This file is a transcription of a recording made on October 3rd obtained at the Southern Comfort conference in Atlanta, Georgia; October 1 - 4, 1992.

The speaker is Dr. Michel Seghers of Brussels, Belgium.

The information here was received in November 1992 from someone who attended the conference, and was known to be valid at that time.

This information is strictly for review purposes only, it does not constitute an endorsement, and any additional questions or clarifications should be discussed by consulting with Dr. Seghers or his staff.

Only minor punctuation was added to make the text flow better for the reader. Only minor portions of the lecture were lost due to interruptions like tape change or a change in microphone position. These interruptions are estimated to be less than 5 minutes of a 2 hour lecture. Slides were presented along with the lecture and the purpose of this file is only to retain some technical information that might be of interest in learning something about the surgical technique.

This document was set using WordPerfect 5.1, courier 10 cpi font, and then converted to ASCII for compressing and uploading. The filename was designed specifically to provide for adding subsequent information or comments to be titled serially for reference purposes. Any additional information or experiences are always important and hopefully will be added, but "please consider" using the same basic format of 6 letters and 2 digits NAME##.TXT or .ARC filename with just a sequential number if possible.

With corrections made from the original tapes and additional comments by Barbara Bertrand 11-26-92 (ending date) (I'm the "someone" who attended the conference and made the recordings.)

CODES:

**A** indicates a speaker from the audience, all other transcribed information

was material presented by Dr. Michel Seghers.

**S** indicates Dr. Seghers replies to audience questions during the Q & A

followup to the lecture.

???? indicates a word that was not understandable.

Double words such as "they they" or "this is this is" were transcribed as spoken.

(?) indicates a word for which the spelling was uncertain.

[ words ] indicate words added for clarification of what was said in the

lecture or audience reactions.

begin text:

INTRODUCTION BY APRIL:

**A** Once again I come before you. You know I'm April. I'm post-op. I'm here today to introduce a gentleman to you that I have personally met twice in his own country. The first time he said no. I had the flu. The second time we were successful. He is without a doubt, in my mind anyway, one of the most humanitarian persons I have ever met in my life. He studied for his doctor of medicine in Belgium, where he's a native. Then he did his residency in Cincinnati, Ohio. So therefore he knows something about the states. He's a great lover of Arizona, by the way. After his residency, and he will tell you more about this, but he went to what used to be the Belgian Congo; it is now Zaire, went to Kinshasa, where he practiced medicine for a while before returning to Belgium. He has held numerous positions in the medicine community in Belgium. He is married; I forget Liz's last uh maiden name; you can tell them that. Anyway he has three children who are very successful in their own right. And so is his wife, she's pharmacist. Like I said, when I went to Belgium the first time, I took a little side trip and I went to Germany before I went on to Belgium. I caught a cold, not a cold, the flu. I was running a high temperature the morning he was supposed to operate. He said no. I begged and pleaded with him that day. He still said no. Well, I was disappointed, I mean after all going all that way.

But, as I thought about it more often, I began to realize why he said no. He was afraid, and rightly so, that there might be complications. This should tell you what type of person he is. I went back later, which was this January. We had a little problem but we worked it out. He did the surgery, and I stand before you today a very happy person. I'd like to at this time, without further adieu, introduce one of the true humanitarians in this world, Dr. Michel Seghers.

Dr. SEGHERS SPEAKING:

Hello to everybody. I must say that I am quite impressed by such a large audience and by the the quality of the of the people being here. I don't now if I deserve it, but anyway I am here and I have paid the reality. And to begin with, I have to thank, really of the depths of my heart, the organizers of this meeting and particularly, Mrs. Montgomery who organized this comfort meeting. The name of Montgomery is dear to me because as a few of you know know, I live 200 yards from Montgomery square. That is where you'd find my street, you have to cross Montgomery square. I have another Montgomery instinct. And when I came, somebody told me that the Southern Comfort was a kind of bourbon. I didn't know, but my history reminded me of my first medical year in central Africa as you told them, in central Africa, not Mexico, and we were supposed to bring a package of medical comfort which was in fact champagne and we used, we had to give that to the peasant people during the dry season. As you see already, in my introduction in fact I will make maybe my introduction a little long so that I keep the best part of the cake for later on and maybe I can be invited another opportunity. And you see I have been really impressed by the tremendous surgical work which can be done in the rough country and in the tropical area in the former Belgian Congo, now Zaire. Besides that I am pleased to meet here, several former patients. And I thank them for their presence, for their testimony and sometimes I wonder, I am afraid if I shouldn't wear a bullet proof jacket, this is strong. Thank you to Mrs. April ----, faithful patient who had to fly twice to Brussels to have a job done and I can confirm what I write in a major American newspaper not too long ago, "the ordeal is over, the change has been made, my maleness is gone with the flick of a blade, in fact, my blade". So, before explaining what I am doing now, I think I should briefly introduce myself or continue the introduction you have done. I am, it's important, the oldest of the family of eight children, born in 32, she had the delicate enough sense not to tell it, but so it makes it 60. And I graduate as a physician of the University of Pluvin(?) in Belgium in the French part of the university in 57 at age 25. Instead of doing a military service, I had the choice, and I chose to spend three years in the Belgian Congo which at that time was not yet independent. The first year I was a general practitioner, general physician in a cane sugar company, or sugar cane company I don't know exactly how it should be said. The two following years were devoted to two years of residency in surgery at the just newborn University of Leopoldville now Kinshasa in Zaire. In 1960, at the end of these 3 first years, I went back to Belgium, in order to complete my surgical training. Later on, 2 years later, in September 62, a new turn in my professional life since I had been accepted for a fellowship, not a residency, I was on* a fellowship in plastic and reconstructive surgery in Cincinnati Ohio, in the department of Dr. J.J. Rongek(?) and Associates, at the Christ and Children's Hospital, Cincinnati Ohio. That was a very busy and interesting time, where I was known, I'm not afraid to tell it, as the "brussels sprouts".

Dr. Rongek(?) has brought my wife or two childrens. We had an addition in Cincinnati, since my wife had three childrens, born in three different continents and 1 year apart. And Eric, our youngest son, who is now pilot for Sabina [Sabina airlines], and still has an American passport and when he flies to Boston with the airbuses using this American passport he has and I don't have.

You certainly must realize that I had the temptation to stay and to practice in the states, since I had passed the ECFMG, the medical examination for foreign graduates. And in fact, Dr. Rongek(?) had insisted to keep us and but I had just obtained an appointment as assistant professor at the University of Kinshasa in Zaire, the former Belgian Congo. This was the country of my first love, not for me professional love, but as it where I had met my wife the pharmacist of the university hospital who happens to be still my wife, and who is supposed to come tonight. I always enjoyed to work there, and you will see through the first slide, maybe the too long introduction, oh, it was really exciting. But 3 years later, in 66, due to the chronic instability of central Africa, and the need for my children to go at school and to complete their education, I decided to go back to Brussels, my home town, and to start a solo practice in plastic and reconstructive surgery. It was not easy at the beginning, since I was not very much interested in the purely cosmetic and aesthetic procedures. I looked for something unusual that not too many were doing. [LAUGHTER] Maybe you can put the first slide please. Now it's time to learn a few... Yes, very good...

SLIDE:

I've chosen a peaceful introduction with my favorite bonsai of last year. The red color will serve as an introduction to the following bloody slides and I hope that everybody will be able to stay with us this early afternoon. Now a few slides from Brussels that... Next please.

SLIDE:

You see a monument close to my office. This was built in 18 hundred and 80 (1880) for the 50th anniversary of Belgium. Belgium was independent in 18 hundred 30 (1830). So, it's a younger country than the United States. And besides both sides of the arcade a former patient [I] know had been visiting that day, saw war museum one side, and exhibition of old cars. It's a safe park to walk in, to walk in. Next please.

SLIDE:

A view of the Grand Place in downtown Brussels. At that time it was a carpet [of] flower, this happens 2 or 3 times per year. With the main building both sides, this is one of the 2 must in Belgium for maybe travelling people.

SLIDE:

The next one. The Catholic cathedral, gothic style, made in the 12th and 13th century. Next one.

SLIDE:

This is the headquarters of the Common Market, a very important building which is now empty because they are doing some remodelling. And the last one I think about Brussels. Next one.

SLIDE:

Yes, the Atomium, a souvenir of the World Fair in 58 in Brussels. It represents an atom of iron.

SLIDE:

Now a few slides with the old St. Joseph that some will remember, this is... yes St. Joseph, St. Joseph. Well known by former patients and where I started my practice when I came back from central Africa in 66. And I continued to work there until March 91, so little more than 18 months from now when it merged with another hospital, the new Foundation Lambert which is 3 blocks away and which was completely remodelled. Next one.

SLIDE:

A closer view of the entrance that a few will remember fondly but now it's this time is over; it's an old building of course. And the next one.

SLIDE:

On top of the street just the other side of the stop for the tram which was convenient to be used, a Catholic church and which we used to, to work. So far, yes, next slide please.

SLIDE:

This is my office, and as is quite common in Europe, office and home are both combined. This is my entrance where I live and my wife enters, yes and one child, the two others having moved. Next one please.

SLIDE:

Yes, you see. So far, so far it doesn't explain how I became involved in the surgical treatment of gender dysphoria. I must confess that I had absolutely no idea of this kind of gender problem, nor of the other problems. During my medical studies of sexuality and related problems were in fact "terra incognita" something completely unknown that nobody spoke about it. Pluvin(?) was, and is still supposed to be a Catholic university, but slowly things are changing. So, I, thinking to that, I realized that maybe I made my studies before the birth control pill and I had in mind, I was wrong, but, that eventually the homosexuality was just something for clever people who wanting to avoid pregnancy. I was not, this was not an easy answer, I had, and that was it. In fact at that time, I was not too interested in that and I kept me busy with my medical studies, playing bridge, playing field hockey and being active with the boy scouts. That was enough at that time. Next slide please.

SLIDE:

This is part of the history. The next one.

SLIDE:

This is the university hospital in Leopoldville where I started my practice of plastic and reconstructive surgery in 63. That view of the hospital where in fact my first son was born. I was so proud to go back there where I had received an appointment as associate professor. Five days after my departure from Cincinnati, I was already there in Kinshasa, Zaire 3 years after their independence. Quite a change. In fact I was anxious to perform a lot of reconstructive surgery and eventually cancer surgery. This was a tremendous dream and in fact, independence had been granted to Zaire in June 30 in '60, three years earlier, and I was convinced that all troubles were over, it was not. But it began differently during my second week in Zaire in October 63 [November actually]. A Friday night listening to the Voice Of America, I learned that President Kennedy, had been murdered, had been shot in Dallas. I was still part of my heart in Cincinnati and I used to hear the voice of America. I set up nights because there was six hours difference in central Africa and here, because it happened I think around noon. I was practically shocked, because I think that I had seen President Kennedy 3 weeks earlier campaigning in downtown Cincinnati, and already at that time he was speaking about the problem of the jobless already in September, the end of September 63. I quickly discovered, that not only Dallas, Texas was dangerous, but dramatic civil war started in Zaire. Of course, I didn't have to fight with a machine gun or something like that but I was in charge of many wounded. Next slide.

SLIDE:

Another closer view of the university hospital, there was some rain. Next one.

SLIDE:

Yes, you see how everything looks so peaceful and nice, but in fact, it was not. Next.

SLIDE:

You see a view from airplane with the streaked red mud and everything looks very nice. Next slide.

SLIDE:

You see now an American plane landing with Belgian soldiers in a campaign airport. Next one.

SLIDE:

Yes, Next.

SLIDE:

A lot of destruction, casualties of all kinds. Next.

SLIDE:

And you realize not only soldiers but maybe civilians and children, like in Yugoslavia now, were wounded and had to be treated. But usually they were arriving very late several days after their accident. The United States Air Force was helping Belgium. They just put paint with different numbers, but in fact they were American planes and saying that they were not in Zaire but in fact they were. Next one.

SLIDE:

And you see a safe being blown out to take the money. Next.

SLIDE:

This was really a rough time, so mercenaries coming from, a few Belgians and a few other ones coming from South Africa. Next one:

SLIDE:

Of GI truck. Next one.

SLIDE:

This is you see, this is you see another you see marines there. In fact they have removed a jeep from out of the airplane and putting on behind the truck and to bring some supplies. Next one.

SLIDE:

Yes that's ok(?). Next.

SLIDE:

But you see, we were brought many soldiers wounded and usually it took 2 or 3 days before reaching the university hospital.

********VOLUME LOST FOR TWO MINUTES********

2 or 3 SLIDES:

Running commentary on how Seghers fixed up a wound ripping off a part of a black soldiers upper lip and most of the skin of the lower lip and jaw. Really as messy as SRS.

********VOLUME LOST FOR TWO MINUTES********

SLIDE:

The last slide of my African practice will be interesting because the next one you will see... You will see this is a long man being a chief and he had been sent to specialized hospital since he was suffering from leprosy. And after he was cured of his leprosy, he was referred to me because he had breasts that he didn't want to have. I just knew that it was connected with the testicular atrophy, but the true reason was not investigated and is still unknown. So I just decided to remove the breast, do subcutaneous mastectomy, so you see I'm doing sometimes things for female to male. But he was a male. Next one.

SLIDE:

After the mastectomy, subcutaneous mastectomy, through peri-areolar incisions. This is you see is not any more afraid to show his face. So now at the end of 66 when I was looking for an interesting field of practice, since I didn't have the kind of patience to talk with patients for cosmetic procedures, despite it could lead to a very easy and rich life. In fact I wanted to perform reconstructive surgery, I didn't find it because, since I am doing now, as you know, constructive surgery. Next slide please.

SLIDE:

This is one of the favorite sentence of Dr. Rongek(?) with whom I trained in plastic surgery. He used to say that "In order to succeed in life you have to find a need and then to fill it". This can be available for everybody in all different fields, just not like that. But I remember that he like to say that to everybody and to give lessons sometimes. Sadly enough, Dr. Rongek(?) has passed away 10 years ago. I did not visit him soon enough, and I will always remember his kindness and welcome and I was always amazed how he was proud of his work, of his city Cincinnati, and how he was proud of the United States. He gave me a great lesson that I will keep for always, and in fact in being here today, and regularly taking care of American patients in Belgium, I have the feeling to pay him back some kind of a debt. Instead of doing reconstructive surgery, I found some constructive surgery in the field you are interested in. In 1967 my attention was drawn to the case of a Belgian surgeon being sued by the justice department because he had done what was called an "unnecessary mutilation" of a young patient who had died suddenly after surgery. This young adult was, in fact, one of the first male to female sex reassignment surgeries done in Belgium. There was no complaint by the family but an anonymous letter came out from the hospital to the justice department who wanted to investigate the question. That's the first real notice I have about the problem back in 67, 68. In reality this patient had died from a huge pulmonary embolism which can occur and which I almost had with one Belgian patient. This is a consequence of excessive use of female hormones and that's why I and we always want patients to stop taking female hormones at least 2 weeks before surgery and some very cautious surgeons require 6 weeks, but I think not too good idea. The case of that surgeon was finally dropped. The surgeon had no more problems except that all potential surgeons became very cautious and reluctant to start that type of surgery. Sometime later a French psychiatrist introduced me the case of one of his patients. This young man, who looked like a female and was badly needing sexual conversion. Several attempts of suicide had already been done in despair. I studied the case, it took some times. I studied the literature and I slowly realized that I had become the only hope for this patient. The psychiatrist insisted that I had to do something otherwise it could finish in full catastrophe. After studying the literature, without having seen any operations performed elsewhere I felt ready. And you see my applicant background helped me to jump, and to try which in fact is not delicate and not so difficult. And my first case was done in St. Joseph's in the early 70's. I was lucky not to have complications and the result was pretty good. I still meet this patient, it means that she is still living.[Laughter & applause] This became known and I have made a communication at the Belgian Society for Plastic Surgery of which at that time, I was accredited. In fact, at that time, at that period, the situation was pretty bad in the Belgium with many accidents and a few vagina-rectal fistulae had been done by a surgeon, always the same one, who was dreaming to build, I think, queen size vagina, 7 inches by 2. That's the best way, that's the best way to look for troubles and there were always big troubles, big complications and a lot of trouble. At that time, such already, fortunately, such surgery could be billed to Social Security, and even when Social Security is taking care, it is very easy, even if you have complications, because they take care of the complications too. So, it's another way to help when I decide such a price for one week for American patients. It's for the complications not for my pocket. Yes it happens.

SLIDE:

So, and at that time the situation as I told you just before was as bad, that two of my first cases had asked just for the penectomy and orchiectomy without any vagina being made. They were so afraid of the complications they wanted to survive and this went of course very easily. They were happy, but I must say that later they had regrets their decision because penile skin had been discarded. Later 1 of these 2 patients had later a secondary vaginoplasty with an intestinal flap done in the Netherlands. I am aware and I have been in touch with a few patients who claimed that they were asexual, asexual or neutral. And I think in a few weeks I will see a patient coming from the west coast who just wants penectomy-orchiectomy because he or she says, she declared as an asexual. This happens and this in my opinion can be connected to the story of Dr. Couchmerre(?), a French physician who hated to be a man but didn't want to be a woman. In fact, there is not too much choice possible but anyway, they want, it seems, that they are too maybe can be discussed later, a few people, unique people, want to have no sex at all. Why not, maybe less fun, but what an economy of problems and certainly life would be easier. No slowly we ?????. Next slide please.

SLIDE:

This will list my requirements, they are classical and well known by most of the eventual... Classical is by the eventual candidates for surgery.

A psychiatrist's report. I am a little uncertain of what level because I know in the states you have M.D.'s, you have Ph.D.'s and psychologists. In Belgium, we need to have a report made by an M.D. I think the Ph.D. in Psychology is the same as an M.D. but I am a little confused in that. I'm safer being in Belgium for that. Next slide please.

SLIDE:

The next requirement is the endocrinology report sometimes it's done by a general practitioner who knows the patient. I want to meet or to have records of somebody knowing the patient since a certain amount of time and telling that he's reliable and he's not taking female hormones in the spring or in the fall and from time to time changing his mind.

A social history written by the patient himself. Sometimes it's included a psychologist's report, but quite often not.

I need two pictures, now I require because I had a surprise with a very heavy patient. One with a passport size picture, and another one with full body height to see if she pass well as a female and to see if because I had a surprise of the patient being admitting 270 pounds and in fact she had sent me pictures with children in front and the children were healthy and I didn't realize that she was not heavy but, very heavy. Next one.

SLIDE:

I require the AIDS test should be non-reactive. It should be done at the maximum, 3 months before surgery and anyway it's checked in Brussels, but it's to avoid complications or discussion. I discovered in August I had an AIDS test I had received, the document maybe wrong and the AIDS test was positive in Brussels and finally the operation had not been performed. In fact I found it easy because not only the AIDS test was positive but this patient was really an advanced case. She was already very sick with few white cells. And so this I postponed and that I decided not to do.

Maximum weight 200 pounds. In heavy patients, usually heavy patients that have a very short penis, sometime you have difficulties with fat to find it. I said 200 pounds, but I have delicacy not to weigh people being a little over. So, I have them before, and my scale's in kilograms, so it's more difficult for me to judge in pounds. So 205 that would be right, I think, but if I write 220, I'm sure 230 or 235 will come. So I had to put a limit.

Minimum age 21 years of age. I had done a few Belgian or French below that age, but with the written agreement of the parents and it happened once with an American girl, but her mother was with her, she was below below 21.

And I need also a report of the general health. This brings me many surprise because you see, when people are afraid to be refused for such reason or another one they have a tendency to conceal a problem which sometimes appears. That is why I have, you see, grey hair and even I ask a E.K.G., a cardiac check above age 35. Because I also had a cardiac, some problems with cardiac complications during surgery and a little after surgery, but so far nobody has died. So far, but I think it could happen, it almost happened because I had a patient from Belgium and she was not covered by the Social Security and I had asked her for a last time to check in my office 4 or 5 days before her surgery. And she came and she said, "Yes doctor, my physician has tell me to tell you that I have some phlebitis in my leg. And I touched that this was hard, this was venous obstruction with clots and some kind of infection. There is a big risk of embolism and I evidently told the girl that I would do the operation but that it would be postponed. Then she started crying "Oh if I knew I wouldn't have tell you. I said "Yes, then if you didn't tell me then I wouldn't see it and I would do the operation, but you told me so, it's postponed". And fortunately because 2 weeks later her physician called me that she had made a massive pulmonary embolism and that she had to stay for 2 weeks in the emergency room, and so far she's not yet, she didn't have her surgery because she's in very poor condition and all the money that she had saved for reassignment, eventual reassignment, had been used for [her recovery from] pulminary complications. So, we have to be careful if there's no Social Security taking care. Next one.

SLIDE:

You see in patients like this, being usually overweight even you don't see the difference between male or female and surgery would be very difficult and it's preferable that I have see... Front view. Next slide.

SLIDE:

You see the gas and the operating table the beds we use are not ready for that type of patient. Next slide.

SLIDE:

You see I have a lot of paperwork and from time to time from I had somebody told me that she didn't get an answer to two letters. Another one, the letter came back but the address was incorrect so it's normal but fortunately it went back. This takes me a lot of time and I write or I dictate certainly 15 letters per week, related to this kind of activity. Now we will start in the real question. Next slide, please.

SLIDE:

You see, once patient has been accepted, this is the beginning of the procedure the patient be lying on the operating table in gynecologic position with just a front, with head a little lower. You see the perineum and the base of the scrotum. Next slide.

SLIDE:

I think this is what I do now, with a long skin flap, perineal flap this posteriorly and which will be used to line the posterior wall of the vagina, and this is has a double effect. It's increased the width of the entrance of the vagina, it increased the size of the vagina and it makes the penile skin to go deeper, so it increases the depth too. This I'm doing routinely since almost 2 years now. And earlier I was doing just a split in the middle of the perineum where there is a kind of scar which is congenital. This is the 2 anterior parts fusing together and that's why in my opinion this flap survives because they are [not] against the rules of plastic surgery. You see 1 of the rules of flaps is that the length should not exceed 3 times the width, otherwise because there is no blood supply, and quite often during surgery during surgery when it is hanging down you see that the end is becoming blue. But I had those flaps very long until going into the base of the penis and this is using to line not only the posterior wall of the vagina, but sometimes for those having a short penis and they are in fact, they are not uncommon. This kind of patient has rather a short penis or they are circumcised or even if they have a big fatty layer, it's difficult and some kind of skin should be added. Before I was using split thickness skin graft taken from the dermatode from one side or the other side of the buttocks or I was using full thickness skin graft taken from scarred scrotal skin. At the beginning I was just doing a midline incision going too deep, after that I made a reverse T, then I made a small triangle, and now I make this longer and longer. This flaps has been certainly helpfull. Next slide please.

SLIDE:

I think, yes. That's another type of a flap to show that here the flap is not going as long as I think the maximum could go. But this is a split, this is divided in the midline to separate and just this end of this flap is attached here to bring blood supply from behind will be attached between the 2 end of the penile skin in which will be divided. You know you see in this slide that there is a kind of line, a kind of scar, this is a congenital scar, and in my opinion, blood supply is not crossing the scar. So it means that there are 2 different blood supplies and I think that's why these flaps are surviving against the rules, the general rules of plastic surgery because we have doubled vascularization. But sometimes it can be some part can die. Next slide please.

SLIDE:

You see, this is a lucky patient and in fact she didn't know that she was lucky. No problem with this type of a penis, but which is quite uncommon, but just except maybe among black patients. In a case like this who is not circumcised, this came from inside the prepuceus skin. It could be discarded because it certainly [is] a huge amount of skin and sometimes but this is rather uncommon, quite often you see the reverse situation. The next.

SLIDE:

You see this is another maybe amusing picture. This is a kind of skin disease with discoloration, it's not very bad the white spots related sometimes in the face to be related to the sun exposure. So you see the shaft of the penis not so long, and it's circumcised. With it's circumcised, certainly you lose at least 1 inch, 1 inch and half of skin which reduces the length of tissue which can be used. On this slide I want you to notice the anus of course, the entrance of the vagina will be here [he points above]. And you have to realize that the penile skin, of the penis is attached in front of the pubis if we use the penile skin to make the vagina, you have to bring this skin down and you lose part of it and some cases and especially in very heavy patients, there's no penile skin left when you arrive at the site of the vagina. And some patients, many say [that] when erect they are 5 or 6 inches, sometimes they claim more. I wish for things from time to time. So you lose almost 2 inches. It is possible to rob the abdominal tissue to gain a little, but at the maximum 1 inch. When I attach the tissue, the abdominal tissue down which is not always possible because some, quite a few patients they had already abdominal surgery before, like hernia repair or some abdominal surgery and the abdominal skin, abdominal tissue is attached to the depth because of previous scars. And that condition is difficult to bring everything down. Sometimes some patients have surprise or they are amazed to see in their lower abdominal in the midline, a dimple, and when it hurts when they push it's because there's a stitch attaching the tissue lower to bring the penile skin in the direction of the perineum and that stitch is supposed to break after 1 or 2 weeks, sometimes longer. Next slide please.

SLIDE:

You see the operation has started. Maybe I should put more slides in between but you see that here that the urethra has been separated from this is the bulbo uh corpus cavernosum, making the shaft of the penis. The urethra has been separated and seceted(?) down but we put a catheter inside with a self retaining tube #20 usually which will stay in place for 8 to 9 days. But this is not a complete urethra because the end, the terminal turn or arm of the urethra is still attached here beneath the skin beneath the tip of the penis which is not yet liberated. And as you see here the base of both corpus cavernosum that will be cut here in "V "and the base of this 2 erectile tissue will be cut to make some kind of look alike or feel alike clitoris. Just beneath, here beneath this is the pubis bone. Next slide please.

SLIDE:

Yes, I have regularly visitors. Some they ask if they could come to the hospital. Some like it, some cannot stand it. This one, she was very sorry to see the penectomy and orchiectomy. She was very sorry for that but fortunately she found husband a few months after.[Laughter] Next slide please.

SLIDE:

Now a center view when the operation has progressed you see the perineal flap which has a grey and little bluish color hanging down. You have to be careful when you dissect because you have to keep it thick and not to go too deep too deep at that place where it will turn because alive blood and blood return too is passing through. This end has to be preserved otherwise it will die and put more problems. You see now that the urethra has been brought upward and there is a forceps or mosquito attached to this triangular piece which is the corpus spongiosum around the urethra. This is the turn, a delicate place between the horizontal male urethra and the vertical male urethra going in the direction of the prostate and the bladder. This is a right angle turn and I must say I am aware that those who have some kind of problem in the direction of their urination it's coming depending on the level where it's cut. There is right angle turn and it's surrounded by corpus spongiosum which is the second erectile male tissue which doesn't help the surgery and later on some patients keep complaints there because it's too swollen or they have pain or swelling when they are excited or it's bulging in the vagina making dilation or intercourse difficult or the penetration difficult. On top of that you see that the other tissue, I don't think that the clitoris has been made because the penile shaft is still upward. Next slide please.

SLIDE:

You will see now the difficult part of the procedure, it's because you see the perianal flap is pulled backward and in front it's pulled upward and this is where it happens, the difficult part of the procedure. I used to say that the removal of the testicles, that's very easy. 100% guaranteed to be quickly done. That's how long it takes for me to do it, it happens. The penectomy, removal of the penis is more delicate because this is erectile tissue you can get bleeding. Bleeding is great risk in that kind of surgery and it's another delicate point, it's the new junction, the making of what you call, some call it the pee hole or the urethra opening. The attachment of the shortened urethra, through the skin or through a hole in the skin is quite often, still too often the site of narrowing and infection. But so we have now, I don't have good slides I think in focus. Seen in the back, this is the part of the procedure I use to prepare the surgical site including some strong stitches on both sides where I go to catch the blood supply to this area and this reduces the bleeding. It makes the surgery easier, faster and less complicated because that's the place where you run, you can run in trouble because after 1 inch, 1 inch and a half, we face a kind of fibrotic sheath over toward the upper neurosis denouvilier(?) (French anatomy) which closes the male pelvis from the prostate to the rectum. And we have to go through that. Just that, not too much in front you go to the prostate, not too far behind in the midline it's dangerous to try to go through. But you have with blunt dissectors, with scissors on 1 side or on the other you try. With experience, it's going now very fast in most cases this is a very tricky a very difficult place because I have to tell you, you know that when we build a place for the vagina we made a split originating from this split but we don't move any tissue. We don't remove a caraffe of tissue and replacing it with skin and mold of sponge either from those that I use to put or mold in the vagina. So, you make a split, you divide, you separate and you squeeze something inside and it has to stay inside. It's amazing to me that it's going so well or not going well in any case. So, next slide please.

SLIDE:

Now this section has been complete. You don't see it well but you have have to believe me. I put some sponge to do some kind of compression because of it will be removed when the penile shaft, when the mold made of skin will be put inside. Here you can see a little of the dimple because because the abdominal tissues have been brought down and attached to the pubis, sometimes it's attached to the clitoris, but that's transitory, but it dissolves in 1 or 2 weeks. You see the penile skin here and the end where it was separated from the glans because the glans is discarded. I tried to save one to save one part of it someone said yes we can use the glans it makes like if you have a cervix in the depth of the vagina and that's dreaming a little much I think. But so the ends of the penile skin is closed with interrupted sutures since it was split in the midline in between we start, you see a little blood running, I try to go fast. When I was in training, when I was performing surgery in the states, I was always amazed that they spent a lot of time to stop all bleeding to coagulate, this is this is for those because it takes a lot of time and they use a cauter[izer]. They burn it with the electricity but the more you burn the more dead tissue you do. And this is jeopardizing the bleeding for later on [usage]. In my opinion, maybe because I worked in Africa, as long as it doesn't bleed too much I go through and I advance and shorten and stop it when everything is finished and not postponing. So if you take an hour longer to make the procedure, it means you find a maybe more blood loss, more medication to stay asleep, and all this, this is a choice you have to study and to judge to evaluate in each case. So you see, this will be attached, this is difficult, because you see that the urethra is staying there, I cannot put it on the table. I have, at this place I have to put it 1 side or the other and this is the reason why, this will amaze you but I had difficulty to put later on the new pee hole exactly in the mid-line. Because that skin is very stretchable and you can't do, I'm amazed myself but I cannot do, I try, when I do it I try, I try to have it in the middle, I paint it in the middle but sometimes it isn't. Next slide please.

SLIDE:

Yes you see, the attachable rear part but it's turned the other way. You see the end of the penile skin, it looks like the blood catheter is going out, this is so, but it's behind. This is has to be, it's out of the way dropped out earlier it was hanging here, now it's hanging the other way. It's stopped going in so the penile skin which is still turned reverse it should be, it will not go in that way, it will like so, it will be turned the other way to have the skin going to the outside, and to have this part against where it will be attached and where it's supposed to be. You see this is interrupted still with suture to the end, it's almost complete at the other way. So usually I start always that way finishing, finishing on this side not to think the ???? maybe because I'm right handed otherwise a left handed would be the other side. So it doesn't make any difference. Next slide.

SLIDE:

You see, it has been turned completely and the skin is inside now. which is the inside of the future vagina, but it's not yet in place. You have to believe me that ????? that section has been closed, the separation, the split, there are a few sponges doing some compression waiting for that will be ready. You see that the posterior flap is going up, it's a little twisted there and going into here. The penile skin is going a little longer. So now the next step would be to fill that with ????. I think... Next slide please.

SLIDE:

You see I started to fill it with some pressure, not to put too much because if you put too much, it's again the question of experience, of feeling, you have a certain amount of tissue. If you put too much or too large here, you have less length. You have to chose what you decide. I know that the dream is better to have it long enough, even if it's narrow. So you, this white stuff it's some vasiline, some kind of vaseline an anesthetic glue to pass it's half filled but it has to be many things and not are easy to say, and some are not always easy to do, and it takes experience. That's why I think it's still changing. Next slide.

SLIDE:

Here you see the iodoform gauze going in. It's the same ????. There it's completely secured. And this has to be completed after... it will be pushed in. It's difficult to render that in slides... maybe in the movies or video... Ok, next.

SLIDE:

That's another continuation of the first 1. You see another case being almost ready, but it's interesting because you see the posterior flap starting here in front of the anus, going to make this, the post of which will line the posterior wall of the vagina, but this patient has a very short penis. You see the entrance of the vagina will be here. There's just maximum 1 inch skin to go inside so there is no tissue to be used, almost no tissue to be used to go inside. In this case that was a very long flap, turning here and this part is a continuation of the perineal flap, this will line the anterior wall of the vagina beneath the bladder, beneath the prostate in the back. And when I see that, when I do that I pray that it will survive. Because I'm not always convinced that it looks well. The flap, a tip of the flap, when it's failed, why, that's no problem maybe it's less arterior blood coming, what's dangerous to have blue flaps. When it's blue it means the blood venous return being impaired and that's the way problems. Next slide.

SLIDE:

This is another case where you see the urethra brought on the left this time. You see the vagina will be just behind the skin beneath since this is the urethra the junction of the horizontal and vertical part so the vagina will be here. You see that the penile tissue remains of a few years ago, and the penile skin must really be short. Again, there's no tissue left when you arrive at the vagina entrance. And so, in this case, I don't do that too often because I'm not convinced that it stays, that it survives... I try to at least I'm intent. This is a split thickness skin graft reversed of course, which makes already some packing inside and that will be squeezed and pushed inside, this will make a vagina with some split thickness skin graft, taken from. That's why we take this type of tissue because because the graft has been taken from behind the thigh this time. But I don't like that too much because the junction of the penile skin which is some thickness, some ductos, I don't know in english... It's not very thick but thick at the junction of these two different tissues there is always a kind of shrinkage and stenosis and a site for pain. There is some vagina, but it's impossible to go there. Next slide.

SLIDE:

You see this is the procedure when it's progressing. You see a open urethra in the middle it has been fastened to a hole and I removed has some skin in the middle. You see that this is the perineal flap is going inside. This is some, this is the iodoform gauze which is held in place and pushed within by the assistant.

This is, this is the place that will be the new urethra opening, this is not yet complete. So the anus, the vagina, the place where she urinates will be here, you see already that 1 side of the labia majora has been done. There is some removal of the scrotal skin. It's attached something like that. You see again it's too wide apart already but we cannot go in the midline because the blood supply is running there. And there is one silicone tube for drainage, you know that in case of bleeding to have it outside better than inside. The left labia majora is not yet finished. There is some excess of tissue to be removed, but it's already marked with methylene blue for the inside. And the outside there is some skin discarded although sometime I was regularly using as a full thickness skin graft. But you see that there is no place for some kind of labia minora, for the small lips which should be a little inside. With lucky patients with a very big penis there is some extra skin you get some extruding, some of the vagina is coming out and later on eventually it can be changed or adapted to look like labia minora. It has just been finished with the second tube. The next slide.

SLIDE:

Yes, you progress again, same ???? as behind. Behind this is the entrance of the vagina with the packing inside. You see that the second lip is closed also with a silicone tube, and in the midline you see passing through a hole, it's not real hole. There is a removal of some skin and through which I pass the urethra, but the urethra is still with the corpus spongiosum around it. There is a stitch there behind, so that it does not bleed, but it will have to be removed. You see here that there is another stitch strangulating the base and limiting the escape of blood. This is again, something technically difficult. Next slide.

SLIDE:

And during many months I have problems of bleeding at the base and I didn't know how to attach or to have a successful attachment of the shortened urethra with the skin. And I am very grateful to Dr. Biber, that I had met at the meeting of the Harry Benjamin Association and I tell, I told him that I had problems there and he said "YES, IT IS QUITE EASY, YOU CAN USUAL DO AND SO AND SO, and he explained me very kindly. I don't know if he regretted that day for long but anyway I was still very grateful for that. You see at the beginning, the urethra was longer, coming up to here. It has been depressed to get you, rope has been removed and it has been split until the other ligation. It is strangulated there is almost no bleeding and you see that it has been split and you see the "Y"

END OF FIRST HOUR TAPE.

BEGINNING OF SECOND HOUR TAPE.

You see here the external corpus spongiosum the main erectile tissue is being drawn down. This is what gave me trouble because it's an erectile tissue, with strangulation it stops but it will have to be removed, because if you have too tight ligation it will die. And you see that there is another layer there that's the mucosa. So, the progress I had made at that time, it was possible to divide and to treat separately. Next Slide.

SLIDE:

You see now, maybe I should, well another time, to put both slides into different steps, but I think it's not at all certain so I don't have to explain too much exactly the different steps from a surgical point of view. You see that I am here busy with the cauter, the electric cauter, I use it but I don't like it too much, but I use it because it's a very useful tool. This is black now because that's the base of the corpus spongiosum which has been coagulated, burned, and it's becoming strong and it's possible to pass sutures through it. And there is another layer in the middle, just against the bladder catheter which is the urethra. And so I will use running stitches at 2 levels. At the deep level attaching this with dexon, some stitch which can be dissolved by reuters(?) and on top of that I will do a second layer of running stitch covering the first 1 and making very tight with the mucosa. That helps me, grieves me, not completely, since some progress has yet to be done and at the end of that the stitch, the still stitch, cannot be seen, strangulating the base should be removed. The next slide.

SLIDE:

You see now, it's almost complete. Again some blood, but I... Here's the 2 layers with a running stitch around the delicate place of urination will happen after the catheter will be removed. I have ligated to the stitches some coagulating gel. We call it "gelcoag" and it's useful, but I'm not convinced that it's necessary. It's a coagulating jelly. It helps to make clots too. And the reason that is I sleep better because I did my best to stop the bleeding, because that's that's one of my main concern, a patient bleeding too much. First they don't like to receive blood, they're always afraid to get some HIV positive or non-tested or barely tested; they don't like that. But if they are too low with the red cells, the transportation of the oxygen is low, the blood rate is too fast and they don't feel well, like they cannot breathe and when they get up they pick out those pains because they don't have enough blood pressure, especially when they get up. You see also again the lines, the unique line in the middle which go inside. Maybe this flap, which I'm not doing since so long maybe some problem because in hairy patient they have some hair growth in the vagina, so maybe that will be a new field, a new area for electrologist.[Laughter] The first complaint I had by a patient was coming from that because I didn't let her know. Fortunately this was done in Belgium, so if it was in the United States, I would be sued in malpractice because there was hair in the vagina and I didn't let her know enough. In fact I didn't think of that, and I was stupid enough to just answer, "It's not bad, it's like a kiss with a mustache." And she didn't like that so she... the letters became here angered.

I have to find where I am now.

Anyway we will proceed. It's almost complete. We still have a special. Next slide please.

SLIDE:

YES, I uh, we are not alone, I am not alone in the operating room. This is Dr. Lambert, the lady anesthesiologist who speaks well when she's not wearing that. She's not doing like that, no. She's preparing this machinery, it sits alone from the table. This is what we call in Europe, "a beastie". You certainly have that in the states but in Europe we call that the "Rolls Royce" of anesthesia. She doesn't have this operatus since too long. You see the patient with the tracheal administration, the IV running here which will stay in place for 3 days. Next slide please.

SLIDE:

You see another view, this is with a counter scope, this is an old type of system. This is my fault, it's twisted [the slide is revearsed], I didn't see it before. And the patient is in the gynecology position but with the head lower and the buttocks a little higher. Next slide.

SLIDE:

Yes, I see you maybe will recognize 1 circulating(?) nurse, you see the IV running and again doctor Lambert behind. And normally [in] the surgery the assistant is here. Next slide .

SLIDE:

Yes. This is what she had to fight to get this new, costing almost a Cadillac. This is very fancy, this is the best we can ever get in Europe, it is German made, but this is sometimes very confusing, because there are always some type of alarm which starts and we don't find any reason. Like airplanes, Eric, my pilot son says, sometime the alarm and what we do we cut the alarm, we make up reasons. Next slide.

SLIDE:

Here this is a view from the face of the anesthetist. And this is my favorite assistant who happens to be my wife. I am doing all surgery myself, but the cleaning and the dressing is the only thing that I'm not doing. It's almost complete. Eventually if you are in a good mood you will see that there is a dimple there where the long abdominal tissue are brought down. They complain a lot about that but they are so happy when they... when it's finished. You see the electrocoagulation, both legs being like that. These are sheets and paper that's used everywhere, now that they are thrown away after one use. The IV running. Next one.

SLIDE:

Yes, we are almost at the end, when we {spirably was idofoam}(?) inside. But we had to do some compression. Since there has been some bleeding, but we had to hold the wall of the vagina and packing inside, and I put some extra gauze here in between the lips. This is pushed inside and later on the 2 labia majora are tied together with strong stitches. This looks a little barbarious, but it's helpful because the bleeding becomes almost impossible, but not impossible. The next slide.

SLIDE:

You see that now here, both lips, that both lips are tied together with heavy stitch which will stay in place for 5 days. They will be removed, they will be removed 1 day before leaving the hospital. 1, 2, 3, 4. This is the place about the place where the patient will urinate later on but both lips are tight, both lips are tied together. The vagina will be here, and the anus here. You see with an infection possible, we try patient not have to have a bowel movement for 4 or 5 days. And when it's almost ready we give an enema to separate but I'm always amazed though it's not going worse. You see here on top, something I do, I do since not too long, because from time to time I had patients having bleeding 2 or 3 days after surgery and blood was coming in front between the 2 labia majora, despite the fact that it was tied. And now I am putting small dressing on top between the lips. This is something easy to say, easy to do, but what you have to do to judge the amount of pressure you will do, because if you don't push enough, you will have some bleeding. If you push too much, certainly no bleeding but you will get necrosis and the inside of the lips could die. You could have laceration, I've seen that. When patients have that I used to put red ointment on top of that so they don't see the difference. Next slide.

SLIDE:

So, this is, this is finished you see. There has been some cleaning after when it's finished. That's the last push I did that's in front, that's behind. 2 silicone tubes which will be removed after 48 hours. You see here's the typical compression to avoid bleeding. That's meaning to have silicone tubes going to here and there. Yes that's true but it's worse you have to choose, bleeding inside or bleeding outside. Bleeding outside is not as bad because you can see that when it's running across the floor of the room. Then you know you have something to do. Otherwise I will show you a slide, where there was no bleeding outside, but diffuse bleeding all around the pelvis with some hematoma and this takes time to be it's over so it's blood lost, the same as it was before. The blood is thick beneath the skin, it still works but it has to be digested and removed. This is seen to be a kind case. Next slide.

SLIDE:

Yes, this is at the end of the procedure you see sometimes it's like after the corridine(?) in Spain, you get the ears and the tail and so on. [slide shown is of testes and corpus cavernosum]. Both testicles with part of the cord, which I cut and ligated. Sometimes for Belgian patients with the social security paying, I want always to have some microscopic examination of the testicles to prove that they were not working. But other patients without Social Security it's just useless money that is thrown away. This is some of the shaft of the penis as you can see it's cut to short since the base was kept as a clitoris. You see the glans which is discarded. A small amount of skin, scrotal skin; it's bigger than it looks, but it shrinks so it's bigger if you look. But after that you can expand that certainly 3 times. Next slide.

SLIDE:

That's after surgery. The patient has been in the recovery room, they are not going back in their room. They stay where there are 3 or 4 patients for 1 nurse being used. They can get some oxygen, they can take some blood pressure, they can have {sectional gas}(?), and they are checked real close. They stay there for 4 to 6 hours. This is in the new facility. Certainly also an improvement. Next slide.

SLIDE:

That will be the last box I think.

Question from the audience:

**A** Dr. Seghers, for patients who come to your clinic, can we have our own blood sent?

Reply From Dr. Seghers:

Normally not, and Dr. Lambert, the lady, normally blood transfusions are the responsibility of the anesthesiologist; and she would refuse to inject something that she wouldn't have taken [drawn] herself, because it can be under the sun or exposed to something else, or she will never be sure that it's really your blood. But I have to say it's so, so that's not accepted. It's rather uncommon to give blood transfusion. It happens, I must say, about 1 case out of 20. It's not usual.

Question from the audience:

**A** Where is the clitoris?

Reply from Dr. Seghers:

Yes, the clitoris is still subcutaneous. The base of both corpus cavernosum were attached together. This makes kind of a small hill like that and it stays subcutaneous. It can be felt with a finger but it cannot be seen. Eventually after secondary surgery it can be a little put through the skin but normally it is not at the first surgery. But I think that in that field some improvement has been done too.

SLIDE:

You see at least the 2 catheters, the 2 silicone tubes, already are still in place. This means that we are two days after. Because you see that the suture strength closing attaching both lips together are behind the place where she will urinate, not in front.

Where I've had from time to time some prolonged bleeding and now I don't do anything with it. In this case this was perfect. It's not too long, some hematoma, but not too much. And at this time, this is rather clean case, some blood here behind going to, near the anus and the rectum, that's why some have after surgery, especially not the younger but the other one, some problem with the hemorrhoids. They complained a lot because they've swollen from pushing a little around the anus. And these will reform there, they can suffer from hemorrhoids. So the tubes will be removed. Next one.

SLIDE:

This is to show where it is better to have external bleeding through the catheter but sometimes you see how it can be a huge amount of blood, but I don't think the patient has received any blood transfusion, but this, I'm sorry for that if some blood lost and even the body has to digest that. If you move it this will disappear in 2 weeks, but it has to take time and it can become infected even if it's going alright it can leave some blood disruption that can break through.

SLIDE:

Another problem with that new camera I use it that you see I use this for making pictures for a 40, 45 centimeter and it is difficult to judge to just what I want to have. Just in the the midline, not out of focus, just out of center. Next one.

SLIDE:

Another case you see, it's going very well. You see the dimple where its attached the lower abdominals tissue. Attached down. Sometimes, it goes more than that. Depends on my mood or what I ate for breakfast. See, this is on day 5, 1 day before leaving the hospital. This is very well, this is a little above average. And this both labia majora will be separated and you will see beneath that the packing from the vagina which in the mean time has changed color. Now it's become brown with old blood, but that blood already lost. Next Slide.

SLIDE.

Now you see the stitches have been severed. I must say about 3 or 4 days, the patient being tied with both lips tied together they start to complain and they are so happy when the stitches are cut, so they feel hope. Their hope is increasing and from step to step each time something is improving, they are happy, they accept that. You see the entrance of the vagina with some of the packing has been already removed. It's brown now because it's old blood and the smell is soon to be very poor. But there is nothing wrong. And here is the place where you see urine, where she will urinate you see the "gelcoag" coagulating jelly, which is a little brown, which when old it looks like intestinal material. I always tell patient this is a special special jelly that I have put and this is not intestinal fistula and we know sometimes they are terribly afraid pieces are falling. Next slide.

SLIDE:

Here's another case. You see this time the jelly is being removed. You see, the blue stitches, which is nylon for the running stitch external. There's another running stitch with dexon deeper. You see the white stuff there, this sometimes some patient refuse... About one third of the patients refuse to look. I said they will look, maybe and I will be there but it's not a good way to do it. Another third, they look when I tell them to look, the other third they are looking almost all day long. The white stuff there is some excess mucosa, the mucosa are in the depth around the catheter. This thin layer (the mucosa) of the urethra but I attached around with a ????. I keep it a little too long, and there's some excess tissue which dies and which will fall and sometimes patient are a little anxious, you see they are tissue is white and white means pus, but it's not that. Just an excess mucosa you see here still the packing in the vagina. In the good case when you separate the lips almost all packing is staying inside. It's not always the same. When patient's coughing you hold your perineum, especially with woman, and it pushes, bulging everything out. So they have a tendency to lose their packing. Or if they have a bowel movement or some kind of tendency to have diarrhea which we have after 4 or 5 days with the anesthetic. And if they lose the packing a little too early, it's not good either. But, sometimes it's difficult to do... Another way I used to put some large dressing on that and to explain to patient to hold with their hands for a few more days to keep everything inside. Next slide please.

SLIDE:

Yes, this is you see already, 1 stitch out of 2 from the lips has been removed. I used to do that in my office on day 8 or so. Eventually after that they eventually can fly home. Because the main part is done. You see the gauze packing has been done, from time to time. And I first start the patient with a plastic holder with plastic dilator to feel inside. Normally the question about the clitoris you can see that it's supposed to be here supposed to be subcutaneously, and again you see that the anterior ends of both lips are too separated, which is not ideal but cannot be... We cannot do a lot with this on the main procedure. This is a delicate place where I instruct patients if you have fresh blood, red blood coming out, you don't have to let it run, you don't have to put thick dressing either because this is just to absorb and you lose your strength. You just put a small dressing here around, and to do compression for 3 minutes without removing and this always stops. Next slide.

SLIDE:

After that, patient will be have to continue... This is another case. Sometimes it's not very clean but it doesn't mean that we run in trouble. You see a few stitches have been removed but this is not very clean. This is not clean feeling, but when we consider that the anus is there, it's not a real problem. It could take some more time. In that case we need some more antibiotic through the mouth.

You see the place where she urinates now since the bladder catheter has been removed. Some crusting, but this is going in a good direction. But that's not the clear[est] case that I have. Next one.

SLIDE:

Yes, this means, sometimes I realize that it's presented to patient as being a one stitch procedure, in fact it is for the main part with 3 forms; removal of the testicles, penectomy, vaginoplasty. But in most of the case it was a little incorrect or at least which could be improved later on and especially for perfectionist patients who know now with disposal, they know how it could be and so they learn, I guess, some improvements can still be done and since they are asking, demanding from the best. They, more people, more patients are requiring to have the best possible, because they know now it's available. So I, normally it's supposed to be one stage surgery, but sometimes a question of the z-plasty that we will see. Next slide please.

SLIDE:

This is another appearance of another patient not yet with z-plasty. This is sometimes the labia majora are a little too thick. They hang a little too much, I know I have a tendency to let ???? on this before. To let too much tissue because as surgeon I want to keep the maximum possible, and not to throw it out. Once it's removed it's removed. Some remaining excess can eventually be trimmed to width later on or be used to make some kind of labia majora. But now I know if I remove a little more than this because some are complaining and more patients complain between each other. They know how it should be. Some patients don't know exactly, so everything's well. So, Next slide.

SLIDE:

I think this is an old case without the posterior perineal flap because you see its a little close there sometimes. This is penile skin with some extrusion and sometimes a split is done there to increase the entrance. It's not a bad result. It was so before, and thus we achieve the maximum depth possible. But this slide, still with the leg room is to show that the 2 labia. That's anterior, that's posterior. That's amazing. The umbilicus is there. But the place where she urinates is here, but you see that the 2 are ended up separated. But you see in the middle the blood supply going to the vagina which is important, to be built, is running, and for me it's a normal plan. I know some surgeons, they go to cut a little more in the midline but from time to time they have complete failure of the vagina. I have a short vagina from time to time, but complete failure I don't think ever. But at my age, I could have forgotten. Next slide.

SLIDE:

This is a view still the same case you can see from the inside of the vagina which is good depth in this case. The union, another difficult thing, I told you earlier is sometimes difficult to put the urinary opening just in the middle. We have also the tendency to put the urinary opening a little too much forward. And so that patient, they still when they sit they urinate a little too much in front, they have to bend to have a direction down, this is also something difficult. Because during surgery to avoid trouble, we should put the urinary opening almost at the entrance of the vagina. That's for later on to have the best result, but during surgery, it's difficult. Next slide.

SLIDE

This is a sketch to illustrate the z-plasty procedure. You see the urinary opening, the vagina behind, the 2 lips with here the stitches, they are removed at that time and you they are too separated. It's possible to make 2 double-zed z-plasties. This is like this here, here, that's 1 "z". The other 1, that's 1, 1, 1. 3 legs and you see they are 2 triangles with the anterior end of the labia majora which are separate and they will be crossed. This and that will be attached inside and that will be doing at the other side. And so again at the end result you see the same position but, this is going inside, it's attached as it should be, the primary vulva is closed in front, both lips are going attached together. This makes a little more scar in the area of the pubic area, but it's not the same... It's not a problem, but this is leaving a good improvement in particular you see this can be done, in my opinion, 6 months after the main surgery. 6 months or later. There's no urgency for that. Most patients are now becoming aware that it's possible to do and at least with the ???? case it's easier for those to come back to Brussels and this is earning now about 10% of the patients. Sometimes in combination I told you that one needs to wait and the pee hole can be brought down, some split can be done behind, some minor things or they come to have breast implants at that time or to have a tracheal shave at this time of secondary revision. But it's not an obligation or necessity, and this can be done back in the states. Next slide.

SLIDE:

You see a real case now with the entrance of the vagina. You see that the urinary opening again a little too far away, but will be split and enlarged backward. And here the z, 1 leg, the other 1 leg. And these 2 parts are the anterior ends of the labia majora will be attached together. Maybe you think and I think when I see this slide that the entrance of the vagina is a little difficult, but you have to realize that these pictures are done when the patient has the thighs flexed which is not always the [best] position. So when the legs are hanging, going at the same level, it becomes hole open. Next slide.

Slide:

This you see at the end. This is the stitches. Staring straight forward at that front sometime. This is the entrance of the vagina there are are stitches and I am certain that in this case when I touch that I used to put for 2 or 3 days there a bladder catheter because this is an absolute dangerous place where you can get bleeding. Next slide:

SLIDE:

So not an end result, but after certain healing at the time you can see the stitches here at the place where she urinates, but it's a little longer on the left. You see the new scar, here they had scar before but that's a small increase of the scar in the pubic area. You see that the hair growth is coming back again. When there is excess skin on both sides of the entrance of the vagina, if you have a good imagination, you can think this can form some kind of labia minora. Next one.

SLIDE:

Here's after the removal of the stitches. Here is what I do about the question about the clitoris. I use, this is some button, some little that I do there, some exteriorization of what's left from the base of the corpus cavernosum. I'm not complaints it always survives, but it helps and it can get some feeling. This is still a little red but the color always improves in time. The next slide.

SLIDE:

Another case with early patient, because early case with some high legs, too much labia majora, sometimes an excision can be done. This is a chance to see the entrance of the vagina with a split you see how it can move not far away from the anus. The next one.

SLIDE:

This is again an early case. It looks as the vagina is closed, but it is because of the position of the table. Anyway now it's not never any more like this because this kind of a strong hymen, and eventually this lady had to see a surgeon if she want to have intercourse with somebody. The place where she urinates, that will be like in the midline. Next one.

SLIDE:

Which is maybe I'm not sure in the same place but the same procedure. But you see here it's not because it's closed here, with a kind of very strong hymen, that you see there was a vagina already though, just the entrance was a little difficult. They were hurt to be done. The place where she urinates, this is. Yet I didn't do z-plasty at that time. This is the place where the top of the clitoris. The next one. We are almost at the end.

SLIDE:

Another one healing. You see when it's open, you see well. The entrance of the vagina not sometimes its not going to be ???? but at least it's something. The stitches will be removed. Next slide.

SLIDE:

Yes another one I modified something inside. It happens. This means that I don't say that I have always the ideal result, it's certainly not at that time, maybe even now. You see some increase of the skin. Next one.

SLIDE:

This was not long ago there was some bleeding at the clitoris which when I was done it was a maxi clitoris. But I think I suppose it will, that they will have a result which is a little big. See the entrance of the vagina with some split which had been done. This is already with the posterior flap going inside. OK.

SLIDE:

Yes, a secondary ancillary procedure that I do very gladly. It's a tracheal shave. Patient lying on her side with a prominent trachea that I refused to do that at the time of the main surgery. But sometimes when the patient really requires, and sometime they demand it or after surgery. If they are well, if they didn't have too much bleeding that they didn't use too much pan killer, that they are eating well and not complaining, I accept to do it under local anesthesia before leaving the hospital. This is the a case done under general anesthesia. Some kind of secondary revision. Next slide.

SLIDE:

This is something very easy because now i am doing as a plastic surgeon. The scar, a shorter scar just at the place where you see the prominent tracheal capillaries. Before, in my early cases I found it more clever to do it high just to be concealed between the maxilla. But this was a tremendous burn, and the incision had to be much longer and sometimes it can be seen. So, this was just to complicate the life of everybody. You can see now with some orthostatic organ and the calculator [a calculus (bone) shaving instrument] in, and it will removed with a poxilla(?). Next one.

SLIDE

This is the .... I don't know how you call this instrument, it's to take small piece of cartilage piece by piece. Next one.

SLIDE:

Then closure in two or three layers usually. Next one.

SLIDE:

Some pain when it's finished. This case was done under general anesthesia but the first was combined with some other procedure. Next one.

SLIDE:

Yes you see, this was one of my nice looking patients. When you see, she was an Italian, she was wonderful. And sometimes I believe the best, the nicest looking woman they are men. But even when you look down below in examination (Next one.) you see they look competely like a woman, but I would see that she was a woman but in fact she was a pre-op, she didn't yet have her surgery done. So...

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Next one.

Next one.

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RESUME GOOD RECORDING

Some others are very are very dangerous, some maybe look maybe funny, but I sometimes, I am also in trouble. Before surgery complications, it happens and few examples. You can miss your plane or your connection at Kennedy Airport. It arrives and you arrive and there is snow or fog and the airport is closed and then you decide to arrive at the last minute, then you are too late.

Luggage lost at London airport or at Amsterdam, it happens. It usually happens that after one or two days you get your luggage. Don't put your travelers checks in your luggage. I recommend all your money, passport, travelers checks, ....

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RESUME GOOD RECORDING

Sometimes people change their mind. And 3 days later she calls me back and say's "Oh yes would you do the surgery?", I said "NO, "If you change your mind just before, I will not change mine." "And I will accept to do it but you have to go back home and to be checked by your psychiatrist and ask new advice, I can understand that you can be afraid being alone maybe too much". Some patients are arriving in Brussels, they have never fly before. When flying on business, I am always amazed by the courage of many of these patients.

Some patients arrive sick, they catch cold, they catch flu, especially when they go in Germany. They're sick during the night, those who smoke 4 packs a day just before surgery they smoke more and more. And they have a tendency to get bronchitis or a new bout of asthma.

I had chance of another experience with patient who was so excited to be with surgery she was during the night in a discotheque and she was involved in a fight and brok an ankle. It's not Brussels, it's a safe city, certainly safer than most than most U.S. cities but at 3AM anywhere, I think anything is possible, especially in a discotheque.

I have, I receive some kind of phone call from a lady, from a friend canceling surgery for somebody else. I said that normally I don't accept that patient I had to call myself, but then since I didn't meet them before, I cannot check this ever. I canceled the operation because I had, I had a phone call and on the day, on the date the patient appeared, I said no, I never called you. Maybe yes, it was somebody who didn't like you has the surgery done and wanted to cancel it without letting them know. So many there are too many complications.

I had just somebody a girl who was ready to have the surgery done and she had a phone call from home telling that the ex-wife had put fire to the apartment or that everything had being stolen from the apartment and the apartment had been moved. All kinds of surprises, more for the patients than for me but sometimes it's not easy time, and as I mentioned I did a few patients that I refused I don't accept, I don't confirm that the surgery can be done at that time. (Dr. Seghers now addresses a former patient in the audience - April) At the time of the last check in my office. But you must say that you have passed the first check and you have been in the hospital and it was canceled the morning of the operation after having received a shot for pain for preparing for anesthesia. It was a surprise for me but something a making a high peak of temperature after that injection. This can just happen for a few hours or it can be the beginning of the sickness of several days. So, it's difficult to judge that but I think I judge that well since you stayed sick for several days. So, I had made the wrong move, the right move.

I remember another patient being about 60, and so she had difficulty to breathe she was very tired from trip that she was coughing all day long. She cigarette after dinner, I said I think didn't refuse her but I told her that the anesthesiologist would refuse her. And she said "Yes, maybe I shouldn't do it and at last I'm happy to have come just before surgery even if it was not done". That lady died 1 year later without having her operation. She died in Las Vegas. She was well known because she appeared in the movie about a gender person done some years ago.

I had another surprise, a patient arrived from California. She said "Yes doctor, I had some surgery one month ago". One month ago it was twenty eight days and this was major surgery. She was opened from here to the pubis because she had a double bypass of the coronary artery. She said "I had that done before". And yes but so. And so it was canceled. So she came 6 months later and she had the surgery done.

This, all the questions which can happen. Now the questions about the AIDS test they are checked and not too long ago I had at last a proof that somebody had lied to me or arranged to fake, a fake result. I was not too happy about that and the position of us and with the agreement with the nurse in the hospital staff at the hospital is that it could eventually be done but everybody has to know in advance that there is a risky patient and that some more precautions should be done. And in my opinion our AIDS / HIV positive they should keep their strength to stay well even they can be well they can stay well for several years but if you do some kind of major unnecessary surgery, that will accelerate the procedure and to reduce their life expectancy, I mean. And the other thing is that if they already catch the HIV test maybe with the operation they would continue to refuse, to increase the risk of other people, because if they want a vagina, that it's maybe needs to be used and I want to be... I don't want to be part of that.

You heavy patients, I told you before I had a surprise last year to see somebody being very huge because when I showed you she had sent me pictures with the children in front and fortunately she was from the east coast and the parents had come for the occasion from the west coast then I had 3 in my office which was good because I could call the parents and said "this is impossible, have you seen such a mountain?" and fortunately the parents were very comprehensive and I remember the father telling, "Oh yes, doctor I know the situation is bad, don't make it worse". And I had proof that she knew that there was was a 200 pounds limit. I'm not too overwhelmed as I told you before I don't weigh patients.

I think now during surgery complications, that's more important because the first complication that I can meet and that I met is that the possibility to pass a bladder catheter because the urethra had to be closed by former ephretiatus(?) in chronic infection venerial disease being treated or not treated. And this was the girl from Califonia. Usually when it's a little narrow we can use a thinner catheter, which not a major problem. We are better after surgery than before. But in one occasion this was completely impossible even a small catheter and I had to call a urologist to make a urethrotomy to cut the urethra and to pass a catheter. And after surgery, the surgery had been done for her but it took some longer time. And after surgery, she told me "Yes doctor, I didn't tell you I forgot but I had passed kidney stones but years ago and every year I had to go to the hospital to have my urethra dilated under general anesthesia". She knew that it could pose problems but she wanted me to save the first operation that she needed before during the other one. And finally it turned well, but this is one of the few girl's I never had any news from.

A major complication would be a cardiac failure. I had with a french girl after surgery some myocardial infarction which was a narrow escape but she went well after some time, and this increased the amount of my grey hair.

I had another surprise with a girl from Kentucky south from Ohio where I trained. They are called hillbilly if I remember. She had told me her condition was very poor, but she had insisted to have the surgery and she was fortunately not alone. She had some relative being with her and the cardiologist disagreed, but Dr. Lambert the anesthesiologist, and I said yes we can if she lowered something and it was quickly evident that there was a cardiac failure, a cardiac collapse quickly at the beginning of the anesthesia fortunately, so the surgery could be stopped. And this finally turned out very well. I returned a big part of the amount which had been paid and I learned a few weeks after that that she had complained at a TV interview that I had put her to sleep to take part of her money and that I knew and I decided that I wouldn't do it. This was not finished because I was not too happy but that's it and I have already too many patients to do. This is so, but it has been interesting. After that she wrote me to ask for a new date and to ask me for another try. Even that she would sign an I answered her that I had learned that she had complained in front of the TV another patient told me that she had seen her on the TV and that she was complaining about the brussels sprout taking her money. So I refused to do. I wrote her that.

With asthma. I have sometimes rare complications. The other major complication would be bleeding. Some we use preventive measures during surgery with the anesthesiologist to lower the blood pressure, to use a blood substitute. Most of the time it's going well but some patients don't respond well and they had some small bleeding from everywhere. When it's big bleeding coming from the major vessel it's easy to ligate but sometimes it cannot be done. My only consolation is that normally [when] the patient's bleeding a little too much during surgery, they don't bleed after. Maybe because their blood pressure is already low, they don't have too much to lose after but the patient with the easy part not bleeding surgery - after surgery, some have a tendency to bleed. Maybe when their blood pressure is going up and they have post operative bleeding. But less and less I have to use blood. I think it's about once in about 60 cases. [After lecture he says 1 in 20]

I have other difficulties sometimes it's completely impossible to dissect the cavity for the vagina. When you go in that, you cannot go past the prostate, and that's related because there's a few patients maybe many with more than 1 I think maybe, they have some sexual activity to the rectum this means laceration to the rectum, separation, and which which induces scar tissue and packed sometimes impossible to go through or if you force you go through you go in the rectum or in the urethra. So sometimes it happens it's surgeries are most impossible. And I remember, I still afraid when I think to that a few days after her surgery I had a phone call from a physician from Los Angeles telling me that such girl couldn't go because she had just been brought to the hospital in an emergency because she had what we call astyorectal(?) abscess. It means a huge abscess around the rectum. If it could, would have blood in a few days later I would be in surgery, inside and be in trouble and would be sure to get intestinal fistula, and a poor result so.

Now the last part. After surgery complications.

There is a complication like stomach pain with nausea, vomiting. This is easily treated with the patient remaining with the IV. They are fed IV for 2 or 3 days. Some medication will help and sometimes Coca Cola helps a great deal.

Difficulties to pass gas, some they have a big belly they cannot pass gas it hurts. It hurts better to not to use too much pain killer because if you, this is another procedure your bowel has to function and you have to pass gas in the right way not to got get nausea, and sometimes it hurts especially if you have wart or some appendicitis or some infection in your abdomen. It can hurt, but not good reason to use too much pain killer because this is stopping the procedure. It doesn't hurt, it just postpones the difficulty.

Bleeding of course, I mentioned there can be bleeding 2 or 3 days after starting. I had once a bleeding when I removed the catheter from the lips on the 2 or 3 days after surgery for drainage. I don't know only bad luck some bleeding started some major bleeding. I had to put this girl asleep and to find from where it was coming because she had been very much swollen. This was an inside bleeding which is still worse than an outside one.

I had also to mention that quite more than a few patients are either depressed or excited, over excited after surgery. Some are depressed because they are weakened by the surgery, they have some depression we treat for that before. They should come here with their medication to explain them, to do it this means to make a lot of talking to sit at their bedside or to call a psychologist to try to arrange things and to gain some time. I don't like too much this depressions but I have maybe more problems with the exited people who want to who always to get up as soon as early, to smoke in their bed when not allowed to smoke in hospital. And sometimes I have a very rough time and this is why I have cut the stay at the hospital after surgery to 6 days after surgery to make a package one week complete. It means 1 night before surgery in the hospital and 6 nights after. Before it was one full week after surgery but after 4 or 5 days, many patients are well and they start to walk in the hospital and to show what has been done to explain they always find somebody speaking english and I have problems with the hospital manager if they are too ???? As long as they are in their room, it's OK. It's no problem at the end sometimes I have rough time.

I do rounds. I see patients twice, usually I do rounds alone. Many patients, American patients have told me that in the state's it's quite different with rounds they come with 3 or 4 and they speak between each other and most are looking at the patient. Physicians after surgeries are talking to the nurse and then they proceed without asking, being afraid to ask a question or to ask the patient if he's well because he start to complain and if complaints he cannot proceed.

I remember another sad case. A girl not talking. She looked depressed but she didn't say anything and I asked her if there was a problem if she had a family or if she missed some news or I could eventually telephone or to have some news or to bring news about her from the states and she said "Oh no doctor you know my family they organized my funeral when I decided to go that way to go the train they arranged the whole family funeral service and they even went to the cemetery and that's alright." It doesn't help to specialize in this delicate, delicate moment.

Another girl had a letter, she was very proud, the ex-wife had given her a letter had signed by the children were almost full-grown to be opened after surgery. And she had a little fetish about that letter she would show me that she didn't open before. The day after surgery, I forgot to ask. The following day she was like that I said "How are you doing?" She was not doing well and I said "Yes, what about the letter?" "Oh doctor, let me see, this was the exwife and the children saying that if you had done the surgery this was not fair amnd would have to cut everything, and that they didn't want to see her again". This is another sad situation. It could be prevented maybe.

And the last maybe major complication would be, but I never had so far, would be rectal-vaginal fistula. To pass the intestinal contents through the vagina which is a very sad condition. During surgery from time to time I hit the rectum, but I always see it and if you see it then you have some time to repair that and to put the flap correctly and maybe not try to make the maximum depth possible, it's healing very easy.

I think I have covered most of the things, maybe our time is passing and I could eventually answer maybe we will just past the last slide. The next one please.

SLIDE:

Yes, this is to illustrate the bleeding. Once again the place around the catheter where you have... where Dr. Biber was so helpful in explaining how not to have that. This patient has to be brought back because of excessive bleeding. But this was several years ago but this can still happen. This means that sometimes certain patients have bleeding tendency and I will ask if they had a certain tooth removed beforeor if they have had some bleeding through the nose during childhood because some have more tendency to bleed than the others. It's not fully the responsability of the physician, but it can be too. Next one.

SLIDE:

Yes I saw diffuse bleeding beneath the skin. This gives some temperature but in the long run it's going very well. Next one.

SLIDE:

Yes, this is the key to success to get a good vagina you have to bring good material to work with. You have to bring good banana. [Laughter] So you see you have more tissue to work with and so the best case I like to leave it for that. Next one.

SLIDE:

When you do injections maybe this was thought about by some patients they have silicone injected into the hips as they say. This was a good illustration you can run into trouble you see when you inject the pain killer or antibiotic or some vitamin or something you can run into trouble usually the lethal dose that they have so much they don't know where it's at that we can start an infection. And I saw these 2 girls with a huge amount of silicone injected directly beneath the skin and in the tissue but this was hard like (knocking on the table)like table. This was hard. And after surgery they would lay on their side and I think they were bound to have trouble.

I had one girl I almost refused the operation but I tried this was open. She could open her legs so i finally decided. She was from Alaska, the cold state; they need good hips.

This is important, I just remember I had another girl I had refused. She had also to comply when at the last examination she said "yes doctor I had problems". She had put breast implants with a plastic surgeon done that and both buttocks 1 almost alright, the other 1 was first running because it was infected. I said I cannot perform the surgery with pus running in great amount through to the surgery and your condition is not good. I plan to remove that implant or eventually it goes. And eventually in treating her I would agree to remove the testicles to do at least something during her trip. This she accepted to have the testicles removed which I did. But she refused that I remove even the pus running from one buttocks. Because she said "Yes, I have a problem with my plastic surgeon. There is some malpractice suit going on with him" so. And then she came but it took 1 year because during she had both implants removed and instead she had a very large tattoo with an American eagle on both.

Just between plain surgery it will certainly get to know that there are certain advantages because the rates in Europe are easier or at least in Belgium because we don't charge the operating room. The operating room is included in the room at the hospital, with the stay. So, that's why I can perform the tracheal shave at almost no extra cost as long as you are an inpatient. If you are an outpatient that you are doing at the hospital, you have to pay room in order to get access to the operating room. That's one of the advantages, but certainly not to be the....

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BEGINNING OF LAST TAPE (about 15 minutes)

The difference between American and European patients, one is that they don't submit well to jet lag. North Americans, they sleep a little during the day and not well during the night because they are confused like I am now here. But, the other thing is they have a tendency to have a temperature, 2 or 3 days they have some temperature but higher in the morning but lower at night. In Europe we have it reversed, normally it's at the end of the day that we have more temperature because we are used to the periodicity between the daytime and the night. So, it takes some time to change but I know when I see the European patient having temperature in the morning I am concerned because I think at night it can be worse. When an American in the morning it should be better at night. Next one.

SLIDE:

This is the entrance of the new Foundation Lambert where I work now. This is the old part of the hospital. This is the building in which I am going, but I don't know where. Next one.

SLIDE:

This is the emergency room open the doors and there are always physicians on hand. That's the entrance that a few know or will know. Next one.

SLIDE:

This a larger view of the old part now I think the next one will be... Next one.

SLIDE:

This will be on the street behind. This is the new wing with obstetrics and children's department. Both so far no patients, no exit. There has yet to be transgendered, cannot be in that wing so far. This is brand new. This is very well but not yet, we are still in the old wing but it was in fact remodeled and we have pretty good equipment. Next one.

SLIDE:

Yes, this is the hotel Derby that many know. It's not the nicest hotel, but it's located about 8 to 10 minutes walking from my office, 15 minutes from the hospital. Even when they have relatives they can walk easily it's not too expensive for student rate. It's not very nice, there is no TV in the room but you pay for that too. And they are very comprehensive, they are used to that and you can feel at peace there. Next one.

SLIDE:

This is a few sights around Brussels that can be visited better before than after. This is Waterloo where Napoleon had been defeated in 18 hundred 15 (1815). 60,000 people died in one day from. Next one.

SLIDE:

This is Brugges. 60 miles outside Brussels for travelling people in Europe, There are two musts in Belgium beside me. It's the Grand Place, downtown Brugges, a little far away but very nice especially when the weather is good. It's like Venecia del Norte [Venice of the North]. With canals, it's very nice in fall. Next one.

SLIDE:

Here this is the mascot of Brussels [A peeing boy]. I agreed to perform the surgery. [Laughter] They are confused that I come up with question. Next one.

SLIDE:

Yes this is the problem I spoke about, it's like the same one like the other one. Next one.

SLIDE:

Yes, that's it. The sunset in front of my home when I was in Kinshasa in Zaire. I had many many sunsets there and I think I always love to see them.

END OF SLIDES

I think... Thank you for your attention and...

**A** Dr. Seghers, can I ask you a couple of questions?

**S** Couple? One.

**A** Let me ask you, when you create the tunnel, the corpora tunnel of the penile flap or graft do you take it up to the base of the peritoneum [perineum], do you take it as high as the peritoneum [perineum], or do you make a judgement on the basis of the length of the plug?

**S** I go almost at the perineum. I think if I go to the perineum, I will go through.

**A** I understand.

**S** But I am about... the only difference you see, I used to feel where the bladder with my thumb on the bladder catheter and I feel where it balloons. Now, but I go far away, but I have a small fingers and short fingers I use 6 and a half for a glove. So I have to use instruments to do it the best because my fingers are too short.

**A** I understand.

**A** Let me ask one or two other things too. How long before you start to advance the drains? If this is right, isn't that about the second or third day? How soon before you begin to start to advance the drains? The ???? drains that you have there?

**S** I remove them out complete. I remove completely out after 48 hours.

**A** After 48 hours, that's what I wanted to know.

**S** In one stage, sometimes there is still some bleeding tendency. I can left 1 but usually I remove it completely. And once I started some bleeding when I had removed in one stage. In one stage.

**A** And last thing, not last thing but rather did I understand that you don't create a pseudo cervix. Did I see on one of the specimens that you had taken the glans and you don't place...

**S** No, No, No, No.

**A** You do not?

**S** I had that years [ago]. I think I can but I don't have the right to make test or experimental surgery on Americans travelling long distances. They have to be well to be able to leave after 8 or 10 days even if they don't have they have to stay longer. They will be trouble with the airlines. Because they don't keep the appointment. But I have done some tests with Belgianss or locals that I can check myself and see after 2 weeks, 3 months, repeatedly. I try to make some kind of cervix. I read the literature and I have a temptation to try something and it fails. And so I did it anyway. I had to be sure it would work before doing it especially on people travelling long distances.

**A** I agree.

**A** Last question, do you take a terminal urine for culture and sensitivity after, just before you take the catheter out, are you?

**S** NO.

**A** You don't do that?

**S** No, no. For common complications maybe I skip that phase. Common complications is a bladder infection urinary infection.

**A** That's right.

**S** Especially a few patients. They like to play a little with their catheter because it's stiff, it cannot be pulled out because there is a self retaining balloon. But they play, pushing it a little inside. That's not good.

**A** I wonder if you did it in the fact that it's in for so long, there might be some bacteria there that had cultures that they would know at least that they would have overt cystitis.

**S** Yes they are. This means some more, some use of antibiotic later on through the mouth so they are under strong antibiotic during 48 hours, ZYNACEF I.V. during 3 times 1.5 gram during 2 days and after that I give BACTERIN, strong, twice a day.

**A** Ah OK, fine. That certainly helps some.

**S** Then we depart you from the hospital when they leave the hospital they stop. And if I hear that they have to urinate too often and the usual sign, in fact told them to drink a lot, to drink a lot, in order to wash their inside and to have to try to avoid an infection, an ascending infection from the outside to the inside. But it happens.

**A** Once in a while.

**S** YES.

**A** Thank you very very much indeed.

**S** Some other questions?

**A** How long does the surgery last?

**S** About 3 hours, but now I say it's 2, 2 hours 30. It's average 3 hours. Rarely more than that, that's why I am able to do 2 in a row. I never did 3, but maybe it will happen eventually. That brings out another factor which you have nothing to do with that but when we keep appointment for some surgery to patients who have their surgery at the end of the month we do that 3 months in advance and I am not sure if I will be in perfect shape at that time. That's sometimes difficult. Sometimes I think tired or without any reason I get flu sometimes and I told you that you had the flu and that you had to fly back home. But if I have patients coming and I have the flu, I cannot do your surgery before next week, this is a difficult question. I work with the flu when it happens. Sometime when I do 2 cases, at the end of the second case I feel ready to start the third 1 and I joke with nurses she can go to take the third patient and there is no third patient, not even a minor case. Sometimes 1 surgery is too much. You never know. This is never a feel for anywhere. On a better day I don't sleep, somebody asks if I would do a favor, generally 7 at night...

**Moderator** We have time for probably, we will extend this session probably for about 15 minutes. For those that want questions, and make sure that they we get them in I want to use the mike in the center of the room and we'll probably keep it to about 4 people or so. So if you have questions then go to use that mike and line up please.

**A** Dr. Seghers, can you tell me if there are unique complications for patients having surgery that have already had a bilateral orchiectomy?

**S** Its not real complications, but I think it's also the case it doesn't help the surgery because there's shrinkage of the scrotum and shrinkage of the penis. So there is less tissue. Most of the patients have not enough tissue or 2 pieces of just [enough]. So it can be done if the patient has all the reasons to have the orchidectomy done before such as not operating the female hormones and being obligeded and cannot go for surgery early. Maybe it can be done, but I don't advise that. But you can say yes I did it to a girl who came with pus running from her buttocks, I tried to do something maybe somebody would say something to take her money. I had removed testicles, it's to please her for little. Otherwise she would do a trick with us who have done nothing but I think I know some do that because it's available it can be paid by insurance, but I don't think that it can be done but... it's not so helpful, and it's not shortening the main procedure that I say between 2 hours and 3 hours. The fact that to remove the testicles happens you save in the maximum maybe 3 minutes.

**A** If you don't have any skin atrophy and other than that there's no other complications?

**S** We have less, less skin atrophy, but somebody told me if I require to stop the female hormones maybe 2 weeks or 3 weeks before surgery it's not to enlarge the penile skin during that time, it's to shorten the time that you recuperate some reflex and some possible extension but it's to avoid the risk of the female hormones with blood clots being circulating in the large veins and to try to avoid the pulmonary embolism which can kill patients almost certainly without the surgery too. But since it's not necessary surgery, we can be in trouble. And there's a possibility with hormones, with the first case in Belgium which died, this, I didn't have yet but it can happen.

**A** Pardonne ma question mes Mon ami, DR. Seghers. Je vous avant cours. Merci beaucoup pour la visit.

**S** Le visit.

**A** I have couple of questions, why you find that hair growth is a frequent complication at the vaginal opening and if so is there anything that can be done about that?

**S** For me, it's not a complications, but the patient argued about that. That it was a complication and the main reason and if she was true, I didn't tell her enough. She felt I was responsible for that not to tell her. I don't ask patients to sign a written consent because if you do that you have to add all complications even that they could die. They have to sign that one. So in Belgium, we are not obliged to do that. With the documents I have that they come for that, that's enough. But maybe that one said she had a rough time with that. To my surprise.

**A** But is it usually serious or is it just something that's a personal problem that people reach?

**S** A more personal problem.

**A** Also where do you recommend having z-plasty done, do you recommend coming back to Belgium?

**S** NO, no. I think it will be done by any plastic surgeon who is willing to take care of that. I used to do that under general anesthesia because with the local I do since I worked at central Africa, we used a lot of local anesthesia and it's possible to do a lot, but American patients it's not so easy for the question of pain.

**A** And finally do most of your patients seem to have sufficient sensation?

**S** Not for the time they are in Brussels because I used to say that the clitoris or what I call the pseudo clitoris that's asleep for 3 months. And after that if you are lucky it can get awake, it gets awake it means you can have pain. Pain and feeling this is a link, the same thing but it's a good sign. When you start to have some pain it means all nerves are growing back again and that the sensitivity is gaining in in importance. In my opinion, it's not the clitoris that I make which is subcutaneous at the beginning. If it is so important somebody, some curious gentleman can eventually feel something there, but the feeling is not exactly the same thing. Some patients say they urinate through their clitoris. This statement is incorrect because they urinate through the urinary opening of the pee hole and it's swollen around because that's the rest of the corpus spongiosum which increases in size when they are excited. This is not so, some think it's the clitoris, but it isn't. When they have a good feeling or some kind of orgasm and many they write me about that they are so proud and so happy, some time they get it when they have when they are doing their dilation, it's coming from the prostate. Because the prostate is staying in place, this is very delicate. This shrinks a little because of the female hormones, but the orgasmic sensation that they get is contraction of the seminal glands which stays in place and at the same time they have some fluid coming out of the urethra, not in the vagina. Vagina is always going to be dry and you have to use lubricant, but the feeling, the orgasm that they get is coming from, in my opinion, from the prostate.

**A** Dr. seghers I have two questions. One is, what general type of insurance do you require or do you accept?

**S** Insurance?

**A** Do you accept any insurance for surgery if there is insurance that will cover it?

**S** I can give receipt and what have been paid for. Insurance, that's your problem. I'm not billing the insurance company.

**A** Yes, I just was wondering.

**S** But I can't get from some perhaps they're going in a rough time because the insurance, medicare and so they are very reluctant to say, to pay anything for reassignment surgery and especially when it's done abroad. And it's... They write that the form that they give the receipts is not correct and after that they want a copy of the operating room report. I send a copy, I have written that an operating report since I am French speaking and the operation is doing in Brussels ... the surgical report is made in French in my chart.

**Moderator** Insurance will be covered in the next section.

END OF RECORDING