The anterior sagittal transanorectal approach: a modified approach to 1-stage clitoral vaginoplasty in severely masculinized female pseudohermaphrodites--preliminary results

Purpose: We present a modified 1-stage clitoral vaginoplasty technique for severely masculinized female pseudohermaphroditism involving an anterior sagittal transanorectal approach with the patient prone after clitoroplasty according to the Passerini-Glazel procedure. Material and Methods: An anterior sagittal transanorectal approach with protective colostomy was performed in 2 patients with severely masculinized female pseudohermaphroditism and a normal rectum. The anorectal sphincteric mechanism was divided only in the anterior midline. and the perineal body and rectum were opened in the anterior rectal wall, providing excellent exposure of the urogenital sinus. The vagina was easily and fully separated from the urogenital sinus, the site of vaginal attachment to the urethra was sutured, and anastomosis was created between the vaginal neo-introitus and vagina. The rectum, perineal body and anterior sphincteric mechanism were reconstructed. Results: Cosmetic and anatomical results are satisfactory. The vaginal neo-introitus is located just below the urethral meatus, the clitoris appears almost normal and in the vulvar region a mucous lining is present in the front wall of the perineum between the clitoris and vagina. Convalescence was uneventful. The patients had normal bowel control after colostomy closure and no urinary incontinence. Conclusions: Our modified technique favors easy and safe posterior anastomosis between the vaginal neo-introitus and vagina under direct vision. Furthermore, suturing the vaginal stump is easier than in the original technique, since the approach to the vagina is posterior, not transvesical.