft inside your neovagina will be thoroughly examined by using extra-speculum. The exact vaginal depth and also the technique for vaginal dilatation will also be shown.

•  When the foley's catheter is removed, you're expected to empty your bladder yourself. Please feel relaxed, the first experience may take time but you finally can do it.

•  The hospitalization is 6-8 days.

•  During the recovery period at recommended hotel, my special nurse team will visit you daily, taking care of your wound and teaching postoperative dilatation

Possible side effect and complication

• Difficulty in urinating after removing the urine catheter
It can sometimes occur due to the swollen stump at the opening of the shortened urethra. You may be asked to retain the urine catheter for a few more days until you are able to urinate.

• Postoperative bleeding or hematoma (collection of blood clot in the wound)
The neoclitoris and the stump of urethral opening are two new structures which tend to get bleeding. The significant bleeding may require re-packing or suturing. Fortunately, this situation is rather unusual.

• Sloughing of the inverted penile skin
This is extremely rare if the inverted penile skin pouch is set with appropriate tension and secure with the soft and pliable petroluem jelly gauze tampon.

•  Sloughing of the skin graft
The graft rejection is possible if it is placed on the inappropriate wound condition (bleeding or contaminated wound) or the skin itself is not well prepared or stored to be a graft.

•  Genital wound infection
This is very unusual unless you have some underlying disease such as diabetic or HIV. Anyway, the previously mentioned complications, for example hematoma or rectovaginal fistula can also induce infection.

•  Rectovaginal fistula (an abnormal path between the rectum and the vagina)
This is the most serious complication after sex reassignment surgery. The preoperative bowel cleansing treatment is believed to be of importance to avoid this sort of complication. In cases in which the rectum is entered during dissecting the vaginal tunnel, the hole can be primarily closed.
Once the recto-vaginal fistula was detected after surgery, the surgical intervention, for example, the fistulectomy (tranvaginal or transrectal) and the colostomy have to be done to convert the contamination.

•  Urethrovaginal fistula (an abnormal path between the urethra and the vagina)
This is very unusual complication.

•  Minor wound open-up is possible at the junction between lower labia and perineum due to wound tension. However, it is not a serious condition and usually healed by itself.

Aftercare and Dilatation

Vaginal dilatation after sex change surgery is the most important thing you can do to ensure the success of your sex change surgery.

If you gain the excellent depth after the SRS performed by me, but you ignore on your part to diligently dilate your new vagina, this will result in shortening the depth and width of the newly made vagina because of the scar contracture.

Failure to dilate properly can result in serious injury. You will be instructed to gently dilate into the right direction after the vaginal packing is removed.

I myself show the patients how to do it properly after the vaginal packing was removed and then you will be taken care of by my special nurse team everyday while staying both in the hospital and recommended hotel.

Dilatation should be done everyday right after the vaginal packaing is removed, this is to make sure that we can maintain the exiting depth and even get more depth.

Timing

• Once the vaginal packing was removed, start doing dilatation 30 minute once a day.

• During the second week, you can gradually increase the time and interval, for example: 2 times a day, 30 minutes each time.

•Between the third weeks to third months after surgery, 3-4 times a day, the total timing should be not less than 1.5 hour.

• Between the third month to sixth months, if everything goes well, you may do it twice a day.

• After six months, you can determine your own schedule. It is your responsibility to do it everyday in the long term to maintain the existing depth or even get more depth.

Technique to dilating the new vagina

•Wash you hands and apply some lubricant K-Y jelly at the vaginal opening and the dilator (just adequate but not too much).

• For lubricant, I recommend the medical grade lubricant such as Surgilube or Johnson & Johnson KY as they are water soluble and non-irritating jelly. The use of liquid sensual lubricant, like Astroglide may interfere with proper healing of the vaginal lining.

•You can do it in either semi-sitting position or lying position, choose the one that you feel easily relaxed.

• If you have difficulty inserting the stent because of vaginal dryness, withdraw the stent after the first try, you do need to apply some additional lubricant, and insert it again. Dilating should not be painful at all unless your wound does not heal well or you push stent in the wrong direction too hard.

•When the dilator reach the end of your vagina, you feel tight and can't pass the dilator forward anymore, at this time, please hold each dilator with constant pressing 10-15 minutes for each size of dilator. The aim of this procedure is to maintain your maximum depth and prevent the contraction of skin graft, which may cause the shortage of your vagina.

• There are four sizes of stents, I provide for my patients after sex change surgery.. Their diameter (cross section) are 0.75 inch (18mm), 1.00 inch( 25 mm), 1.20 inch(30mm) and 1.36 inch( 34 mm).

For those who need more detailed dilator set, I recommend you to purchase a commercial set of medical grade (medical grade silicone or stainless) stents with 1/8 or even 1/16" increase in cross-sectional area of stent. A goal of working will be probably up to 1 6/8".

Douching

•The skin graft is so new during the first three weeks after Sex change operation, so I recommend not to douche as the water remained in your vagina after douching may cause dampness of the inside graft.

• After one month, douching can be done safely once a day with very mild form of antiseptic solution.

General instruction after sex change surgery

• You can bathe as usual, and wash the wound gently with soap.

• You are again on female hormones as before surgery after going back home.

• All stitched are all self-dissolving, but need time (may be 2-3 months) to loose the notch and coming off. If the end of stitched is so hard and make you discomfort, you can have them removed.

• No food restriction.

• You have to limit your activities for six weeks after surgery. Too much walk or lifting heave stuff may cause wound around vaginal opening.

• You may begin intercourse after the sixth week period. You have to use the lubricant jelly every time during sexual intercourses