The abdominal sonography technique is found to have a sensitivity of 100% in identification of internal female genitalia 17. In our study, a lower ultrasound sensitivity of 71.4% was reported. This low sensitivity may be related to the experience of the radiologist and the quality of the ultrasound machine. However, the sensitivity obtained by us is very close to the sensitivity of 77.8% reported by Elhalaby 18. Retrograde genitography was found to have a sensitivity of 64.3% in determining the length of the common channel. This is close to the results reported by other studies (60% by Chertin et al.17, 55.6% by Elhalaby 18 and 72% by Vanderbrink et al.19). Hence, endoscopy is considered to be a crucial step in genitoplasty, as it identifies the anatomy of the common channel and enables insertion of a Foley or Fogarty catheter into the vagina through the communication to the UGS 20.
In the present study, the policy of early one-stage correction was adopted. Graziano et al.21 agreed that early intervention is associated with better compliance with dilatation, a reduction in the parents’ concerns regarding their child, and a lesser psychological impact on the child at an early age. In contrast, Alizai et al.22 support postponing vaginoplasty until puberty claiming the availability of supple and genital skin and avoidance of revision after early surgery. However, we agree with Elhalaby 18 on the ease of handling the vagina in young children.
The length of the urethra proximal to the confluence with the vagina is more important than the length of the common channel, with a high risk of incontinence when the urethra is too short 23,24. This study found that the relationship between the length of the common channel and the degree of virilization is not statistically significant (P=0.106). However, Escala et al.25 found a direct relationship between the length of common sinus and the Prader score.
Studies on urinary function after TUM revealed well-preserved continence mechanisms postoperatively 23,30. However, Rink et al.9 discussed the concerns associated with the very proximal, circumferential dissection above the pubourethral ligament and described the technique of partial urogenital mobilization that limits the chance of injury to the urinary sphincter, clitoris, and their innervation. This latter technique was used in most of the patients in this study, and all evaluated patients were found to be clinically continent.
UGS mobilization is a valuable tool in feminizing surgery in many aspects. It solves technical problems and facilitates dissection, maintains adequate blood supply to the urethra and vagina, minimizes blood loss and requirements for blood transfusion, and has good cosmetic outcome with low incidence of complications and without affecting mechanisms of urinary continence.
There are no conflicts of interest.
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