Evaluation of surgical procedures for sex reassignment: a systematic review

[ino3]

doi:10.1016/j.bjps.2007.12.009
Copyright © 2007 British Association of Plastic, Reconstructive and
Aesthetic Surgeons Published by Elsevier Ltd
Review

Evaluation of surgical procedures for sex reassignment: a systematic
review

P.A. Sutcliffea, , , S. Dixona, R.L. Akehursta, A. Wilkinsona, A.
Shippama, S. Whiteb, R. Richardsc and C.M. Caddyd
aSchool of Health and Related Research, University of Sheffield,
Sheffield S1 4DA, UK
bEast Midlands Specialised Commissioning Group, Grove Park, Leicester
LE19 1SS, UK
cDerbyshire County PCT, Babington Hospital, Derbyshire DE56 1WH, UK
dNorthern General Hospital, Herries Road, Sheffield S5 7AU, UK

Received 16 August 2006; accepted 6 December 2007. Available online
28 January 2008.

Summary
Objectives

To evaluate earlier reviews and literature concerning five individual
surgical procedures for male-to-female (MTF) transsexism:
clitoroplasty, labiaplasty, orchidectomy, penectomy and vaginoplasty.
Further evaluations were made of eight surgical procedures for female-
to-male (FTM) transsexism: hysterectomy, mastectomy, metoidoplasty,
phalloplasty, salpingo-oophorectomy, scrotoplasty/placement of
testicular prostheses, urethroplasty and vaginectomy.

Background
Increased prevalence and advances in surgical options available to
patients requesting gender reassignment surgery have made this an
important consideration for research. There remains a lack of
systematic reviewing of the evidence, in particular, of the individual
surgical options available.

Methods
Searches were undertaken in six electronic databases (Applied Social
Sciences Index and Abstracts [ASSIA], Cochrane Library [Wiley Online],
Embase [Ovid Online], Medline [Ovid Online], Medline in Process [Ovid
Online], Psycinfo) providing coverage of the biomedical, grey
literature and current research.

Results
Eighty-two published papers (38 MTF; 44 FTM) met the inclusion
criteria identified across the 13 surgical procedures. For MTF
transsexism there was no evidence satisfying the inclusion criteria
concerning labiaplasty, penectomy or orchidectomy procedures. A large
amount of evidence was available concerning vaginoplasty and
clitoroplasty procedures. For FTM transsexism satisfactory outcomes
were reported. Outcomes related to the ability to perform sexual
intercourse, achieve orgasm and void whilst standing. Some
complications were reported for both MTF and FTM procedures.

Conclusions
The evidence concerning gender reassignment surgery in both MTF and
FTM transsexism has several limitations in terms of: (a) lack of
controlled studies, (b) evidence has not collected data prospectively,
(c) high loss to follow up and (d) lack of validated assessment
measures. Some satisfactory outcomes were reported, but the magnitude
of benefit and harm for individual surgical procedures cannot be
estimated accurately using the current available evidence.

Keywords: Gender reassignment surgery; Transsexism; Male-to-female;
Female-to-male; Evidence-based research

Article Outline
Transsexism and GRS
Prevalence
Literature searches
Sources searched
Keyword strategies
Search restrictions
Inclusion and exclusion criteria
Data extraction strategy
Quality assessment strategy
Results
Core surgical procedures for MTF transsexism
Clitoroplasty/neoclitoris construction
Labiaplasty
Orchidectomy
Penectomy
Vaginoplasty/neovagina construction
Core surgical procedures for FTM transsexism
Hysterectomy
Mastectomy
Metoidioplasty
Phalloplasty
Salpingo-oophorectomy
Scrotoplasty/scrotum construction/testicular prothesis
Urethroplasty
Vaginectomy/vaginal closure
Discussion
Future research
References

A male or female with gender identity disorder (GID) suffers from a
constant feeling of psychological discomfort related to their
anatomical sex and has a desire to live and be accepted as a member of
the opposite sex. One method that attempts to resolve this discomfort
and assist with anticipated sense of completeness is gender
reassignment surgery (GRS). Through GRS a person's external sexual
characteristics are altered to resemble those of the opposite sex. In
this review we aim to systematically evaluate the literature concerned
with the core surgical procedures for male-to-female (MTF) and female-
to-male (FTM) transsexism.

Traditionally, the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV)1 has used the term ‘transsexualism’ and states that
for a person to be diagnosed with GID they must show strong persistent
cross-gender identification (not merely a desire for any perceived
cultural advantages of being the other sex). In adolescents and
adults, the disturbance is manifested by symptoms such as: a frequent
passing as the other sex; stated desire to be the other sex and to
live or be treated as the other sex; the conviction that he or she has
the typical feelings and reactions of the other sex. Furthermore,
disturbance can be manifested by a preoccupation with removing primary
and secondary sex characteristics (e.g. request for hormones, surgery,
or other procedures to physically alter sexual characteristics to
simulate the other sex) or belief that they were born the ‘wrong’ sex.
In the present review the authors have chosen to use the term
‘transsexism’, in recognizing that GID has no direct association to
sexuality, but is directly linked with sexual identity.

Transsexism and GRS
The process by which a person comes to receive GRS is complex and
occurs over a series of stages. The Harry Benjamin International
Gender Dysphoria Association (HBIGDA)2 has provided a set of standards
that have been widely adopted by service providers. In the UK,
transsexuals typically receive a diagnosis of GID by a psychologist
(e.g. mental health professional, clinical psychologist) or
psychiatrist. A medical consultant may then prescribe the patient with
hormones. In general, persons with transsexism are required to live
and work, full time, in the new gender role for 2 years to obtain real-
life experience. After successful completion of this stage, a second
professional confirms the diagnosis and only then can they be referred
for genital surgery. It is important to recognize that this pathway is
not universal.

Prevalence
The DSM-IV1 states that, ‘Data from smaller countries in Europe with
access to total population statistics and referral suggest that
roughly 1:30 000 adult males and 1:100 000 adult females seek sex-
reassignment surgery.’ Other reports present different numbers of
prevalence. Only a small amount of routine data is available in the UK
that may be used to estimate the prevalence of transsexism.3 The
Scottish Needs Assessment Programme4 estimated the prevalence of
transsexism in Scotland, through sending questionnaires to relevant
professional groups in Scotland and to transsexual self help groups.
The study found that 300 patients with transsexism were receiving
treatment in Scotland and the prevalence was 8:100 000. MTF patients
outnumbered FTM patients by about 4:1. The reported prevalence of
transsexism has been found to vary throughout the world. Van Kesteren5
found the prevalence of transsexism in The Netherlands to be 1:11 900
(MTF) and 1:30 400 (FTM). Tsoi6 found prevalence levels of 1:2900 for
MTF and 1:8300 FTM patients in Singapore. A Swedish study suggested
that the number of individuals requesting GRS is 0.17 per 100 000.7

The aim of the review was to retrieve all available literature
published since 1980 concerned with:

• The surgical treatment for persons undergoing GRS.

• Individual surgical treatment for male-to-female (MTF) and female-to-
male transsexism (FTM).

We limited the search to ‘core’ surgical procedures, as outlined in an
unpublished report by Whittaker et al.8 We included procedures
routinely commissioned as part of a programme of treatment for
patients with gender dysphoria (see Figure 1). We recognize that other
core surgical procedures are available (e.g. prepuce construction),
but these were outside of the scope of this review. We aimed to
provide all levels of evidence available, based on the hierarchy
presented by NHS Centre for Reviews and Dissemination Group
recommendations.9

Full-size image (54K)
Figure 1. Core and non-Core procedures: surgical and non-surgical

View Within Article

Literature searches
Sources searched
Searches were undertaken in six electronic databases (Applied Social
Sciences Index and Abstracts [ASSIA], Cochrane Library [Wiley Online],
Embase [Ovid Online], Medline [Ovid Online], Medline in Process [Ovid
Online], Psycinfo) providing coverage of the biomedical, grey
literature and current research. The publication lists, current
research registers, and health services research related organizations
were consulted via the world wide web (www). Keyword searching of the
www was undertaken using the Google search engine. In addition,
reference lists were searched for cross-references, and abstracts from
conference proceedings and meetings were checked.

Keyword strategies
Sensitive keyword strategies using free-text and, where available,
thesaurus terms were developed to search the electronic databases. All
the core surgical procedures listed in Figure 1 were searched using
keywords. In addition, a comprehensive list of terms related to GRS
were used: male-to-female, mtf, female-to-male, ftm, sex-changed, sex-
changing, sex-change, sex chang*, sexual reassignment, sex
reassignment, sex-reassignment, gender reassignment, gender-
reassignment, reassignments, reassignment surger*, trans-sexual*,
trans-sexual, trans-sexualism, trans-sexually, trans-sexuals, trans
sex, transsexual*, transexual*, transvestitism, transvetism,
transvetite, transvetitism, transvestitismus, transvestism,
transvestite*, gender dysphoria, gender-dysphoria, gender dysphoric,
gender-dysphoric, gender-dysphorics, gender identity disorder, gender-
identity-disorder, gender-identity-disordered, gid, gid-n, gid-us,
gender transformation, gender-transformed, gender-variant,
transgender, transgender-identified, transgender-specific,
transgendered, transgendered-were, transgenderedness, transgendering,
transgenderism, transgenderist, transgenderists, transgenderness,
trans-gender*, cross dresser, cross-dresser, cross-dressers, cross
sex, cross-sex, intersexuality, gender transition, transition. All
search terms were searched in upper and lower case.

Search restrictions
Searches were restricted to English language literature. All searches
were undertaken to retrieve literature from 1980 onwards. These
searches can be extended to previous years using our search strategy,
or expanded to include other techniques (e.g. hand searching of
journals) and although every attempt had been made to cite all
relevant literature it is possible that omissions were made. All
searches were undertaken between October and November 2005.

Inclusion and exclusion criteria
One reviewer independently screened all titles and abstracts. Full
paper manuscripts considered relevant by the reviewer were obtained.
The relevance of each study was assessed according to the criteria set
out below. Any uncertainty was discussed with a second reviewer and
resolved by discussion. We included all publications that reported an
individual core surgical procedure (see Figure 1) for transgender
males and females and discussed the outcomes of the procedure. We did
not restrict our inclusion to specific outcome measures. Unlike
previous reviews (e.g. Pfäfflin and Junge)10 we did not restrict
inclusion based on the number of participants, therefore, a wealth of
single case studies were extracted.

Studies were excluded if they involved: expert opinion and review
articles; multiple surgical procedures; non-transsexism/gender
dysphoric populations; non-core surgical procedures (Figure 1); non-
humans (e.g. animals); patients aged below 18 years; or publication
before 1980.

Data extraction strategy
Data relating to both study design and quality were extracted by one
reviewer into a standardized data extraction form and independently
checked for accuracy by a second. Any discrepancies were resolved
through consensus. Where multiple publications of the same study were
identified, data were extracted and reported as a single study.

Quality assessment strategy
The level of evidence was assessed, based on NHS Centre for Reviews
and Dissemination Group recommendations.9 Individual studies were
assessed by one reviewer and independently checked for agreement by a
second. Disagreements were resolved through consensus. Included
studies were assessed for level of evidence and methodological details
without any bias towards the results of the study, and there was no
blinding of authorship.

Results
A total of 1170 references were screened which identified 117
published papers concerned with core surgical procedures.

Core surgical procedures for MTF transsexism
This section discusses each of the core surgical procedures outlined
above for MTF transsexism. A total of 38 published papers were
included (Table 1) and a further 13 papers were excluded (Table 2).

Table 1.
Included studies concerned with MTF surgical procedures

Study Design N Surgical procedure Level of evidence
Fang et al. (1992)11 Case series 9 Clitoroplasty III
Giraldo et al. (2004)12 Case series 16 Clitoroplasty III
Rehman and Melman (1999)13 Case series 10 Clitoroplasty III
Harder et al. (2002)21 Case study 1 Neovagina construction IV
Liguori et al. (2001)22 Case study 1 Neovagina construction IV
Siemssen and Matzen (1997)23 Case series 11 Neovaginal construction
III
Blanchard et al. (1983)51 Case series 55 Vaginoplasty III
Blanchard et al. (1987)52 Case series 22 Vaginoplasty III
Bodsworth et al. (1994)24 Case study 1 Vaginoplasty IV
Bouman (1988)131 Case study 55 Vaginoplasty IV
Cova et al. (2003)25 Case series 10 Vaginoplasty III
Eldh (1993)26 Case series 20 Vaginoplasty III
Freundt et al. (1993)27 Case series 19 Vaginoplasty III
Freundt et al. (1994)28 Case study 1 Vaginoplasty IV
Fugate et al. (2000)29 Case study 1 Vaginoplasty IV
Hage and Karim (1998)30 Case studies 6 Vaginoplasty IV
Hage et al. (1998)31 Case studies 2 Vaginoplasty IV
Hage et al. (2000)32 Case series 390 Vaginoplasty III
Hoebeke et al. (2005)33 Case series 31 Vaginoplasty III
Jarrar et al. (1996)34 Case series 37 Vaginoplasty III
Karim et al. (1995)35 Case series 200 Vaginoplasty III
Karim et al. (1996)36 Case studies 7 Vaginoplasty IV
Krege et al. (2001)16 Case series 66 Vaginoplasty III
Kwun et al. (2003)37 Case series 28 Vaginoplasty III
Lemberger and Bishop (2001)38 Case studies 4 Vaginoplasty IV
Liguori et al. (2004)39 Case study 1 Vaginoplasty IV
Liguori et al. (2005)40 Case studies 5 Vaginoplasty IV
Loverro et al. (2002)41 Case study 1 Vaginoplasty IV
Maral et al. (2002)42 Case studies 4 Vaginoplasty IV
Perovic (1993)43 Case series 25 Vaginoplasty III
Perovic et al. (2000)44 Case series 89 Vaginoplasty III
Small (1987)53 Case series 11 Vaginoplasty III
Stein et al. (1990)45 Case series 14 Vaginoplasty III
Toolenaar et al. (1993)46 Case series 13 Vaginoplasty III
Trombetta et al. (2004)47 Case series 10 Vaginoplasty III
Van Engeland et al. (2000)48 Case studies 3 Vaginoplasty IV
Van Noort and Nicolai (1993)49 Case series 27 Vaginoplasty III
Wedler et al. (2004)50 Case series 53 Vaginoplasty III

Full-size table
Note: level of evidence is based on NHS Centre for Reviews and
Dissemination Group recommendations (2001).9

View Within Article

Table 2.

Excluded literature concerned with MTF surgical procedures

Study Design N Surgical procedure Level of evidence Reason for
exclusion
Maas et al. (1999)54 Expert opinion 1 Colpopoiesis and vaginoplasty V
Expert opinion
Karim (1996)55 Review NA Neovagina construction NA Review
Mate-Kole et al. (1990)18 Prospective non-randomised controlled study
40 Neovagina construction, orchidectomy and penectomy II Multiple
surgical procedures
Hage et al. (2001)19 Case studies 4 Orchidectomy IV Procedure combined
with vaginoplasty
Hirsch et al. (1993)20 Case series 6 Penectomy III No reported
outcomes of penectomy procedure
Rubin (1993)17 Case series 13 Pseudoclitoris construction and
orchiectomy III Multiple surgical procedures
Frederick and Leach (2004)132 Case studies 2 Sacral colpopexy IV
Corrective surgical procedure
Alberta Heritage Foundation for Medical Research (1997)56 Review NA
Vaginoplasty NA Review
Cairns and deVilliers (1980)133 Review NA Vaginoplasty NA Review
Hage et al. (1994)14 Review NA Vaginoplasty and clitoroplasty NA
Review of multiple surgical procedures
Krege et al. (2001)16 Case series 66 Vaginoplasty and clitoroplasty
III Multiple surgical procedures
Hage and Karim (1996)15 Case series 60 Vaginoplasty and
neoclitoroplasty III Multiple surgical procedures
Hage et al. (1996)57 Case studies 7 Vaginoplasty and vulvoplasty IV
Multiple surgical procedures
Full-size table
NA = Not applicable. Note: level of evidence is based on NHS Centre
for Reviews and Dissemination Group recommendations (2001).9

View Within Article

Clitoroplasty/neoclitoris construction
Three studies met the inclusion criteria[11], [12] and [13] and three
additional papers were excluded.[14], [15] and [16] A range of
surgical procedures were reported concerning cliteroplasty/neoclitoris
construction. For example, Giraldo et al.12 evaluated the anatomic
differences among four distal designs of the pedicled island
neurovascular flap of the glans penis: dorsal, lateral, ventral and
corona glans clitoroplasty in MTF patients. Another reported procedure
involved the neoclitoris being sculptured during the actual one-stage
vaginoplasty,14 although, clitoris sculpturing can also be completed
in subsequent procedures in patients where the glans has not been used
for this purpose. All three included papers reported successful
results in terms of function and cosmetic appearance with few or no
complications (e.g. urine leakage). Rehman and Melman13 reported that
the neoclitoris had remained intact postoperatively in eight out of 10
patients and the functional and cosmetic appearance was comparable to
a normal clitoris. In two patients, however, the results were not
satisfactory because of necrosis of the neoclitoris.

Using the dorsal portion of the glans penis with the dorsal
neurovascular pedicle for clitoroplasty, the neoclitorides in nine
patients survived well, and six patients reported sexual satisfaction.
11 However, the transpositioning of glans on the long dorsal
neurovascular pedicle appears to be a procedure with high risks.14
Overall, several studies have reported that the neoclitoris
construction can result in good preservation of light touch and sexual
sensation.[11], [12], [13], [15] and [17]

Labiaplasty
This procedure involves the creation or reshaping of the labia. No
relevant literature was found concerning labiaplasty surgery in MTF
transsexism.

Orchidectomy
No study met the inclusion criteria and three papers were excluded.
[17], [18] and [19] This procedure is also called gonadectomy,
commonly known as castration. A bilateral orchidectomy involves the
removal of both testicles. Hage et al.19 concluded that, although
there are many reasons for castration, they advise that bilateral
orchidectomy be performed in the course of GRS for MTF transsexism.

Penectomy
No study met the inclusion criteria and two papers were excluded.[18]
and [20] Penectomy is the complete removal of the penis.

Vaginoplasty/neovagina construction
Thirty-two studies[16], [21], [22], [23], [24], [25], [26], [27],
[28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38],
[39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49],
[50], [51], [52] and [53] met the inclusion criteria and a further
eight papers were excluded.[14], [15], [16], [18], [54], [55], [56]
and [57] Vaginoplasty involves the creation or reshaping of the
vagina, this is frequently referred to as neovagina construction. A
common vaginoplasty technique performed on MTF transsexuals uses
tissue from the existing genitalia to create the vagina; this is often
referred to as the penile inversion technique. In some patients a lack
of tissue may require additional skin grafts to be taken from the
buttocks/hip area. Other patients may have a two-stage procedure that
requires labiaplasty surgery to be undertaken on a separate occasion.
Alternatively, a more complicated technique uses a segment of the
colon (colovaginoplasty).

Satisfactory cosmetic and functional results have been reported in a
large number of studies concerned with vaginoplasty/neovagina
construction.[15], [16], [27], [32], [34], [40], [41], [44] and [51]
One study reported that vaginoplasty combining inversion of the penile
and scrotal skin flaps produced poor functional outcomes.50 Krege et
al.16 also reported that major complications during, immediately and
after surgery occurred in nine of the 66 patients (14%), including
necrosis of the distal urethra (n = 1), necrosis of the glans (n = 3),
a rectal lesion (n = 3), and severe wound infections (n = 6). However,
in using a long-term follow-up questionnaire, Krege et al. found more
than 90% of their patients were satisfied with the cosmetic result and
capacity for orgasm, and 58% reported having sexual intercourse.

Core surgical procedures for FTM transsexism
This section discusses each of the core surgical procedures outlined
above for FTM transsexism. A total of 44 published papers were
included (Table 3) and a further 19 papers were excluded (Table 4).

Table 3.
Included studies concerned with FTM surgical procedures

Study Design N Surgical procedure Level of evidence
Saridogan and Cutner (2004)58 Case study 2 Hysterectomy IV
Burcombe et al. (2003)64 Case study 1 Mastectomy IV
Colic and Colic (2000)65 Case series 12 Mastectomy III
Hage and Bloem (1995)66 Case series 70 Mastectomy III
Hage (1996)68 Case series 32 Metoidioplasty III
Perovic and Djordjevic (2003)69 Case series 22 Metoidioplasty III
Akoz and Kargi (2002)71 Case study 1 Phalloplasty IV
Barrett (1998)72 Cohort study 63 Phalloplasty III
Bettocchi et al. (2005)73 Case series 85 Phalloplasty III
Cavadas and Landin (2005)74 Case study 1 Phalloplasty IV
Chesson et al. (1996)75 Case series 25 Phalloplasty III
Chivers and Bailey (2000)76 Case series 39 Phalloplasty III
Fang et al. (1998)77 Case series 20 Phalloplasty III
Fang et al. (1999)78 Case series 22 Phalloplasty III
Fisch et al. (1993)79 Case study 1 Phalloplasty IV
Gilbert et al. (1987)91 Case studies 6 Phalloplasty IV
Hage (1997)80 Case study 1 Phalloplasty IV
Hage and Bouman (1992)81 Case series 120 Phalloplasty III
Hage and Monstrey (1998)82 Case series 3 Phalloplasty IV
Hage and Winters (1996)83 Case study 1 Phalloplasty IV
Hage et al. (1993)84 Case series 25 Phalloplasty III
Hage et al. (1993)85 Case series 46 Phalloplasty III
Hage et al. (1993)86 Case series 28 Phalloplasty III
Hage et al. (1993)87 Case series 79 Phalloplasty III
Hage et al. (1993)88 Case study 1 Phalloplasty IV
Hage et al. (1996)89 Case study 1 Phalloplasty IV
Hoebeke et al. (2003)90 Case series 35 Phalloplasty III
Hoebeke et al. (2005)33 Case series 24 Phalloplasty III
Jarolim (2000)92 Case series 7 Phalloplasty III
Khouri et al. (1998)93 Case series 3 Phalloplasty III
Lief and Hubschman (1993)94 Case series 9 Phalloplasty III
Noordanus and Hage (1993)95 Case study 1 Phalloplasty IV
Papadopulos et al. (2001)96 Case series 24 Phalloplasty III
Papadopulos et al. (2002)97 Case series 18 Phalloplasty III
Rachlin (1999)98 Case series 27 Phalloplasty III
Santanelli and Scuderi (2000)99 Case studies 5 Phalloplasty IV
Santi et al. (1992)100 Case study 1 Phalloplasty IV
Vesely et al. (1992)101 Case study 1 Phalloplasty IV
Vesely et al. (1999)102 Case series 38 Phalloplasty III
Vesely et al. (1994)103 Case study 1 Phalloplasty IV
Zielinski (1999)104 Case series 127 Phalloplasty III
Zielinski (2001)105 Case series 209 Phalloplasty III
Sengezer and Sadove (1993)117 Case study 3 Scrotal construction IV
Hage et al. (1999)118 Case studies 4 Testicular prosthesis IV

Full-size table
Note: level of evidence is based on NHS Centre for Reviews and
Dissemination Group recommendations (2001).9

View Within Article

Table 4.
Excluded literature concerned with FTM surgical procedures

Study Design N Surgical procedure Level of evidence Reason for
exclusion
Futterweit and Deligdisch (1986)116 Case series 19 Bilateral salpingo-
oophorectomy, pelvic surgery and androgen treatment III Multiple
surgical procedures
Hage et al. (1993)119 Expert opinion 50 Construction of a scrotum V
Expert opinion
Chapin (1993)59 Expert opinion NA Hysterectomy V Expert opinion
Hage et al. (2000)60 Case study 2 Hysterectomy and salpingo-
oophorectomy IV Multiple surgical procedures
Hage and van Kesteren (1995)67 Review NA Mastectomy NA Review
Lim (1986)61 Case series 16 Mastectomy, hysterectomy, testicular
prosthesis III Multiple surgical procedures
Alberta Heritage Foundation for Medical Research (1996)106 Review NA
Phalloplasty NA Review
Byun et al. (1994)107 Case studies 5 Phalloplasty IV None transsexism
population
Dabernig (2005)108 Expert opinion NA Phalloplasty V Expert opinion
Hage (1994)109 Expert opinion NA Phalloplasty V Expert opinion
Hage and Bloem (1993)110 Review NA Phalloplasty NA Review
Hage and de Graaf (1993)111 Review NA Phalloplasty NA Review
Hage et al. (1993)112 Review NA Phalloplasty NA Review
Hage et al. (1993)113 Review NA Phalloplasty NA Review
Meyer et al. (1986)62 Case study 1 Phalloplasty, hysterectomy, vaginal
closure, neoscrotum construction IV Multiple surgical procedures
Mulcahy (2003)114 Review NA Phalloplasty NA Review
Rohrmann and Jakse (2003)115 Case series 25 Phalloplasty, neourethra,
vaginectomy, and urethroplasty III Multiple surgical procedures
Ozgur and Ozcan (1995)120 Expert opinion NA Scrotal construction V
Expert opinion
Ergeneli et al. (1999)63 Case series 8 Hysterectomy, bilateral
salpingo-oophorectomy, vaginectomy and phallic construction III
Multiple surgical procedures
Full-size table
NA = Not applicable. Note: level of evidence is based on NHS Centre
for Reviews and Dissemination group recommendations (2001).9

View Within Article

Hysterectomy
One study met the inclusion criteria58 and five additional papers were
excluded.[59], [60], [61], [62] and [63] This procedure involves the
surgical removal of the uterus. A total hysterectomy is the removal of
the entire uterus and the cervix. Saridogan et al.58 reported two FTM
case studies who had the hysterectomy procedure. The estimated blood
loss from the operation was from less than 50 to 350 ml, the total
operating time was 1.5 to 2 h and both patients made a good recovery
and went home 2 days later. Saridogan et al. reported that a
laparoscopic hysterectomy using the McCartney tube for FTM GRS was a
useful procedure in overcoming difficulties encountered due to
restricted vaginal access.

Mastectomy
Three studies met the inclusion criteria[64], [65] and [66] and two
additional papers were excluded.[61] and [67] The mastectomy procedure
involves the surgical removal of the entire breast(s). Colic and
Colic65 found the use of a circumareolar approach for subcutaneous
mastectomy produced flatter masculine breasts, leaving sufficient
dermal vascularization for the nipple-areola complex. Of the 12 FTM
patients all were very satisfied with the outcomes of surgery mainly
because of the periareolar scar. It was reported, however, that two
areolar necroses occurred due to perforation of the thin vascular
dermal pedicle.

Metoidioplasty
Two studies met the inclusion criteria.[68] and [69] A metoidioplasty
procedure (sometimes spelt ‘metaidioplasty’) uses the clitoris,
overdeveloped by hormonal treatment, to construct a microphallus.
Lebovic and Laub70 first introduced this technique and named it
metoidioplasty. Hage68 found successful results of the metoidioplasty
procedure in 32 FTM patients. The average stay in hospital was 11 days
and only one complication in the form of a severe haematoma occurred.
The procedure was considered satisfactory in 17 patients but the
remaining five required additional phalloplasty, following
complications of urethral stenosis in two and fistula in three
patients.69 The metoidioplasty procedure produces a very small phallus
(e.g. mean = 5.7 cm, range = 4–10 cm),69 hardly capable of sexual
penetration, if at all. Only 10 of the 32 patients were able to void
whilst standing.68 It should be noted that in the study by Hage et al,
18 patients combined the metoidioplasty procedure with the
construction of a bifid scrotum in which testicular prostheses were
implanted. Overall these two studies found metoidioplasty was an
appropriate method where the clitoris seems large enough to provide a
phallus and satisfies the patient.

Phalloplasty
Thirty-six studies met the inclusion criteria[33], [71], [72], [73],
[74], [75], [76], [77], [78], [79], [80], [81], [82], [83], [84],
[85], [86], [87], [88], [89], [90], [91], [92], [93], [94], [95],
[96], [97], [98], [99], [100], [101], [102], [103], [104] and [105]
and 12 additional papers were excluded.[62], [63], [106], [107],
[108], [109], [110], [111], [112], [113], [114] and [115] This
technically demanding surgical procedure involves the construction of
a penis in FTM transsexism. The Alberta Heritage Foundation for
Medical Research106 provided the only review of phalloplasty in FTM
transsexism. There appear to be limited data on outcome measures,
including social integration, patient satisfaction and physiological
function. Good operative results have been reported in terms of
appropriate size and stiffness without vascular compromise[71] and
[100] and in terms of psychological outcomes.72 In addition to an
aesthetically appealing look either while being nude (81%) or wearing
a tight swim suit (91%), to void whilst standing appears to be an
important goal for many FTM patients.87 It is important to recognize
that there are a range of phalloplasty procedures available with mixed
findings being reported in terms of effectiveness. Hage et al.85
reported several serious complications such as vesicovaginal,
urethrovaginal fistulas and urinary incontinence. Furthermore, unlike
the metoidioplasty procedure, free flap phalloplasty techniques
produce extensive scarring to the donor site, unless techniques such
as tissue expansion are used.111 Of the 85 FTM patients who had a
phalloplasty fashioned from suprapubic abdominal wall flap that was
tubed to form the phallus, Bettocchi et al.73 reported the cosmetic
appearance of the phallus was considered good in 68% of the patients.
Major complications (n = 60) were associated with the neourethra
(75%), stricture formation (64%) and/or fistulae (55%). It should be
noted that the complication rates found by Bettocchi et al. were
significantly less (P < 0.001) when the neourethra was created in two
stages. In contrast, Khouri et al.93 concluded by using a
prefabricated lateral arm free flap technique it is possible to
achieve a fully functional penis with stable long-term results and
excellent patient satisfaction.

Salpingo-oophorectomy
Three studies reported the use of the salpingo-oophorectomy.[60], [63]
and [116] All involved other surgical or androgen treatment and were
therefore excluded. Salpingo-oophorectomy involves the surgical
removal of a fallopian tube(s) and an ovary. This procedure is often
completed when undertaking other surgical procedures. For example, FTM
transsexism patients may request a total hysterectomy with bilateral
salpingo-oophorectomy; this involves the removal of the fallopian
tubes and ovaries in addition to the uterus and cervix. Futterweit and
Deligdisch (1986)116 concluded that increased blood levels and
increased ovarian concentrations of testosterone may result in the
morphological features of polycystic ovarian disease. The details of
two other studies[60] and [63] are provided in the hysterectomy
section of this report.

Scrotoplasty/scrotum construction/testicular prothesis
Two studies met the inclusion criteria[117] and [118] and four
additional papers were excluded.[61], [62], [119] and [120]
Scrotoplasty involves the creation of a scrotum. This procedure is
generally accomplished by hollowing out the labia majora, inserting
silicone implants, and attaching the labia to develop a single scrotal
sac. Implant expulsion, rupture or dislocation is encountered in a
small number of patients.118

Urethroplasty
One study was found which reports the use of this procedure in FTM
transsexism115 but this did not meet the inclusion criteria.
Urethroplasty involves an operation to repair a defect in the walls of
the urethra. A one-stage total phalloplasty and urethroplasty was
associated with a significant rate of fistulas and strictures.115

Vaginectomy/vaginal closure
Three studies reported this procedure in FTM transsexism[62], [63] and
[115] but they did not meet the inclusion criteria. Vaginectomy
involves the surgical removal of all or part of the vagina.

Discussion
In the first section concerning MTF surgical procedures, 38 published
papers met the inclusion criteria (23 case series and 15 case studies)
with an additional 13 papers excluded (four case series, three case
studies, four reviews, one prospective non-randomized controlled
study, one expert opinion). The level of included evidence was of poor
quality.9 There was a clear lack of randomized controlled evidence and
only one excluded study included a control group comparison. No
studies met the inclusion criteria for labiaplasty, orchidectomy or
penectomy procedures. A large amount of evidence is available
reporting vaginoplasty and clitoroplasty procedures. Some
complications have been reported. All the studies report, to various
degrees, satisfactory outcomes in terms of being able to have
penetrative sexual intercourse and achieving sexual fulfilment.

In the second section concerning FTM surgical procedures, 44 published
papers met the inclusion criteria (26 case series, 17 case studies,
one cohort study) with an additional 19 papers being excluded (seven
reviews, five expert opinions, four case series, three case studies).
The majority of included evidence was of poor quality.9 Many of the
studies reported good satisfactory outcomes with few complications for
each of the individual procedures. The main outcomes reported were the
ability to perform penetrative sexual intercourse and achieve orgasm.
Another key factor requested by many FTM patients was the ability to
void whilst standing. Whilst successful results were reported by many
studies for phalloplasty procedures, an inability to perform sexual
penetration due to the construction of a small phallus was a common
problem reported following the metoidioplasty procedure. Some of the
FTM core surgical procedures are frequently completed along with other
surgery, making it difficult to assess the effectiveness of each
procedure alone. Furthermore, the assessment of effectiveness is also
confounded by the lack of controlled evidence, unclear outcome
measures, and a reliance on case series and case studies.

Six previous reviews have reported the clinical effectiveness of GRS.
Six reviewed evidence in MTF patients[3], [10], [121], [122], [123]
and [124] and three of these also reviewed evidence in FTM patients.
[10], [123] and [124] Of these, three were systematic reviews.[3],
[121] and [123] These earlier reviews provide a summary of
approximately 172 individual studies. Two recent unpublished reports
provided a brief summary of some of the reviews.[8] and [125] Several
key points were raised in these previous reviews. The first related to
the quality of the evidence and study design. Concerns were raised
about the lack of randomized controlled evidence, the majority of
evidence involved case studies and case series, with few studies using
group comparisons, standardized measures or the follow up of
participants. A second concern related to the validity of findings.
Many studies involved a combination of different surgical procedures.
Thirdly, there was concern about the validity of outcome measures.
Despite many reports of positive outcomes of patients, there was
little consensus of how to measure effectiveness. The large range of
outcomes reported across studies makes it difficult to accurately
evaluate the overall outcomes of individual surgical procedures.

Several previous reviews reported a controlled study18 which compared
20 patients having immediate surgery with 20 patients awaiting surgery
for penectomy, orchidectomy and the construction of a neovagina. The
remaining studies reflect lower grades of evidence, and had further
problems in their design such as selected patient groups,
retrospective analysis and losses to follow up. Conclusions from the
reviews are understandably tentative, but highlight improvements in
patients across most studies, although 10–15% of patients with
transsexism who undergo GRS have poor outcomes.

The quality of evidence included in this review has been poor due to
the lack of concealment of allocation, completeness of follow up and
blinding. As well as the fundamental limitation in study design,
several other issues regarding the interpretation of the evidence are
worth consideration. Firstly, all the reviews, and many of the
individual studies within them, examine different types of GRS. The
Mate-Kole study,18 for example, is essentially an evaluation of three
surgical techniques. Clearly, trying to reach a robust conclusion
about GRS as a whole is not possible when the combination of
techniques varies across studies. Secondly, the patient populations
within, and across studies, are heterogeneous and we have little idea
about the referral, diagnosis, assessment and selection processes that
precede inclusion within the studies. Consequently, Brown122 concludes
that a lengthy differential diagnosis and a specialized approach to
interviewing gender dysphoric patients are needed. Thirdly, the choice
of outcome measures varies across studies, with very little use of
validated health-related quality of life (QOL) measures. This
complicates further our ability to draw conclusions, and also limits
the commissioners' ability to identify studies that use outcomes that
are relevant to their role. Finally this review has focused on a
subset of surgical procedures that are used within this field. Whilst
these are considered to be the most routine,8 it is recognized that
other procedures are currently used and these too need to be
critically appraised in future reviews.

No published evidence on cost-effectiveness was found. Best and Stein3
speculate that some cost offsets are possible following surgery due to
the reduced need for psychiatric and hormonal treatment, but no
evidence is available for this. The lack of generic QOL measures means
that measures of cost-effectiveness that can be used to assess value
for money relative to other healthcare interventions are not possible.

When trying to consider all of the evidence together, there is a
dilemma regarding its interpretation. Reviews of heterogeneous patient
groups and interventions clearly give the greatest depth of evidence,
but give little in the way of specific information that is of use to
purchasers. In contrast, studies of individual techniques have a more
limited evidence base but allow us to focus on specific clinical
questions with more consistent reporting. But these provide
information on purchasing decisions that are less realistic, as some
procedures are unlikely to be purchased in isolation. In between these
extremes, are sets of studies that investigate various combinations of
multiple procedures, but matching these studies to the activity of
different providers and patients, is extremely complex.

Taking this reasoning further, some would argue that assessment of GRS
in isolation is difficult to interpret, as it is the final step in a
longer treatment process. This is more contentious, as many patients
do not reach the point of referral for surgery and many do not wish to
undergo any surgery. Also, taking this argument to its extreme would
require studies of the effectiveness of treatment from initial
diagnosis to the end of post-surgical follow up; such studies do not
exist.

Despite these difficulties in interpretation of review evidence the
conclusion about the strength of evidence regarding GRS appears clear:
little robust evidence exists.

Future research
There is a need for good quality controlled trials based on clearly
defined diagnosis and assessment criteria.

An important consideration for future studies is how best to evaluate
the effectiveness of a surgical procedure. One possibility is
assessment of patient satisfaction and regret following surgery.[126],
[127], [128] and [129] More importantly is the need for standardised
measures to assess the outcome of surgery. One suitable method, which
has received limited research, is the use of QOL measures in samples
before and after GRS. Rakic et al.130 investigated several aspects of
QOL after GRS in 32 patients with transsexism (22 MTF, 10 FTM). Four
aspects of QOL were examined: sexual activity; attitude towards the
patients' own body; relationships with other people; and occupational
functioning. For the majority of persons with transsexism, QOL
improved after surgery in terms of these aspects. All patients (100%)
were satisfied with their GRS. However, only 20 patients (62%) were
satisfied with how their bodies looked. In a study by Barrett,72 they
used the General Health Questionnaire and assessments of depression
inpatient groups. More controlled studies using this type of
experimental design are needed to provide a better measure of surgical
effectiveness.

For many patients undergoing GRS, their desire is to look ‘normal’ and
be capable of having a normal sexual relationship. The results
presented in this review have provided little evidence on how
successful individual surgical procedures are in achieving these
goals. Further research is needed to investigate these specific
outcome measures of satisfaction and function.

In conclusion, we have confirmed the findings from previous reviews
that the evidence to support GRS has several limitations in terms of:
(a) lack of controlled studies; (b) evidence has not collected data
prospectively; (c) high loss to follow up; and (d) lack of validated
assessment measures. We have extended these findings from previous
reviews by providing a summary of the evidence available for each of
the ‘core’ procedures for MTF and FTM transsexism. In the majority of
studies a large number of persons with transsexism experience a
successful outcome in terms of subjective well being, cosmesis, and
sexual function. We conclude that the magnitude of benefit and harm
cannot be estimated accurately using the current available evidence.

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Corresponding author. Address: School of Health and Related Research
(ScHARR), University of Sheffield, Regent Court, 30 Regent Street,
Sheffield S1 4DA, UK. Tel.: +44 114 222 0869; fax: +44 114 272 4095.

Journal of Plastic, Reconstructive & Aesthetic Surgery Volume 62,
Issue 3, March 2009, Pages 294-306

[Tynk]

[ino3]

doi:10.1016/j.bjps.2009.01.004
Copyright © 2009 British Association of Plastic, Reconstructive and

Aesthetic Surgeons Published by Elsevier Ltd

Commentary

Evaluation of surgical procedures for sex reassignment: a systematic
review

J. Joris Hagea,

aDepartment of Plastic and Reconstructive Surgery at the Netherlands
Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121,
NL-1066 CX, Amsterdam, The Netherlands

Received 4 January 2009; accepted 7 January 2009. Available online
23 February 2009.

Article Outline
Conflict of interest/funding
References

Sutcliffe et al. are to be applauded for having initiated the immense
task of assessment of study design and quality available on the
outcome of 13 distinctly defined gender confirming surgical procedures
over the 26-year period from 1980 through 2005.1 Based on their work,
the authors conclude that the magnitude of benefit and harm of these
procedures cannot be estimated accurately using the currently
available level of evidence. Although I tend to agree with this
observation, I have not been able to reproduce their study and its
outcome. This seems to be caused largely by flaws of the study's
methodology or, possibly, flaws of the description of that
methodology.

As such, I could not reproduce the authors' selection of references to
be screened. Using the 13 core procedures listed in their Figure 1,
merely a PubMed search yielded 45,217 references published from 1980
through November 2005. Entering the comprehensive list of additional
terms related to gender confirming surgery provided by the authors in
the text yielded 97,622 references. Omitting the terms that the
authors wrongly related to such surgery (e.g. transvestitism etcetera,
cross-dresser etcetera, and intersexuality),2 the PubMed search still
yielded 94,241 references. I fail to understand just how the authors
reduced these large numbers of references to the 1170 that were
actually screened.

Second, I found none of the included studies concerned with male-to-
female surgery as listed in Table 1 to address the inclusion criteria
set by the authors as all reported on the outcome of multiple,
combinedly performed surgical procedures and not on the outcome of
solely the core procedure mentioned. Obviously, all primary
vaginoplasties over the 26-year period have routinely been performed
in combination with penectomy, orchidectomy, and labiaplasty. Since
1996, clitoroplasty has routinely been included in this one-stage
procedure by almost all gender confirming surgeons. Secondary or
salvage vaginoplasties build on on the result of previous efforts.
Likewise, most (not ‘some’) of the female-to-male core surgical
procedures are completed along with other surgery. In this light, the
authors rightly observed that ‘studies of individual techniques.[..].

provide information on purchasing decisions that are less realistic,

as some procedures are unlikely to be purchased in isolation.’ This
may easily be a gross understatement as it is anatomically and
surgically unjustifiable and often, even, unethical to offer certain
procedures separately. Consequently, I fail to understand on what
basis some studies were actually included by the authors, while others
were not. This misunderstanding may further be explained by the
authors' failure to mention what hypotheses were actually tested in
the studies they reviewed.

Then there are some flaws of semantics or definitions. As such, it
should be obvious that the patients' sex rather than their gender is
reassigned by surgery. Hence, the term ‘sex reassignment surgery’ or,
even better, ‘gender confirming surgery’ is to be preferred over the
one used by the authors: ‘gender reassignment surgery’. Although I
agree with the authors that the term ‘transsexuality’ wrongly suggests
that this form of extreme gender dysphoria implies a sexual
orientation, I fear that ‘transsexism’ equally wrongs the patients as
their dysphoria has no association what so ever with any
discrimination on the basis of sex. Moreover, are we then to call
gender dysphoric people, ‘transsexists’?

Next, the authors' apparent confusion regarding the prevalence of
transsexuality may easily be explained by the misconception that the
prevalence of gender confirming surgery is representative for the
prevalence of transsexuality. It is not, because the coming out of
transsexuals is largely linked to the level of acceptance of gender
dysphoria, the availability of treatment, and the outcome of surgery
in the transsexuals' social environment. The authors' observation that
many transsexuals do not ‘wish’ to undergo any surgery adds to this
misconception; transsexuality, by DSM-definition, is manifested by the
preoccupation with getting rid of primary and secondary sex
characteristics.2 In other words, true transsexuals certainly urge to
undergo surgery, but they might not do so because it is unavailable or
inadequate to them. These issues are raised not as mere semantics but
because they touch the very hearth of understanding transsexuality
and, more important, transsexuals.

Furthermore, the definition of urethroplasty used by Sutcliffe et al.
differs from what gender confirming surgeons (such as Rohrmann and
Jakse3 who were cited by the authors) define as a urethroplasty. In
the current context, urethroplasty refers to the surgical lengthening
of the female urethra up to the level of the neophallus (pars fixa
urethrae),[3], [4] and [5] through the length of the neophallus (pars
pendulans),6 or both.7 Repair of defects in the wall of the urethra is
simply referred to as ‘fistula repair’.3 This misconception may have
led to the authors' failure to trace adequate data on urethroplasty in
female-to-male transsexuals.

Based on these flaws and misconceptions, I cannot but infer that
Sutcliffe and his co-workers did not succeed to provide any sound
evidence for their conclusions. Still, I fully agree with the authors,
who admittedly could not accurately estimate the outcome of gender
confirming surgery, that in the majority of studies a large number of
patients reportedly experience a successful outcome in terms of

subjective well being, cosmesis, and sexual function.

Conflict of interest/funding
None.

References
1 P.A. Sutcliffe, S. Dixon and R.L. Akehurst et al., Evaluation of
surgical procedures for sex reassignment: a systematic review, J Plast
Reconstr Aesthet Surg 62 (2009), pp. 294–306. Article | PDF (270 K) |
View Record in Scopus | Cited By in Scopus (3)
2 American Psychiatric Association, Diagnostic and statistical manual
of mental disorders (4th ed. - Text Revision), American Psychiatric
Publishing, Arlington, VA (2000).
3 D. Rohrmann and G. Jakse, Urethroplasty in female-to-male
transsexuals, Eur Urol 44 (2003), pp. 611–614. Article | PDF (188 K)

| Full Text via CrossRef | View Record in Scopus | Cited By in Scopus
(17)

4 F.G. Bouman, The first step in phalloplasty in female transsexuals,
Plast Reconstr Surg 79 (1987), pp. 662–664. View Record in Scopus |

Cited By in Scopus (12)

5 J.J. Hage, F.G. Bouman and J.J.A.M. Bloem, Construction of the fixed

part of the neourethra in female-to-male transsexuals: experience in
53 patients, Plast Reconstr Surg 91 (1993), pp. 904–910.

6 J.J. Hage, F.G. Bouman and J.J.A.M. Bloem, Preconstruction of the

pars pendulans urethrae for phalloplasty in female-to-male
transsexuals, Plast Reconstr Surg 91 (1993), pp. 1303–1307. View
Record in Scopus | Cited By in Scopus (6)

7 J.J. Hage and J.J.A.M. Bloem, Review of the literature on
construction of a neo-urethra in female-to-male transsexuals, Ann

Plast Surg 30 (1993), pp. 278–286. Full Text via CrossRef | View
Record in Scopus | Cited By in Scopus (10)

Journal of Plastic, Reconstructive & Aesthetic Surgery Volume 62,
Issue 3, March 2009, Pages 307-308

doi:10.1016/j.bjps.2008.04.026
Copyright © 2009 British Association of Plastic, Reconstructive and

Aesthetic Surgeons Published by Elsevier Ltd

Commentary

Evaluation of surgical procedures for sex reassignment: a systematic
review

Gennaro Selvaggia, and Stan Monstreyb

aClinca Parioli, Rome, Italy
bUniversity Hospital, Ghent, Belgium

Received 31 March 2008; accepted 1 April 2008. Available online 20
June 2008.

Article Outline
References

We want to congratulate Sutcliffe et al. on their systematic review on
the valuation of surgical procedure for sex reassignment surgery,
published in the Journal of Plastic, Reconstructive and Aesthetic
Surgery, in January 2008.1 They clearly and properly evaluated the
literature they were able to find (review articles, surgical
techniques), at the time of their investigations.

Sutcliffe et al. performed their web investigation in October and
November 2005; their article was received in August 2006; and it was
accepted for publication in December 2007. The purpose of their work
was to provide and evaluate the most updated literature on this
subject. However, we noticed the following: Sutcliffe et al. reported
133 references, from 1980 until November 2005. A few references,
already present in the scientific literature in November 2005, are
missing from their article.[2] and [3] Moreover, since this article
was received in August 2006, further techniques/follow ups were
published,[4], [5], [6] and [7] subsequent to the original Sutcliff
investigation; finally, there was an 18 month gap between original
receipt and publication. More articles were published in this period.
[8], [9], [10], [11], [12], [13], [14], [15], [16], [17] and [18]

All of these resulted in a 2009 systematic review, which already needs
updating after its publication.

In conclusion, with this comment, we thank again Sutcliff et al. for
their work on reviewing the literature on sex reassignment surgery,
and we aim to provide some further references, which should be
mandatory in a 2009 evaluation of current follow ups and surgical
techniques for sex reassignment surgery. This comment, together with
the Sutcliff article, can give to the JPRAS readers an updated
spectrum of the current literature on sex reassignment surgery.

References
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surgical procedures for sex reassignment: a systematic review, J Plast
Reconstr Aesthet Surg 62 (2009), pp. 294–306.
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online 05 June 2006. Article | PDF (183 K) | View Record in Scopus |

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6 S. Weyers, G. Selvaggi and S. Monstrey et al., Two-stage versus one-
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Journal of Plastic, Reconstructive & Aesthetic Surgery Volume 62,

Issue 3, March 2009, Pages 306-307

[Tynk]

> techniques for sex reassignment surgery. This comment, together with ...
>
> read more »

Tynk does SRS in her garage all the time, with her A C Gilbert
discecting kit and Microscope set. Let Tynk the Tranny give you a
discount USENET special price on getting that pubic area
rearranged........

[camel toe]

"Tynk" <bobandcarole...@gmail.com> wrote in message
news:65adb924-9a81-4c25-9d33-Tynk does SRS in her garage all the time, with

her A C Gilbert
discecting kit and Microscope set. Let Tynk the Tranny give you a
discount USENET special price on getting that pubic area
rearranged........
>
>
>

teh gav treatment?

[kb9rqz]

On Jun 15, 4:41 pm, "camel toe" <puncegot...@yahoo.com> wrote:
> "Tynk" <bobandcarolesneighbort...@gmail.com> wrote in message