Miscellaneous

Corporeal Sparing Dismembered Clitoroplasty:

An Alternative Technique for Feminizing Genitoplasty
João L. Pippi Salle, Luis P. Braga, Nicanor Macedo, Nicolino Rosito and Darius Bagli
From the Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada

Purpose: Management for clitoral enlargement remains controversial. New understanding of clitoral function stimulated a
search for more conservative surgical approaches, such as recession or partial resection. However, these techniques risk
decreasing clitoral sensation or causing painful erections. Moreover, irreversibility continues to be the principal problem that
fuels patient, surgeon and societal anxiety in the management of this challenging developmental issue. We describe a new
technique, corporeal sparing dismembered clitoroplasty, that dismembers the corporeal bodies and preserves all clitoral
structures.
Materials and Methods: After obtaining full informed consent and institutional review board approval 8 consecutive
patients with clitoral enlargement underwent corporeal sparing dismembered clitoroplasty. Five girls had congenital adrenal
hyperplasia (Prader IV and V in 4 and 1, respectively), 1 had ovotesticular disorder of sexual differentiation and 2 had partial
androgen insensitivity syndrome. One pubertal girl was tested with warm, cold and pain clitoral stimulation before and after
surgery. For the clitoroplasty technique the glans and its neurovascular bundles are dissected from the corpora. The isolated
corpus is then completely divided starting at the bifurcation. Each separated hemicorpus is rotated inferior and lateral, to be
placed inside the labial scrotal folds. The glans is reduced by superficial excision of its epithelium and fixed to the pubic
attachments. Labia minora are constructed with preputial Byars flaps. Labioplasty and vaginoplasty are then routinely
performed.
Results: Eight patients 6 months to 13 years old underwent this procedure. Followup was 6 to 12 months. All patients
recovered well from surgery without early complications. The initial cosmetic result was good in all girls. The hemicorpora
were easily palpated inside their labia majora pouches, which retained the desired cosmetic appearance following feminizing
genitoplasty. All glans clitoris were preserved. The teenaged patient does not report painful erections. She has maintained
clitoral sensation and is satisfied with the cosmetic result.
Conclusions: Conservative reconfiguration of the female genitalia without removing genital structures is feasible in girls
with clitoral enlargement. The cosmetic appearance of the genitalia is acceptable, at least to the surgeon and parents, in that
the enlarged clitoris is hidden. The physiological consequences of the current operation and any surgery in the future to
reverse it are unknown. With these aspects in mind we believe that corporeal sparing dismembered clitoroplasty should be
incorporated into the armamentarium of surgeons involved in the treatment of clitoral enlargement and presented as an
option for feminizing genitoplasty.

Key Words: abnormalities, clitoris, genitalia, reconstructive surgical procedures

anagement of CE remains controversial because ral sensation.7,8 We agree with others that maintaining all

M of the nature of intervention in a structure so

vital to psychological body image and gender.
Initial efforts to correct CE consisted of partial or total
clitoridectomy based on the belief that permanent reduc-
tion of the enlarged clitoris was necessary to treat or
prevent gender dysphoria.1 However, understanding that
the clitoris has a crucial role in the development of female
sexuality has stimulated a search for more conservative
surgical approaches. This prompted the development of
techniques to bury or recess the clitoris.2,3 Unfortunately
fixation of the enlarged clitoris to the peripubic attachments
may lead to painful erections during sexual arousal.4 To avoid
this complication strategies for reduction clitoroplasty have
been described, including removal of the corporeal erectile
tissue with preservation of the neurovascular bundle to the
glans.5,6 Unfortunately these techniques risk decreasing clito-
Study received institutional ethics board approval.
clitoral structures is important to optimize postoperative clito-
ral sensation as well as minimize psychological trauma.9
Moreover, irreversibility continues to be the principal prob-
lem that fuels patient, surgeon and societal anxiety in the
management of this challenging developmental issue. In an
effort to optimize psychological and sexual function as well
as decrease anxiety surrounding the difficult surgical deci-
sion that patients and their families must make we devel-
oped a new technique, CSDC, that dismembers the corporeal
bodies and preserves all clitoral structures.
MATERIALS AND METHODS
Following extended discussion of all available alternatives
and with full informed surgical consent 8 consecutive pa-
tients with clitoral enlargement underwent CSDC for femi-
nizing genitoplasty. Institutional ethics board approval for
chart review was obtained. Furthermore, all patients inde-

0022-5347/07/1784-1796/0 1796 Vol. 178, 1796-1801, October 2007

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.03.167
 CORPOREAL SPARING DISMEMBERED CLITOROPLASTY 1797

Size (cm)
Pt
No.—Age Diagnosis Clitoris UGS Prader Vaginoplasty Result

1—6 Mos CAH 3.5 3 4 PUM ⫹ UF Mild introital stenosis

2—18 Mos XY, ovarian/testicular DSD 3 2.5 4 PUM ⫹ UF ⫹ FF Good
3—6 Mos CAH 3.5 3.5 5 Clitoroplasty ⫹ vulvoplasty Good
4—13 Yrs XY–DSD 4.5 3 4 PUM ⫹ UF ⫹ FF Good
5—6 Mos CAH 3 3 4 PUM ⫹ UF ⫹ FF Good
6—14 Mos CAH 3 2.7 4 PUM ⫹ UF ⫹ FF Good
7—12 Mos XY–DSD 3 3.5 4 PUM ⫹ UF ⫹ FF Good
8—10 Mos CAH 3 2.0 4 PUM ⫹ FF Good

pendently consented to have their results published. All
except 1 patient had never previously undergone surgery. A
13-year-old girl with partial androgen insensitivity had un-
dergone bilateral orchiectomy and introitoplasty 6 months
and 9 years previously, respectively. This patient was coop-
erative and accepted testing to evaluate preoperative and
postoperative clitoral sensation using cold, warm and vibra-
tion stimulation. The table lists patient characteristics.
Clitoroplasty Technique
The clitoris is degloved and the neurovascular bundles of the
glans are dissected off of the corpora cavernosa (fig. 1). This
dissection should start as ventral as possible, entering the
distinct avascular plane that exists between the albuginea
and the first layer of Buck’s fascia. If the correct plane is
entered, it is possible to separate the neurovascular bundle
and the entire glans from the corpora without much bleeding
(fig. 2). The corporeal bodies are dissected down to their
bifurcation. Starting at the level of the bifurcation the cor-
pora are divided with sharp dissection, entering a tightly
defined plane that exists in the midline between the 2 hemi-
corpora. Rigorous attention with sharp dissection in this
midline plane of the corpora accomplishes separation with-
out significant bleeding (fig. 3). The lateral edges of the
opened albuginea of each hemicorpora are approximated
using fine absorbable sutures (fig. 4). A dartos pouch, similar
to that used for orchiopexy, is constructed in the labia ma-
jora. Each hemicorpus is rotated lateral and inferior to be
placed inside the respective labial pouch (fig. 5).
Glans reduction is then performed. This is accomplished
by superficial excision of the epithelium of the glanular
groove to stimulate future adhesions to the prepuce. An
effort is made to excise as little glans tissue as possible, only
partially de-epithelializing it. The glans clitoris is then fixed
to the pubic bone approximately 1 cm above the original
bifurcation of the corpora. The prepuce is incised in the
midline (Byars flaps) to reconstruct the labia minora. It is
important to limit this incision, leaving enough intact skin
to produce an anatomical preputial clitoral hood. Vagino-
plasty is performed by partial UGS mobilization. The poste-
rior vaginal wall is constructed using a combination of an
inverted U cutaneous flap for the posterior medial aspect
(FF)10 and the redundant tissue from the divided UGS at the
6 and 12 o’clock positions, as described by Rink.11 The latter
is rotated latero-inferior and used to build and enlarge the
lateral aspects of the vagina and introitus. Vulvoplasty is
then completed by bringing the lower aspect of the recon-
structed labia minora to the lateral aspect of the exteriorized
vagina (fig. 6).
RESULTS
Eight patients 6 months to 13 years old underwent CSDC, as
described. Mean followup was 12 months (range 3 to 16). All
patients had an uneventful postoperative recovery and none
had postoperative bleeding or hematoma. The 2 hemicorpora
were easily palpated inside the labia majora pouches, which
retained the desired cosmetic appearance following feminiz-
ing genitoplasty. All glans clitoris were preserved. In 7 pa-
tients vaginoplasty was performed using PUM. One severely
virilized girl with CAH-Prader 5 and a hypoplastic high
vagina underwent CSDC and reductive vulvoplasty alone,
leaving vaginoplasty to be performed later (fig. 7). The 18-
month-old patient with ovotesticular DSD underwent lapa-
roscopy and bilateral gonadal frozen section biopsy before
CSDC and vaginoplasty. Pathological examination con-
firmed the diagnosis of bilateral ovotestis. Another 12-
month-old girl with partial androgen insensitivity underwent
prior bilateral orchiectomy and pathological examination was
consistent with bilateral immature testes. This patient un-
derwent CSDC and PUM of the 4 cm vagina located 2.5 cm

FIG. 2. Glans clitoris and its neurovascular bundle are separated

from corpora cavernosa. Dissection at tunica albugineal level allows
FIG. 1. Outline of incisions to deglove clitoris separation without much bleeding.
1798 CORPOREAL SPARING DISMEMBERED CLITOROPLASTY
FIG. 3. Two hemicorpora are separated in midline, starting at bi-
furcation.
from the bladder neck. In this particular patient partial
mobilization of the UGS would not allow the vagina to reach
the perineum, requiring division and separation to be
brought down. Its anterior and posterior walls were con-
structed using UGS and FFs, respectively. This maneuver
allowed the reconstructed vagina to reach the perineum
without tension (fig. 8). The 13-year-old pubertal patient
was tested postoperatively. She denied painful engorgement
of the labia or decreased genital sensitivity after surgery and
seemed to be satisfied with the cosmetic result. She re-
mained on periodical vaginal dilation, which was discontin-
ued after she became sexually active (fig. 9). Our first pa-
tient underwent posterior vaginal wall construction using
the redundant UGS exclusively, as previously described.12,13
This patient had introital stenosis and required introito-
plasty because she retained a significant amount of urine in
the vagina. This procedure was successfully performed 1
year after CSDC. Following this case we started using a
combination of FFs and UGS flaps to construct the posterior
vaginal wall and enlarge the introitus, avoiding stenosis in
the remaining patients. The table lists patient characteris-
tics, technical surgical details and results.
FIG. 4. Opened albugineal layer of each hemicorpus is approxi-
mated with fine absorbable suture to prevent bleeding.
FIG. 5. Each hemicorpus is rotated lateral and inferior to be placed
inside respective labial pouches.
DISCUSSION
Surgical treatment in infants with CE remains controver-
sial. There are also controversies regarding the time of and
need for clitoral reduction.14 However, leaving a grossly
enlarged clitoris untouched during childhood underscores
the psychological impact that this situation can cause to the
untreated child.13,15 Recent consensus statement on the
management of intersex disorders suggests that cosmetic
surgery in girls with severe virilization (Prader III to V)
should be performed in the first year of life, when appropri-
ate, in conjunction with common UGS repair.16 On the other
hand, there are a number of publications reporting a loss of
sensation and decreased ability to achieve orgasm in women
who underwent various techniques for clitoroplasty.7,16,17
Although many of these complaints are related to vagino-
plasty rather than to clitoral surgery, there remains a sig-
nificant group of patients with decreased sensitivity in the
clitoris following clitoroplasty.7 Moreover, up to 5% of pa-
tients with CAH may have gender dysphoria later in life and
wish that they could revert decisions made by parents and
caregivers earlier in their lives.18
Although fully informed consent was obtained that ex-
plained the potential risks of clitoral surgery, in this report
FIG. 6. Posterior vaginal wall is constructed using combination of
inverted U cutaneous flap (FF) and redundant UGS tissue (UGS
flap). Vulvoplasty is then completed.
 CORPOREAL SPARING DISMEMBERED CLITOROPLASTY 1799

FIG. 7. Preoperative (left), transoperative (middle) and postoperative (right) views of severely virilized female with CAH and Prader 5.
Despite enlarged clitoris good cosmetic result was achieved with corporeal preservation.

we consciously do not present a detailed discussion about
gender identity issues, indications and timing for clitoral
surgery. We agree with others that irreversible genital sur-
gery should be avoided and we present a conservative alter-
native technique.14,19 Most contemporary clitoroplasty tech-
niques consist of excising the erectile tissue of the enlarged
clitoris. The consequence of such removal is largely un-
known. It is possible that, as in males, clitoral sensation is
enhanced during erection of the corpora. Our technique at-
tempts to spare this erectile tissue, which may have a role in
genital sensation. Although remarkable dissection is done
during this procedure, we believe that by doing the proce-
dure correctly and respecting the tissue planes most clitoral
components will likely have their enervation and sensation
preserved. Starting the separation of the neurovascular bun-
dle as ventral as possible, as routinely done in cases of
hypospadias, is an important step to minimize injury to
nerves.20 Dissection similar to the proposed clitoroplasty
technique is performed in some males with epispadias, in
whom the corpora are completely disassembled. We have
followed some of these adolescent males with epispadias who
underwent major penile reconstruction and maintained un-
changed sensation as well as the ability to achieve erection,
ejaculation and orgasm. We believe that the technique pre-
sented has the potential to preserve clitoral sensitivity, sim-
ilar to males with comparable interventions.
There is a possibility that these operated females could
have painful erections during sexual arousal. However, un-
like previously described clitoral recession techniques in
which the clitoris was sutured to the pubis, we keep the 2
hemicorpora relatively free inside the labia majora. We hope
that this will permit a certain mobility of the corpora and
prevent painful erections. Furthermore, one could argue
that unpleasant labial engorgement could occur during cli-
toral erection. If this is the case, there would still be the
option of removing the 2 hemicorpora through labial inci-
sions with the advantage of including the patient in this
difficult decision making process.
Moreover, irreversibility continues to be a dilemma for
patients, their families and the multidisciplinary team in-
volved in their care. Using the preserved erectile tissue
would be potentially feasible in patients with gender dys-
phoria who desire phallic reconstruction.
Finally, we believe that it is important from the psycho-
logical standpoint that all clitoral parts are still in place but
simply redistributed in the perineum. This aspect may have
been underscored in importance compared to other proce-
dures because some patients may manifest castration feel-
ings after the removal of genital tissue.
We acknowledge that our technique still has limited,
short followup for drawing definitive conclusions and only 1
pubertal patient was suitable for objective assessment. How-

FIG. 8. View of 18-month-old patient with ovotesticular DSD who underwent PUM, vaginal separation and reconstruction using combination
of UGS flap and FF to reach perineum without tension.
1800 CORPOREAL SPARING DISMEMBERED CLITOROPLASTY
FIG. 9. View of 13-year-old girl with XY-DSD who underwent preoperative and postoperative testing for clitoral sensitivity with warm, cold
and vibratory stimulation. No change in sensation or painful labial engorgement was noted by patient after surgery.
ever, it is gratifying to see that she is satisfied with the
surgical results and does not report postoperative changes in
genital sensation or painful labial engorgement. Despite
good initial results we are aware that late complications
related to patient dissatisfaction can occur but they could be
potentially managed without the need for major interven-
tions. Therefore, we do not see any disadvantages of CSDC
compared with the current techniques in use. Based on that
we believe that it is reasonable to propose this procedure as
an alternative technique to be presented to families when
surgery for CE is contemplated.
CONCLUSIONS
Conservative reconfiguration of the female genitalia is fea-
sible in girls with CE and the anatomical structures of the
clitoris seem to survive after CSDC. The cosmetic appear-
ance of the genitalia is acceptable, at least to the surgeon
and parents, in that the enlarged clitoris is hidden. The
physiological consequences of the current operation and any
surgery in the future to reverse it are unknown. With these
aspects in mind we believe that CSDC should be incorpo-
rated into the armamentarium of surgeons involved in the
treatment of CE and presented as an option for feminizing
genitoplasty.
Abbreviations and Acronyms
CAH ⫽ congenital adrenal hyperplasia
CE ⫽ clitoral enlargement
CSDC ⫽ corporeal sparing dismembered clitoroplasty
DSD ⫽ disorders of sexual differentiation
FF ⫽ Fortunoff flap
PUM ⫽ partial urogenital mobilization
UF ⫽ urogenital sinus flap
UGS ⫽ urogenital sinus
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1. Gross RE, Randolph J and Crigler JF Jr: Clitorectomy for
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2. Lattimer J: Relocation and recession of the enlarged clitoris
with preservation of the glans: an alternative to amputa-
tion. J Urol 1961; 86: 113.
3. Randolph J and Hung W: Reduction clitoroplasty in females
with hypertrophied clitoris. J Pediatr Surg 1970; 5: 224.
4. Allen L, Hardy BE and Churchill BM: The surgical manage-
ment of the enlarged clitoris. J Urol 1982; 128: 351.
5. Kogan SJ, Smey P and Levitt SB: Subtunical total reduction
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6. Glassberg KI and Laungani G: Reduction clitoroplasty. Urol-
ogy 1981; 17: 604.
7. Crouch NS, Minto CL, Liao LM, Woodhouse CRJ and Creighton
SM: Genital sensation after feminizing genitoplasty for congen-
ital adrenal hyperplasia: a pilot study. BJU Int 2004; 93: 135.
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SM: The effect of clitoral surgery on sexual outcome in indi-
viduals who have intersex conditions with ambiguous genita-
lia: a cross-sectional study. Lancet 2003; 361: 1252.
9. Newman K, Randolph R and Parson S: Functional results in
young women having clitoral reconstruction as infants.
J Pediatr Surg 1992; 27: 180.
10. Fortunoff S, Lattimer JK and Edson M: Vaginoplasty tech-
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11. Rink RC, Metcalfe P, Cain MP, Meldrum KK, Kaefer MA and
Casale AJ: Use of the mobilized sinus with total urogenital
mobilization. J Urol 2006; 176: 2205.
12. Peña A: Total urogenital mobilization: an easier way to repair
cloacas. J Pediatr Surg 1997; 32: 263.
13. Rink RC and Adams MC: Feminizing genitoplasty: state of the
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 CORPOREAL SPARING DISMEMBERED CLITOROPLASTY
EDITORIAL COMMENT
For a number of years now it has been clear that the long,
previously held presumption that gender imprinting did not
become fixed until ages 15 to 18 months is incorrect.1 Gender
imprinting begins in utero. The quandary faced by those
who treat DSD is how to measure how much imprinting has
occurred in an infant. That is an unresolved dilemma. From
the consensus statement it is quite clear that we know in a
couple of diagnoses exactly where we should be making the
gender assignment (reference 16 in article). In general fe-
males born with CAH will be happy in a female gender role.
Likewise, those with complete androgen insensitivity maybe
satisfactorily raised as female. However, there is no real
consensus on other DSDs.
There is a conflict between the desire not to burn any
bridges and preserve maximally the choices for a child and
the difficulty of parents raising a child whose genitalia look
frankly abnormal at every diaper change. That sets up
stresses for many families that simply are unacceptable.
1801
Accordingly I think that these authors are creative in
arriving at a potential way to perform feminizing genito-
plasty that does indeed preserve options. While this is a
limited and preliminary report, I think that such innovative
steps should be encouraged. Further followup of these cases
will provide an answer as to whether this should become a
definitive part of our surgical armamentarium for DSD. It is
important for all of us caring for these children to keep an
open mind about innovations because it is clear that we still
have a long way to go in the management of these difficult
gender assignment and surgery issues.
Howard M. Snyder, III
Division of Urology
Children’s Hospital of Philadelphia
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
1. Zderic SA, Carr MC, Canning DA and Snyder HM: Pediatric
Gender Assignment: A Critical Reappraisal. New York:
Kluwer-Plenum Press 2002.