PEDIATRIC UROLOGY

Passerini-Glazel feminizing genitoplasty: modifications in 17 years of experience with 82 cases
Lesma A, Bocciardi A, Montorsi F, Rigatti P
Department of Urology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
Eur Urol. 2007; 52: 1638-44

• Objectives: To describe modifications of Passerini-Glazel feminizing genitoplasty and report on long-term functional outcome.
• Methods: Modifications include vaginal dissection and disconnection from the urethrovaginal sinus as the initial stage of the procedure; large dissection of the neurovascular bundle on both dorsal and lateral faces of the clitoris; plication of the skin around the reduced clitoris; and suturing the lateral edge of the proximal portion of the mucocutaneous plate with the labia majora’s medial edge to a plane deeper than the subcutaneous tissue. These modifications reduce bleeding and operating time, better preserve clitoral sensitivity, form the clitoral prepuce, and create labia minora.
• Results: Eighty-two patients underwent modified Passerini-Glazel feminizing genitoplasty. Mean operating time was 120min (range: 100-180). Forty-six patients (46 of 82, 56%) were assessed at a mean follow-up of 5 yr (range: 2-9). There were no cases of clitoral vascularization defect or urethrovaginal fistula. The urethral meatus was never hypospadic. The vaginal introitus was large and elastic in all cases. Vaginal caliber at the internal suture line was as large as the vaginal introitus and the distal native vagina in 20 (43.5%) of the 46 girls. All mothers and patients reported satisfaction with external genital appearance.
• Conclusions: These long-term results suggest that our modifications of one-stage Passerini-Glazel feminizing genitoplasty facilitate the procedure and produce good cosmetic results.
  
  
• Editorial Comment
  In this manuscript, consecutive cases from 1988-2005 were reviewed. 82 primary cases were done by the Passerini-Glazel feminizing genitoplasty technique with some modifications. There were 22 remaining cases that had undergone surgery elsewhere and the primary cases were operated in an average age of two years while the secondary cases were operated at an average age of 13 years. The manuscript has a good description of the procedure and excellent diagrams for those who might be less familiar with the procedure. Complication rates of the procedures seem acceptable and the long-term follow up that was done. 56% of the patients underwent general anesthesia months to years after surgery showing good results.
  Modifications of the procedures recommended by the authors were:
  1. to dissect the urogenital sinus from the vagina first before it is separated from the corporal cavernosal bodies
  2. complete removal of the corporal spongiosum minimizes bleeding and operating time
  3. it is important to separate the posterior vaginal wall from the inferior urethral wall for a length of about 1 cm, which allows mobilization of the native urethra and avoids vaginal stenosis
  4. to reduce vaginal stenosis at the suture line they recommend aggressive removal of the distal dysplastic segment of the vagina
  5. make a U-shaped inverted skin flap in the perineum to rotate in and become part of the vaginal exterior suture line
  6. make incisions in the corporal cavernosal bodies at 3 and 9 o’clock to minimize neurovascular bundle compromise
  7. if the glans clitoris needs to be reduced they recommend a wedge from the ventral midline rather than two lateral triangles as was originally described
  This procedure is helpful in difficult urogenital sinus cases and this manuscript and its illustration will be beneficial to surgeons who undertake these procedures.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA