World J Urol (1998) 16: 212±218
Richard C. Rink á Mark C. Adams
Feminizing genitoplasty: state of the art
Abstract Surgical management of intersex states con-
tinues to evolve such that today's e€orts achieve near
normal cosmetic and functional results. In this article we
discuss the reconstruction of the female genitalia in those
that have had signi®cant androgen stimulation as well as
those with near normal external genitalia but signi®cant
urogenital sinus anomalies. The initial evaluation as well
as postoperative follow-up management is addressed.
One of the more devastating problems that can befall
new parents is the ®nding that their child has ambiguous
genitalia. The psychological implications can be over-
whelming. This is truly an emergency necessitating a
team approach by the neonatologist, endocrinologist,
geneticist, and pediatric urologist. This team should
work quickly to identify the genetic sex and biochemical
makeup of the child. The causes of genital ambiguity are
varied, with congenital adrenal hyperplasia being by far
the most common. Today the genitalia of these children
can be reconstructed to achieve a nearly normal male or
female phenotype. This paper discusses only the recon-
struction of female genitalia. Patients being recon-
structed along the female line generally fall into two
groups: those with excessive androgen stimulation
(usually congenital adrenal hyperplasia) and those af-
¯icted with other intersex conditions such as mixed go-
R. C. Rink (&)
Pediatric Urology,
James Whitcomb Riley Hospital for Children,
Indiana University School of Medicine,
702 Barnhill Drive, Room 1739,
Indianapolis, IN 46202, USA
Tel.: +1-317-274-7472; Fax: +1-317-274-7487
e-mail: rrink@iucc.iupui.edu
M. C. Adams
Pediatric Urology,
Vanderbilt University Medical Center,
435 Medical Arts Building,
Nashville, TN 37212-8591, USA
Ó Springer-Verlag 1998
nadal dysgenesis or true hermaphrodites. A third group
of patients warrant discussion: girls born with pure
urogenital sinus abnormalities, although these patients
may have nearly normal external genitalia.
Successful reconstruction is dependent upon an accu-
rate preoperative de®nition of the anatomy, particularly
with the urogenital (UG) sinus (vaginal) abnormalities.
Initial evaluation begins with a careful history and must
be followed by a detailed physical examination, with any
phallic enlargement or prominence of the corporal bodies
being noted. Labial anatomy and the location of the UG
sinus opening in relation to the genitalia and rectum is
noted. Anterior displacement of the rectum is not un-
common in the more severe forms of UG sinus and is
related to the persistent cloaca. The size, location, and
consistency of any gonadal tissue must be noted.
Prior to any operative procedure the child should
undergo an abdominal and pelvic ultrasound examina-
tion to identify the uterus, vagina, and gonads. The key
consideration in surgical reconstruction is the anatomy
of the UG sinus. This is delineated ®rst by genitography,
whereby contrast is injected retrogradely through the
perineal meatus of the UG sinus. The level of the con-
¯uence of the urethra and vagina should be demon-
strated. (Fig. 1). At times in the severely masculinized
female with a high con¯uence the vagina may not be
identi®ed radiographically and may be noted only on
careful endoscopy by a few small punctuate openings at
or near an apparently ¯attened verumontanum [2].
Endoscopy is very critical in the de®nition of this anat-
omy. With experience, however, the location of the
vaginal entrance into the UG sinus can usually be
identi®ed. If the vagina has not been identi®ed on ge-
nitography, a small catheter can be left in the vagina at
the time of endoscopy for later contrast studies. These
UG sinus abnormalities occur in a spectrum (Fig. 2).
Powell et al. [75] have classi®ed these into four types: I ±
labial fusion; II ± distal con¯uence; III ± high, proximal
con¯uence; and IV ± absent vagina. Although not every
patient ®ts neatly into these groupings, for example,
those patients with duplicate vaginas, it can be helpful

Fig. 1A,B Genitography show-
ing the urogenital sinus, ure-
thra, vagina, and bladder. A
Low con¯uence of the vagina
and urethra. B High con¯uence
for the surgeon to consider the level and nature of the
con¯uence when planning the surgical management.
The state of the art in reconstruction for ambiguous
genitalia has evolved over many years, with numerous
surgeons making signi®cant contributions. The compo-
nents of reconstruction involve clitoral reduction when
necessary, use of skin for labial reconstruction, and va-
ginoplasty. Nowhere is this evolution more evident than
in the history of surgery for the prominent clitoris. Early
reconstruction involved simple amputation of the clito-
ris. Since then, e€orts at concealment, plications, reces-
sion, and reduction have evolved. Currently, every e€ort
is made to provide a normal cosmetic appearance
without sacri®cing sensation or vascularity of the glans.
This is achieved by subtunical reduction of erectile tissue
as described by Kogan et al. [9] or by one of its modi-
®cations. This allows preservation of the glans with its
neurovascular supply intact along Buck's fascia and the
dorsal tunic of the corpora, yet the cavernous erectile
tissue is excised to improve cosmetics and prevent later
painful erections.
Similarly, many urologists have contributed to the
current state of reconstruction of the vagina. Many re-
Fig. 2a,b Spectrum of vaginal con¯uence with the urethra. a High (suprasphincteric) con¯uence. b Low (infrasphincteric) con¯uence
Fig. 3 Cut-back vaginoplasty
213
pairs utilize a posteriorly based perineal ¯ap as described
by Fortuno€ et al. in 1964 [4] and preserve the phallic
skin for labia minora construction as described by
Marberger [10]. In their classic paper in 1969, Hendren
and Crawford [8] recognized the variable anatomy of
the UG sinus. They noted that the vagina may insert
proximal to the external sphincter (suprasphincteric
con¯uence) or distal to the external sphincter (inf-
rasphincteric). Their description of the vaginal pull-
through procedure for the high con¯uence was a major
advance and remains the basis for reconstruction today.
Unfortunately, this procedure as initially described can
be quite complex and, at times, leaves an isolated vagina
with some tendency toward stenosis; therefore, several
modi®cations have been described [16]. Vaginal recon-
struction has evolved toward four basic procedures:
1. The cut-back vaginoplasty (Fig. 3) should be used only
with simple labial fusion.
2. In the ¯ap vaginoplasty the posterior wall of the UG
sinus and the vagina are opened but the vagina is not
detached anteriorly. The procedure has been appro-
priately applied to those sinuses with an infrasph-
incteric, low con¯uence.
214

Fig. 4A,B Preparation and po-

sitioning for feminizing ge-
nitoplasty. The entire lower
body is prepared with the child
lying through the aperature in
the drape, allowing access to the
perineum and abdomen. The
child can easily be rotated
prone (A) to the supine position
(B)

3. The pull-through vaginoplasty, with complete separa-

tion of the vagina from the urethra, is thought to be
applicable to the high suprasphincteric con¯uence.
4. Complete vaginal replacement is reserved for those
with an absent or rudimentary vagina.
It is our belief that the spectrum is not easily divided into
these well-de®ned categories and that one must realize
that a ¯ap vaginoplasty does not change the level of
con¯uence but merely opens the UG sinus more widely.
Clearly, some of those patients with a con¯uence in the
midportion of this spectrum would be better served by
vaginal separation and a pull-through procedure. This
will prevent a short urethra with a hypospadiac urethral
meatus and the resultant vaginal voiding, stasis, or uri-
nary leakage.

Operative techniques
Preoperatively the patients undergo an enema and the
medium-to-high vaginal con¯uence patients undergo
complete bowel preparation with Golytely. They receive
preoperative antibiotics. Endoscopy is performed and a
Fogarty catheter may be left in place through the UG
sinus into the vagina with the balloon in¯ated. A
marked sponge is placed into the rectum. In all but the
most minor procedures we now prepare with povidone-
iodine the entire lower half of the child from the xiphoid
process to the toes. The legs are wrapped and the entire
patient is placed through an aperture in the drapes. This
allows complete access to the perineum and abdomen;
the patient can easily be turned from the supine to the
prone position (Fig. 4). We ®rst address any clitoral
hypertrophy.
Surgical management of the clitoris and low vaginal
con¯uence
In patients with ambiguity and signi®cant clitoral hy-
pertrophy we would ®rst repair the phallus prior to
proceeding with vaginoplasty. With the patient in the
supine position the proposed incision is outlined with a
skin scribe. The phallus is retracted by a stay suture, and
parallel lines are drawn on either side of the clitoris,
leaving what would be the equivalent of the urethral
Fig. 5a Initial outline for the skin incision in patients with clitoral
hypertrophy. b The glans is secured to the pubis or corporal stumps.
The proposed incision into the posterior wall of the UG sinus
plate between these lines (Fig. 5A). The incision is then
made along these lines and carried around the corona of
the phallus. Incisions are continued inferiorly around
the urethral meatus. The preservation of this urethral
plate in our experience has allowed improved cosmesis
and provides more blood supply to the glans (Fig. 6A).
The phallus is then degloved, leaving the preputial skin
intact. The neurovascular bundle is identi®ed along
Buck's fascia, and lateral incisions into the tunica of the
corpora are made along the phallus from the glans
backward proximal to the corporal bifurcation. The
cavernous erectile tissue is then dissected from the infe-
rior aspect of the dorsal tunics and is excised (Fig. 6B).
The proximal and distal ends of each corporal body are
then suture-ligated. This allows the glans to remain at-
tached to the intact Buck's fascia with its neurovascular
bundle and to the ventral plate. DeJong and Boemers [1]
have destroyed the proximal corporal tissue by dilating
the corpora with a metal sound. We have not found this
to be necessary. The glans can at this time be secured to
the inferior aspect of the pubis or to the corporal
stumps. Care should be taken not to place the glans too
high on the pubis.
Following completion of the clitoral reduction, at-
tention is turned to the vaginoplasty. With the child

Fig. 6A Catheter in the UG
sinus. The urethral plate to the
glans is preserved and the
phallic skin is degloved. B
Erectile tissue (in forceps) is
excised, preserving the dorsal
tunics and neurovascular bun-
dle
remaining in the supine position, a posteriorly based
U-¯ap is drawn with its corners on either side of the
perineal body near the rectum (Fig. 5A). The ¯ap length
in this situation is determined by the distance necessary to
reach the posterior vagina. It must be made wide enough
and long enough to allow a tension-free anastomosis
without compromising its blood supply or the perineal
body. After the incision is made to develop this posterior
¯ap, it is retracted and dissection is carried out strictly in
the midline between the rectum and the UG sinus. In the
reconstruction for a distal, low con¯uence the posterior
aspect of the UG sinus is opened widely (Fig. 5B). It
must be noted that the distal one-third of the vagina is
nearly always narrowed and the vagina must be opened
proximal enough to enter into its normal caliber. In this
situation, sutures are individually placed through the
posteriorly based ¯ap and then into the split posterior
wall of the vagina. After all of these sutures have been
placed, they are then tied (Fig. 7A). In such cases of low
con¯uence the anterior wall is not disturbed and,
therefore, no anterior ¯ap is necessary. Thus, the phallic
skin can be divided in the midline, similar to Byar's ¯aps
for hypospadias repair, and moved inferiorly to create
Fig. 7a The posterior ¯ap is sewn in place, which opens the UG sinus
widely. Proposed incision into the phallic skin. b The phallic skin is
split in the midline to create the labia minoria. Proposed incisions at
the base of the labia majora to allow inferior placement alongside the
vagina
215
the labia minora (Fig. 7B). These two wings of tissue are
sutured on either side of the ventral urethral plate and
inferiorly alongside the new vaginal opening. The su-
periorly placed labial scrotal folds can be mobilized and
moved inferiorly as a Y-V plasty to create more normal-
appearing labia majora. These labia are sutured to the
new labia minora medially and to the inferior aspect of
the lateral edges of the perineal ¯ap. If the glans appears
to be too prominent, glans reduction can be carried out.
This should be done by excision of the central ventral
tissue, leaving the two lateral aspects intact, as it has
been shown that the neurovascular bundle enters later-
ally and then converges medially at the tip [13]. This will
avoid loss of the blood supply or of sensation.
Reconstruction of the high, or supersphincteric, vaginal
con¯uence
We would agree with Hendren that the high vaginal
takeo€ is best treated by complete separation of the
vagina from the UG sinus and that some modi®cation of
a vaginal pull-through procedure should be completed.
We would, however, extend this procedure to include
those that join in the midaspect of this spectrum. Sep-
aration of the vagina can be a very dicult dissection,
Fig. 8a,b Proposed incisions. a A posterior U-shaped ¯ap is created in
the pure UG sinus with the patient in the prone position. b For
ambiguity the clitoral recession is ®rst performed with the patient in
the supine position
216
Fig. 9a±d Posterior prone approach. a The posterior ¯ap is elevated
and dissection proceeds in the midline, exposing the UG sinus. b A
Deavor retractor elevates the intact rectum from the UG sinus and the
proposed incision into the posterior wall of the UG sinus is noted. c
The UG sinus is opened through the distal atretic vagina . The
retractor, now in the vagina, exposes its anterior wall con¯uence with
the urethra. d The vagina is completely mobilized and the UG sinus is
closed in 2±3 layers as the neourethra. (Reprinted with permission
from Rink et al. [16])
Fig. 10a The posterior vaginal wall is opened. b The anterior vaginal
wall is opened. (Reprinted with permission from Rink et al. [16])
particularly the separation of the anterior wall of the
vagina from the UG sinus, urethra, and bladder. It is
made even more challenging by the limited exposure.
With inaccurate or inadequate separation due to poor
exposure, complications such as stricture, ®stula, or di-
verticulum formation from a retained distal vagina may
occur. Vaginal stenosis may also be a problem. Because
of these diculties, many surgeons have recommended
delayed vaginoplasty.
Recently, Pena et al. [14] have recommended ap-
proaching these patients through a midsagittal posterior
incision, splitting the entire rectum in the midline to
provide improved exposure of the UG sinus. This re-
quires reconstruction of the rectum and sphincteric
mechanism and, more importantly, temporary colos-
tomy. Hendren and Atala [7] have described lateral
mobilization of the rectum to increase exposure but have
found this to be too dicult. Hendren [6] later described
mobilization of the rectum in the prone jackknife posi-
tion, followed by its retraction posteriorly to expose the
high vagina. We have recently described a midline peri-
neal prone approach to the high UG sinus that requires
neither division nor mobilization of the rectum yet allows
excellent exposure for the high vagina, even in infants
[16]. The following is a description of that approach.
For a pure UG sinus abnormality with normal ex-
ternal genitalia the procedure is started with the patient
in the prone position with the legs spread and the pelvis
elevated on rolls. A posteriorly based U-¯ap is again
created and the ¯ap is retracted away from the UG si-
nus. In the patient with ambiguity and a high vaginal
takeo€ the procedure is begun with the child in the su-
pine position as described above for the low con¯uence
until clitoral reduction has been completed and the
posteriorly based ¯ap has been mobilized (Fig. 8). At
this point the child is rotated to the prone position, and
dissection is carried out in the midline along the UG
 217

sinus. (Fig. 9A). The rectum is simply retracted superi-

orly with a small Deavor retractor and does not require
incision or mobilization. This exposes the entire UG
sinus (Fig. 9B). In the usual situation the entire UG si-
nus is opened posteriorly in the midline from its meatus
all the way back to the level of the vaginal con¯uence.
This will expose the distal atretic vagina, which is then
opened further on its posterior aspect to expose the more
normal-caliber vagina.
The dissection of the back wall of the vagina is carried
quite high. Donahoe has recommended extending this all
the way to the peritoneal re¯ection in more severe cases to
allow adequate mobilization of the vagina. The Deavor
retractor is then placed within the vagina and directed
upward to allow even more exposure of the most critical
aspect of this operative procedure, that is, the dissection Fig. 11a,b Options for tissue to cover the neourethra and create the
of the anterior wall of the vagina away from the proximal anterior vaginal wall. a In the pure UG sinus abnormality a labially
urethra and bladder (Fig. 9C). A small incision is made based ¯ap is elevated. b With ambiguities the phallic skin is used to
between the anterior wall of the vagina and the urethra. construct the anterior ¯ap. (Reprinted with permission from Rink
This plane is at times quite dicult to develop and the et al. [16])
tissues are quite thin. One should always err on the side of
entering the vagina rather than the urethra. As the dis- or laterally based as described by Parrot and Woodard
section is carried along in the proper plane the wall of the [11]. If a labially based ¯ap is used, the inferior mobili-
vagina becomes more substantial, and the plane is more zation of the labial scrotal tissue to create normally lo-
easily developed the more proximally the dissection is cated labia majora will need to be done as a secondary
carried along the urethra and the bladder. procedure, at least on one side (Fig. 12).
This prone approach provides excellent vision for A Foley catheter is left indwelling, and a Penrose
retubularization of the UG sinus as a neourethra drain is placed in the vagina and left in place for about 3
(Fig. 9D). This is done in two to three layers with ®ne days. The rectal sponge is removed and a perineal
absorbable suture over a Foley catheter. There is often dressing is placed. When multiple ¯aps have been de-
healthy fatty tissue, which can be brought together in the veloped the child's legs are wrapped for a short period to
midline to separate the urethra further from the vagina. prevent any separation of the ¯aps. For the very high
In those vaginas located at the midportion of the sinus vagina, Passerini [12] and, later, Parrot and Woodard
the vagina can frequently be mobilized all the way out to [11] proposed a transtrigonal approach to separation of
the perineum without the need for an anteriorly based the vagina from the UG sinus. We have found this to be
¯ap. In the higher vagina the vaginal length is often necessary in only one patient. It is noteworthy that
short, and various ¯aps will be necessary to reach the Passerini [12] has reported that this is necessary in only
vagina and allow it to have a normal perineal location. very few patients and would be done only after an at-
Again, the vagina is usually atretic in its distal third tempt at detaching the vagina from the perineum has
and is best opened in its midline anteriorly and poste- been unsuccessful.
riorly to allow an adequate caliber to prevent future
stenosis. (Fig. 10). In such cases an anterior ¯ap of tissue
is necessary to reach this vagina. In those patients with
ambiguous genitalia, rather than dividing the preputial
skin in the midline as described above, we would make a
small incision is the midportion of the ¯ap as a modi®-
cation of a Gonzales ¯ap and use this tissue to reach the
anterior wall of the vagina [5] (Fig. 11B). This is usually
redundant enough not only to act as an adequate ¯ap
but also to allow creation of the labia minora. In the
severely masculinized urethra the distal urethra can be
mobilized from the phallus, opened dorsally, and in-
corporated into these preputial ¯aps as a modi®cation of
the procedure described by Passerini [12]. In those pa-
tients with a pure UG sinus abnormality and no prep-
utial or urethral tissue for use as an anterior ¯ap, a labial
¯ap may be easily constructed to reach the anterior va- Fig. 12a,b The labia majora are mobilized and moved posteriorly to a
gina (Fig. 11A). The ¯ap may also be developed from position lateral to the vaginal introitus. (Reprinted with permission
the buttocks as described by Dumanian and Donahoe [3] from Rink et al. [16])
218
Timing of the procedure
The issue of timing for vaginoplasty, particularly for
those patients with a high con¯uence, has been a source
of great debate. Until recently, nearly all surgeons have
recommended that those patients with a high UG sinus
associated with ambiguity have two-stage repairs, with
the clitoral reduction being done early in life and the
vaginoplasty being postponed. With the posterior prone
approach that we have described, vaginoplasty can be
done very early in life, even in patients with the very high
con¯uence. We have done this in patients aged less than
6 months without diculty and have found that the
tissues are more mobile. This one-stage approach po-
tentially allows use of the phallic skin as an anterior ¯ap.
Vision and exposure are excellent, even in the smallest of
children. Recently, Donohoe and Gustafson [2] reported
the results they obtained with a one-stage repair in three
children aged between 8 and 12 months. They found no
increased risk and thought that the tissues were more
mobile and that the procedure was no more dicult than
those in older children. Even earlier repair has been
proposed by DeJong and Boemers [1], who performed
one-stage clitorovaginoplasties in children in the ®rst 3±
4 weeks of life. It was their feeling that the maternal and
placental estrogens produced vaginal enlargement from
mucus secretion and that vaginal wall hypertrophy al-
lowed easier mobilization of tissues for the vagina pull-
through. Although we have not done our repairs in
children in the 1st month of life, we have encountered no
diculty in performing these reconstructions in the ®rst
few months and feel that this provides signi®cant sur-
gical as well as psychological advantages.
Postoperative care
For those children with a very high vaginal takeo€ we
have found endoscopy to be quite helpful in the early
postoperative period for evaluation of the urethral and
the vaginal reconstruction. The posterior prone ap-
proach has been used in our last 12 patients with a high
takeo€ with excellent early success. One patient has been
noted to have a small urethrovaginal ®stula. Four pa-
tients were originally started on daily vaginal dilatations,
but these were stopped in the postoperative period after
endoscopy revealed the vaginas to be widely open.
Conclusion
Nearly all children can undergo genital reconstruction in
one stage very early in life and achieve near normal
cosmesis. Care should be taken during clitoral reduction
to preserve the neurovascular supply to the glans. It is
imperative that the surgeon de®ne early the location of
the vagina and its relationship to the sphincter and the
bladder neck. We would recommend a posterior ¯ap
vaginoplasty only in those with a very low con¯uence. In
all other situations we would recommend complete
separation of the vagina from the UG sinus and com-
plete reconstruction of the UG sinus as a neourethra.
The vagina is brought to the perineum as a modi®cation
of Hendren's pull-through procedure. The midline prone
approach described provides excellent exposure for the
critical portion of this procedure, even in neonates. In
this article we have attempted to provide a guide to our
approach for feminizing genitoplasty. This is an area of
surgery that requires the surgeon to have the knowledge
of many technicians as well as creativity and adapt-
ability. Regardless of the age of the patient, the anatomy
must be well understood, attention must be paid to de-
tail, and the reconstructive surgery must be meticulously
performed.
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