The Center for Transgender Medicine and Surgery at Mount Sinai encompasses a variety of specialties covering transgender surgery including Urology. The Department of Urology's gender affirmation surgery program is led by Dr. Rajveer Purohit, Director of Reconstructive Urology, is an expert in the field of genital gender affirmation surgery. Together, the physicians have experience with over 2,000 genital transgender surgeries that informs their care of each new patient. They have recently co-edited a textbook, Atlas of Operative Techniques in Gender Affirmation Surgery published by Elsevier in 2023.
In this video, Miroslav Djordjevic, MD discusses his approach to multiple vaginoplasty techniques including penile inversion vaginoplasty, robot assisted peritoneal flap vaginoplasty, robot assisted sigmoid vaginoplasty and minimal depth vaginoplasty. In addition, he presents a variety of masculinizing genital surgeries are also reviewed including techniques for metoidioplasty and for phalloplasty. Advantages and disadvantages, and preparation for the variety of surgeries are discussed.
To refer a patient, please call: 212-604-1730CTMSproviderreferrals@mountsinai.org
My name is Vira Georgie and I'm coming from Belgrade Serbia. And uh today, I think uh I'm one of the oldest uh urologist who works with the transgender population because I started to do this 30 years ago. Our department of urology is very well known over the the world. And uh I'm very proud that I joined this department uh five years ago and started to work here together with uh my colleagues. We cover all uh issues like reconstruction, uh congenital, an uh transition urology and finally, transgender surgery in both ways, male to female and female to male. Um I worked in many countries over the world um uh be a part of many uh meetings, uh former president of uh Jani and reconstructive Surgeon Society. And finally, I'm a member of uh urology Department in Mount Sinai. And uh I tried from the beginning till now to develop not only surgery to develop the, the better conditions for our clients uh and also to show the world that uh we have to do everything according to our skill set experience, to help to this huge uh population. I prefer to work with the transgender population. Not only to give, uh, uh, and to offer, uh, some results in the surgery. I'm working in bioethical principles. Also, I'm, uh, uh, one of the, of the parts of uh many groups in the world who are going to, to try to find a better conditions for, for, for health, for, um, a better life. And then, so I found that, uh, is very, very important today to, uh, continue to work, not all in the surgery. And from the 2016, uh we opened a transgender uh medicine at Mount Sinai and uh from this period in the last 56 years, so we developed almost all disciplines here. So now I can tell that Mount Sinai has uh uh especially our Center for transgender Medicine. Uh He has uh uh in place a very important role in the United States. And uh I hope that in a couple of years, we will be the leading center, not only in United States, but over the world, if we discuss about uh female to male transgender surgery, geering surgery, we can split this um uh this field in two groups. One group is uh how to create a small neal from enlarged glittery. This procedure is well known as Meio and another group of, of uh uh procedures are phys total pylos using um either microvascular transfer of the tissue or maybe some local flaps if you discuss about meio. Uh It is one of my specialties uh started to develop this procedure 30 years ago, uh modified several times. And today, we can tell that this procedure is very simple, very safe and incorporate a removal of the uh all um remnants of female uh internal external genitalia like uh uterus ovaria vagina. Then a lengthening of creation of scrotum insertion of the implants and also lengthening of the clitoris with only one uh goal to give appearance of the male genitalia in this um trans trans men. Our main goal is to uh offer to our patients to void, standing from the tip of the new creative and also to give a possibility for normal sexual um uh sensitivity and intercourse, but without possibility for penetrative sexual intercourse. Uh For this reason, we usually recommend the PLO plastic surgery. It means uh that we are going to use some tissue from the patient body uh and then create a neal that is a tube created from the skin tissue and maybe sometimes uh with the uh we incorporate a piece of the muscle. And after that, we are going to join this neal with the smaller pal or with the G for better sensitivity and erogenic sensation. Uh We have a plenty of the techniques for uh uh neophyte. One of the gold standards is using of the arm of the tissue from the arm that that um is well known as a flap pals. Another option is um uh a LTP that means using a piece of the for the creation of the new uh Neal. But our preference is to use plastic. And we developed this technique 20 years ago and found that this technique can give the best volume of the opal. That means all this available for the two penal implants uh with the with the without possibility for reduction of the size with age and also uh the completely natural appearance. That means also a reduction of the visible scars of the body like from the arm. Our experience is very high. We publish too many articles in the leading journals. Uh We publish many chapters in the book and I can tell that the complication rate in this type of surgery is not too high and the main complication is related with the uh lengthening of the. So for this reason, they are going to do several steps how to lengthen your to the very long opus. And we usually use uh some graphs like uh or graphs in one or in a multi state procedures. Uh is procedure how to lengthen the clit and create a small neal. It means that you are going to reduce all um connective tissue under the clitoral skin and then to uh radically divide all ligaments to advance the clitoris and to give a better length. According to our findings in more than 2000 clients that we had in the last 25 years, average of the size after this type of surgery is approximately 5.7 centimeters and ranged from four till 10 centimeters. It depends on patient built also. So if you have a client who is overweight, who is little, uh who is obese or something like this, visibility of his neal will be smaller. So for this reason, we recommend preoperative reduction of body mass index for better periods of of the neal. Another technique that we offer is a reduction of the fatty tissue from the moss region. It uh is well known as mos plasty. It means to reduce the old fatty tissue with some skin from the moss region, creating the very flat plate here and to give a better uh appearance of the new created falls from a large glitter candidates for meio plasty are not defined as a best candidates or uh not good candidates. And then meiotic presents one of very nice technique and very nice procedure how to make a final surgical transition. But if you discuss about the final outcome and satisfactory results, it depends on a patient built on the body mass index, on anatomy and um nature of these patients. The ideal candidate is who is not obese, who has a body mass index, 125 who has a, a good build with the uh a lot longer than uh 56 centimeters with a good developed a minor and major. So in this case, we can uh promise that we will do a very, very good result. But me blas presents one of the basic technique that means that with this technique, we can offer to our clients uh final transition and finish bottom surgery. Always possible in the future. If our candidate looks for uh longer and bigger new files, we always have a possibility to continue with the surgery and to create this from another tissue to do some of the procedures named blasting. We have one group of our clients who uh showed the interest to uh preserve vagina at a place. So for this reason, we offer this possibility and uh uh in the case that they would like to have a lengthening the risk of uh uh complications like uh uh fistula is higher because we don't have uh find uh a good tissue to give us support for new created ure from the bottom. That is a place of vagina, but we can do this and we can preserve vagina at a place. Uh In the case is who would like to preserve ure opening and vagina uh as in a female anatomy, we create a small neal from clitoris. We do meio and also we finalize this with the scrotoplasty and with the possibility to insert or not to insert the implants so we can do everything with the female genitalia today. According to our experience, scrotoplasty in a, in a female to male transgenders, uh is usually um uh is usually um enable using a Libya major. The simple procedure is joining of labium major in the middle line and then insertion of the testicular implants with appropriate size. In the last couple of years, we found an interest how to make advanced scrotum. But uh it depends on anatomy. And today, this is something like a fashion. Everybody looks for this possibility and everybody thinks that that is not necessary to have a good anatomical relationship to have a good sized scrotum and to be, that will be advanced. Uh uh and and uh will be uh in the front of the, of the genitalia. So everybody today starts to do this without any preoperative measurement. And then my recommendation is we can do this but only selected cases in opposite, you can create a new that will be advanced, but without volume inside. So it will be not space to put any of the implants smaller size or maybe uh medium or, or appropriate size according to the build Plasty is a procedure that we can split in several stages. But in our hands here at Mount si I can promise you that we can do everything in one stage. That means a removal of female genitalia, internal or external creation of the opal scrotoplasty and everything in approximately four hour surgery with one day in a hospital. So it is based on our experience, not only in a transgender surgery, this is experience arise from our work in pediatric congenital animals. Also that the principle are almost the same is a technique that we developed almost 20 years ago in the first place. Uh to create a neal in uh Children who born with very difficult animals like extra uh congenital absence of the penis or uh hypoplastic penises. Later, we continue to work on this field and to use the same principle to create a neal in transgender population. Uh We prefer this technique uh due to uh very good advantages. One of the main advantages is uh good size and good volume of the neal. Another advantage is um uh non visible scar formation because the scar is located on the back of our body and all possible to cover. Uh Next uh advantage is that we have always enough space to continue to lengthen ure and to put in good volume follows. And finally, to put a two implants of penile prosthesis, two rows of penal prosthesis. And of course, there is a, there are disadvantages. One of the main disadvantages is absence of tactile sensation if you discuss about tactile cessation. This is something like philosophy today between uh can candidates and surgeons. So all of the candidates showed interest to have a perfect tactile sensation. But uh my opinion is that the tactile sensation uh plays no role in aerogenes activities and aerogenes sensation. So for this reason, if you discuss about absence of tactile sensation and in opposite good uh size of the neo without possibilities for reduction. With the, with the time, my preference is our preference is to do everything in one state. It means to do something like that is lengthening, lengthening, using vascularized hairless tissue from female genitalia, like minor and clitoral skin and to lengthen this uh with a good vascularized tissue maximally. That is the first part together with. After this surgery, patient can expect uh to be in the 1st 3rd or maybe in the mid of the opal depends on his anatomy. In a second state, we are going to Langton mo abdominal plasty presents one of the methods for creation of the opal. The technique is very simple and safe because uh technique is based on using of local lower abdominal skin with the surrounding uh fatty tissue surgery is uh time consuming in approximately 2 to 3 hours. We can create a wood tube to put the base of the neo files in the proper size, usually to cover the defect and to close the defect without any special and additional tissue. But uh regarding a long term follow up, we can expect maybe some reduction. It means if the client is going to lose some weight with the time for any of the reasons, he can expect a losing of the uh girth and the volume of the opal. This is one of disadvantages. Another disadvantage is also limited sen uh tactile sensation. And based on this, our research is going further and we started at Mount Sinai to develop a project, how to use nerve transplantation for another parts of the body and to incorporate it in our nealis to give a better sensation, tactile. And internal neo vaginal plasty presents a technique how to create neo varina uh using uh another tissue. If we discuss about neo vaginal plasty in uh male to female transgenders, we have several options today. Gold standard uh still is still a penal inversion, vaginal plastic. That means using of the penal skin combined with some scrotal flaps or graphs to create a good uh depth of the neo vagina. This technique is very safe and uh approximately 80 85% of all centers in the world perform only this technique. You know, supposed we have a couple more options. One of the uh good options is uh using of colonic segments for creation of neo vagina. And our preference is using of sigmoid colon. Why? Because the sigmoid colon is very close to the uh to the pelvis. That is not necessary to dissect too much this segment to bring to the channel and to create neo vagina. Moisture of this vagina is a perfect. Uh We usually use a short segment to prevent the beds melt and the complication rate is really very low. But we usually recommend this type of surgery as a uh variant too, especially in the candidates who had a failed penal inversion vaginal plasty. In the last couple years, we developed a new technique that is uh using of peritoneal flap to creation of new vagina. This technique is very, very well known for more than 2025 years. And we usually use this technique in these females who born without vagina, but there is a big difference between male and female anatomy. So if you can tell that this procedure is very simple in a these females due to anatomy and the length of the pill pelvis in male to female transgender, we have to do too much to make a good flaps, good length flaps and to give a good appearance, good, moisturing and good final result of the new vagina. When we discuss about the final decision, we have to follow our patients, our clients who are looking for the best option according to uh the themselves opinion. So if we see that the, the client wants to have a sigmoid or um a vaginal plastic, we are here to explain and to ask what is preference to do this technique instead today, well known gold standard penal inversion. So our goal is always to follow our patients and to do the best surgery and to make a satis uh good sati satisfactory after surgery. Our goal and our opinion is that is the satisfactory result. Our satisfactory is based on satisfactory of our client. So according to human rights, there is no reason. According to the bioethical uh principles, there is no reason to tell to the patient you uh can have only aversion and we cannot do uh colonic or peritoneal vaginoplasty. This is not our decision. This is the decision of the patient of any of the persons in the world. Why? Because they are owners of our body and we are here to ge get permission and to trust to surgeons for some parts of surgery for some changes in our life. Sexual activity after um a male to female vaginoplasty is possible almost eight weeks after surgery, but it depends on personality. If we discuss about complications. After uh creation of the new vagina, we can split these complications, uh early complications and late complications. Uh early complications, uh uh includes some postoperative bleeding, uh some openings of the wounds after surgery, uh and some problems with avoiding after removal of the catheter and usually uh result spontaneously if he discovers about late complications. Uh One of the main complications is uh stenosis or absence of the vaginal dept. For this reason, we have to offer another additional surgical procedure using some other tissue like colonic segments of peritoneal flaps. In case if you do, uh if you did the uh penal inversion as the primary surgery and some very difficult complications are injury of the some organs in the pelvis and in the abdomen, like rectal injury, injury, prostate injury, bra injury. But these complications are really very, very rare in experience scans. I would like to tell something uh for all of the surgeons and for all of the candidates who are ready for transition. It is very important today to have a good experienced surgeon who is going to do some of the procedures we have today, more than 300 transgender surgeons in the United States. And I found that some of surgeons spent a couple of weeks with uh some more experience and starting to work on this field. But it is not the issue only in the United States. It is the issue today in all parts of the world. Be careful. We are going to make a final decision and to change life for our candidates, we have only one chance to give their life better. So for this reason, stay in touch, communicate with another surgeons develop your techniques and your skills. And if you're not sure that you can do good and safe surgery, please wait and please try to educate more to be sure that uh some life will be better after your procedures. All candidates for transgender surgery are a good, very good researchers. So all of candidates who visited me are to showed a very good interest and uh very huge research before coming and before final decision about surgery. So my recommendation is for the of our clients to make a good research before final decision, when to come and where to come our future in uh transgender medicine starting yesterday. So uh today, if you discuss about situation today. I'm sure that is a very short period that we will have a better, better options for our transgender population regarding surgical options. So one of the main field will be transplantation of the organs. For this reason, we started several years ago to develop a programs how to transport uterus, how to transport testicles, how to transport penises. And according to this, I'm very proud that we did one uterus transplantation and one testicle transplantation 1st, 1st time in the uh in uh in the world. And now we are, we are in a huge projects in Mount Sinai and in my university of and prepare to do maybe penal transplantation in trans in trans men.
