by M. Italiano
Ulrich T. Hinderer (1), in 1974 was the first to develop the sensate pedicle technique for its apllication in intersex persons with ambiguous genitalia with the preservation of a reduced clitoral glans based exclusively on the dorsal neurovascular bundle. He also is the first to suggest total excision of the corpora cavernosa, including the crura to prevent dispareunia.
The first respectable surgeons to use Hinderer's technique for transsexuals in the 1980's were Terrence Malloy of Pennylvania Hospital (U.S.) and Ulrich T. Hinderer(Madrid, Spain) himself. While this was an improvement over using only some corpus spongiosum (which surgeons such as Stanley Biber of Trinidad, Colorado and Roberto Granato of New York, New York were using) or of reduced corporal tissue sewn together (which surgeons such as Rodolphe Meyer of Switzerland and Larry Lipschultz of Houston, Texas were using) for clitoral reconstruction, it hadn't shown a difference in the orgastic ability of the limited sample studied by Lief and Hubschmann (2). Only 4 of the patients in this sample were orgastic. Two (50%)were from Biber (using only spongiosum) and the other two (50%)from Malloy (using the sensate pedicle technique). So there was no demonstration of an advantage of one technique over the other as far as achieving orgasmic capabilities, in this regard. Although Hage (3)found favor in Hinderer's technique, he did not investigate sexual function. Furthermore, in Hage's report, he suggests removal of the cavernosa and the crura to prevent painful intercourse.
However, at least one other respeected surgeon, Donald Laub, Sr. of Palo Alto, California, reported in a dozen post-operative male to female transsexuals (4), that of the top 6 erotic aspects of male to female anatomy, the cura and cavernosal stumps were rated as 3rd and 4th respectively, and were therefore not painful, but highly pleasurable. So, with Laub's technique, it appears that one can use the sensate pedicled technique and STILL retain parts of the erectile tissue bodies. In fact, the way the tissue is buried with the formation of scar tissue in this area may be directly related to the issue of whether the preservation of erectile tissue will be painful or pleasurable. Certainly, advocates of Hinderer's technique, as used by Hage, Melman, Meltzer, Preecha, and others may be in direct contradiction to some recent reports on the innervation of the phallus. Baskin, et. al. (5) and Yang, CC and Bradley, W.E.(6), have independently confirmed that the lateral and ventral portions of the penile shaft were innervated by branches arcading from the dorsal midline radiating toward the ventral surface. These branches were in both reports, seen to penetrate the corpus spongiosum(thus its not imaginary that patients with the spongiosum technique were orgastic) and at the junction of the corpus spongiosum and the corpus cavernosum in the Baskin report. Thus, in another report by Baskin, et. al.(7), they state "The concept of lifting the dorsal nerve off of the tunica at the 11 and 1 o'clock positions seems to be inconsistent with the fact that the nerves fan out extensively around the dorsal and lateral aspects of the clitoral body." They also address the removal of erectile tissue in severely masculinized cases. They write "Standard treatment was to amputate the erectile bodybof the clitoris at the pubic arch, leaving...the neurovascular bundle with a strip of dorsal tunica. To our knowledge the long-term effect on sexual function of removing this erectile tissue is unknown. In contrast, leaving too much erectile tissue has been reported to cause pain at puberty. A compromise may be to incise the corpora cavernosa on the ventral surface or bottom at the 6 o'clock position and remove erectile tissue within the tunica to reduce the size of the erectile body, preserving some erectile tissue and all clitoral nerves." Thus, in a third paper by Baskin, et. al. (8), they sternly warn about the possibility of the sensate pedicle technique and the likelihood of damage to nerves perforating the spongiosum, and the area of the crural bodies on the ventral lateral surface.
Of course, Schrang's technique of keeping some of the corpora and the crura, and shortening the dorsal neurovascular bundle has great hope that the cut dorsal nerves will regenerate-likely false notion to a great degree.
The technique which Petra mentioned about the entire dorsal bundle being retained with the loop technique would probably be promising. Papageorgiou, et. al. (9) have a promising technique used in an intersexual of preserving both the dorsal and ventral pedicles. This may be applied to transsexuals by retaining the tunica, with its nerves, removing unnecessary erectile tissue, and folding the tunica. Also a fine technique, although not in its proper location, is the technique of inverting the glans and putting it into the vagina with nerves intact as does Jalma Jurado (Brazil)(10).
However, he does seem to use spongiosa tissue (urethral mucosa) in the place of the clitoris. This is not so unusual, since the normal female clitoris also contains spongiosa (11). Sava Perovic (Yugoslavia)(12)uses some nerve tissue in the place of the clitoris, as a sensate pedicle type of technique, but ALSO uses the other part of the glans/nerves in an inverted form into the vagina. Thus, he has a combination technique. Clearly the best techniques at clitoroplasty are being discovered.
1)Hinderer, U.T. (1974) La Cirugia Plastica en el tratamiento del intersexo. Acta Soc. Endocrinol. Madrid 6: 39.
2)Lief, H.I. & Hubschman, L. (1993) Orgasm in the post-operative transsexual. Arch. Sex. Beh. Apr; Vol. 22,(2): 145-55.
3)Hage, J.J. (1993) A new method for clitoroplasty? Plast. Reconst. Surg. June; Vol. 91(7):1303-7.
4)Laub Sr., D.R. (1997) Erotic Aspects of Male-to Female-Anatomy. Paper presented at the 15th Harry Benjamin International Gender Dysphoria association.
5)Baskin, L. et. al. (1997) Neuroanatomical ontogeny of the human fetal penis. British J. Urol. Apr;79(4):628-40.
6)Yang, C.C. & Bradley, W.E. (1998) Neuroanatomy of the penile portion of the human dorsal nerve of the penis. British J. Urol. Jul;82(1):109-113.
7)Baskin, L. et. al. (1999) Anatomical Studies of the Human Clitoris. J. Urol. Sept., Vol. 162, 1015-1020.
8)Baskin, l. (2000) Anatomy Of The Neurovascular Bundle: Is Safe Mobilization Possible? J. Urol. Sept., Vol. 164, 977-980.
9)Papageorgiou, T. (2000) Clitoroplasty With Preservation Of Neurovascular Pedicles. Obstet. and Gynecol. Nov., Vol. 96, No. 5., Part 2, 821-823.
10)Personal Communication from Wal Torres, Aug., 2002.
(11)van Turnhout, Arjen A.V.M. (1995) The female corpus spongiosum revisited. Acta. Obstet. Gynec. Scand. Vol. 74: 767-771.
12)Perovic, S.V. et. al. (2000) Vaginoplasty in male transsexuals using penile skin and a urethral flap. B.J.U.Int. Nov., Vol. 86 (2): 843-50.