INVESTIGATIVE UROLOGY

The laparoscopic management of intersex patients: the preferred approach
Denes FT, Cocuzza MA, Schneider-Monteiro ED, Silva FA, Costa EM, Mendonca BB, Arap S
Division of Urology, University of Sao Paulo School of Medicine Hospital, Sao Paulo, Brazil
BJU Int. 2005; 95: 863-7

• Objective: To present possibly the largest series of the use of laparoscopy for treating intersex patients.
• Patients and Methods: Fifty intersex patients (34 with male and two with female pseudohermaphroditism, nine with gonadal dysgenesis, four with true hermaphroditism, and one with complex hypospadias), aged 0.5-46 years (mean 18.3), underwent laparoscopy to remove gonads and/or ductal structures incompatible with the social gender, or for gonadal tumour or a potential risk for malignancy. When necessary, genitoplasty was performed concomitantly.
• Results: At the laparoscopic evaluation, 10 gonads of six patients were absent, while four were identified as ‘vanishing’; 72 gonads (46 dysgenetic, 17 normal testes, one normal ovary, one ovotestis, seven gonadoblastomas or dysgerminomas) were removed; two ovotestes were replaced in the scrotum after removing the ovarian segment, as was one normal testis. Twelve patients with a urogenital sinus had its vaginal component removed, 11 including a hysterectomy. Three of these patients had a combined perineal approach to complete its removal, together with masculinizing genitoplasty. There were no intraoperative complications or conversions; two patients had complications after surgery.
• Conclusions: Laparoscopy allows the straightforward identification and removal of gonads. All abnormal ductal structures must be removed, as this increases the chance of resecting unidentified gonads. Removing the uterus and vaginal component of the urogenital sinus in patients with male social sex is feasible, with low morbidity. Genitoplasty, according to the social sex, can be performed in the same procedure.
  
  
• Editorial Comment
  The authors present the largest series of patients with intersex treated by laparoscopy. Different from the most recent series of intersex patients, due to specific social and geographical conditions of a developing country, most of the patients in this study were first evaluated as adults, and therefore treated accordingly to the already defined sexual situation. Nonetheless, whenever necessary, associated genitoplasty was performed, according to the sexual function of each patient.
  Laparoscopy is usually used for gonadal evaluation, resection or biopsy, and for identifying internal ductal derivatives. It is also used for removing all normal structures contrary to the assigned social sex, as well as gonads that are dysgenetic, nonfunctional or malignant or of increased malignant potential. In the present work, the authors completed all procedures in 50 patients with minimal blood loss. The duration of the procedures was 55 to 270 min, including associated genitoplasty. There were no complications during surgery or conversion to laparotomy. When there was only a laparoscopic procedure the hospital stay was 1 to 3 days, and with associated genitoplasty, the stay was 6 to 11 days.
  The authors concluded that this technique allowed easy identification and removal of gonads. They also found that other organs could be removed and genitoplasty performed with minimal morbidity.

Dr. Francisco J.B. Sampaio
Full-Professor and Chair, Urogenital Research Unit
State University of Rio de Janeiro
Rio de Janeiro, Brazil