Discussing Corrective Surgery with Mr. Timothy Terry

By Kim E. Humberstone; edited by Anne A. Lawrence, M.D., Ph.D.

On 7th August 2000, I had a consultation with Mr. Timothy Terry at the BUPA Hospital Leicester to discuss some post-operative problems I was encountering. My original gender reassignment surgery was carried out by Mr. Terry on 8th April 2000, so I was now 4 months post-operative.

Initially Mr. Terry enquired about my progress since he had last seen me 2 months ago: whether the deep vein thrombosis (DVT) in my right leg had cleared up, and whether I had now re-started hormones. Fortunately both of these problems had been resolved. A regular regime of cycling, swimming and jogging had cleared up the remaining muscular problems left over from the DVT, and Dr S. Machin, the Professor of Haematology at the University College London had given me the all clear to restart hormones – Oestrogel (17B Oestradiol) 4 x 0.75 mg per day and Duphaston (progestagen) 1 x 10mg. Professor Machin had recommended that I should not take the synthetic hormone ethinyl-oestradiol, because it increases the risk of a further thrombosis.

I then briefly explained my current problem: the amount of erectile tissue surrounding the penile stump is excessive. The stump is still a visible feature, about 25mm in length, and has lead to two problems. The urethra outlet has been positioned at the top of the stump, basically where it was originally cut back to during the penectomy and in such a position that any slight swelling of the erectile tissue changes the angle of the outlet so that it points upward. This has resulted in the flow of my urine arching over the toilet seat, across my knickers and onto the floor. The second problem is that the excess erectile tissue prevents penetration into the vagina when I am in any position other than lying flat on my back. In addition to this problem a significant amount of scrotal hair has grown inside my vagina, further restricting access and making dilation uncomfortable.

Mr. Terry started by giving me an internal examination, checking on the extent of the scrotal hair and on the size of the penile stump. He commented that generally my vagina had healed well, it had a satisfactory appearance and a good depth and width had been achieved.

Mr. Terry then explained that as a matter of policy he does not like to perform non-emergency corrective surgery on any patient until they are about 12 months post-operative. He gave three reasons for this: Firstly, it is his experience that it can take up to 10 months for the surgery site to fully settle, with various tissues settling at different rates so that some problems reported during that period are only temporary. Secondly, as corrective surgery has its associated risks, it is his general recommendation that if a patient can live with a problem then they should try and do so; 12 months is a reasonable timescale to check whether a problem can be lived with. Finally, he had had a few patients who had rushed to have something corrected and later regretted their haste.

With regard to the problem of hair inside the vagina, Mr. Terry said that he had not been previously aware of the problems which this can create. He was also unaware that electrolysis or laser treatment could be undertaken before surgery. I gave him a copy of the diagram and notes prepared by Dr. Toby Meltzer in the USA. Mr. Terry said he would discuss the implications of this with the plastic surgeon with whom he works, with a view to changing his recommendation regarding pre-operative treatment. For my condition, the only thing he could offer was to take me in as a day patient and, under a local anaesthetic, scrape the hair out with the assistance of a speculum. This would have to be done on a regular basis. He did say that if anyone knows of a better method of removing the hair, please let him know.

Mr. Terry then went on to describe the procedure for removing the excess erectile tissue around the penile stump. The procedure is performed under a general anaesthetic, and requires up to three days hospital bed rest afterwards. A vaginal pack is not required this time. Basically the procedure involves cutting open the outer layer of flesh around the penile stump and then removing the erectile tissue which surrounds the urethra. The outer layer of flesh is then re-packed and the wound sewn up. The procedure carries two significant risks: The penile stump has two major blood vessels, which feed it, both of which come off main arteries. There is a risk of significant blood loss if these blood vessels are cut or punctured. Also, the urethra itself is made of a fairly thin membrane, and when the flesh around it is repacked and heals, there is a risk of scarring of the membrane itself, possibly leading to painful strictures and long term difficulties in urinating. Mr. Terry said that he had performed the procedure on a number of occasions before, including on former patients of Mr. J. Dalrymple and Mr. M. Royle.

His recommendation was that I think about how serious the problem is to me and come back in six months time to discuss it again if it remains an issue.

I then enquired about labiaplasty, and whether he was able to tidy up my labia and give me a clitoral hood. During the primary GRS procedure, Mr. Terry creates “V” shaped labia, and makes no attempt to close them at the top over the clitoris. Instead, the clitoris is to some extent shielded by the ridge of the “V”. I had brought along some pictures showing the work of Dr. Toby Meltzer, whose second stage labia is very realistic. Mr. Terry described the procedure, which is taught at the University Hospital in Amsterdam, which is basically to make a “W” or double “Z” incision in the skin above the clitoris and then invert it to form an “M” shape linking up the top of the current “V” shaped labia performed in the original operation. This is virtually identical to the second stage operation performed by Dr. Seghers in Brussels. Mr. Terry said that he had never performed the procedure but had seen how to do it in a reference book. The procedure could be performed at the same time as the corrective surgery.

Mr. Terry said he would send me a letter detailing the cost of both procedures.

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