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Background:  The goals of penile reconstruction and phalloplasty include aesthetics as natural as possible and the ability of patients to void while standing and to have sexual intercourse. This article presents two more rare indications and techniques, the phalloplasty using free radial forearm flapin case of intersexuality and after penectomy due to penis carcinoma., Patients and Methods:  In transsexual individuals numerous phalloplasties in Gottlieb and Levine`s technique, by means phalloplasty of free radial forearm-flap of the non-dominant forearm, were performed in our department over the last few years. However, this technique also has its significance for phalloplasty in non-transgender persons.Two patients are considered in detail with regard to indication and surgical technique and were followed up in a multimodal setting.Patient 1 is genetically male, thirty-five years old with a micropenis in the case of pseudohermaphroditism masculine and androgen resistance.Patient 2 is a fifty-one-year old genetically male and as a result of a penis carcinoma his penis had to be amputated at the level of penis root. After absence of recurrence for 1,5 years, the penile reconstruction took place after complete resection of the remaining residual penile stump and corpora cavernosa. Both patients underwent multimodal follow-up 15 months postoperatively with regard to phalloplasty sensors and donor-site restrictions., Results:  An aesthetic and functional acceptable result could be obtained for both patients. Both patients are able to void while standing. The multimodal follow-up 15 months postoperatively revealed relevant differences in the sensory findings of both patients, which are due to the different anatomy of reinnervation., Conclusion:  In microsurgical experienced departments, the technique of A. radialis phalloplasty can also be used successfully in more rare indications, as shown here, a satisfying result can be achieved in terms of function and aesthetics. The complications shown here do not differ from those using phalloplasty in transgender persons., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Persistent mullerian duct syndrome (PMDS) is a rare, autosomal recessive disorder. It is a form of male disorder of sexual differentiation in which mullerian duct structures are present in male phenotypes and 46XY karyotypes. In affected individuals, uterus, fallopian tubes, cervix and vagina are present., Methods: A 2-month-old boy was admitted to hospital with a right-sided inguinal hernia. The physical examination showed a phenotypically normal boy with a right sided indirect inguinal hernia and impalpable testis. During herniotomy, a uterus and two fallopian tubes were found in the pelvic peritoneum adjacent to the two gonads. Initial biopsies were taken from the gonads and blood was sent for karyotyping., Results: The biopsy showed normal testicular tissue without any ovarian tissue and the karyotyping result was 46XY; therefore, the diagnosis of persistent mullerian duct syndrome (PMDS) was made. In a second laparoscopically assisted operation the uterus and fallopian tubes were dissected, an orchidopexy of the left testis and an orchiectomy of the right testis were performed. The postoperative course was uneventful., Conclusion: In the case of an incarcerated inguinal hernia in combination with impalpable testis, a PMDS should be considered as a differential diagnosis.

Background: More and more frequently, the registration of life satisfaction is being used to evaluate different medical treatments. So far, there have been only few such surveys on transsexuals (TS). Therefore, the aim of this study was to evaluate the general and the health-related life satisfaction of transsexuals after gender transformation operations., Patients and Methods: Forty patients took part in this German cross-sectional study. The Questions on Life Satisfaction Module (FLZ) and free questions on different aspects of the new gender identity were used as measuring instruments., Results: Of the TS studied, 85-95% were "very satisfied" or "satisfied" with the results of their gender transformation operation in respect to gender identity. The TS were significantly less satisfied (P>0.001) in overall "general life satisfaction" than the general population. In overall FLZ scores for "health-related life satisfaction", no differences were seen., Conclusion: These data indicate a discrepancy between subjective satisfaction with new gender identity and current life situation, and they identify problems with life satisfaction.

After a review of the historical development of ideas about transsexualiam and the discussion of possible somatic and psychological causes of this condition, the results of explorations of 12 male and 6 female transsexuals who desired a hormonal and surgical approximation to the opposite sex are reported. Two of the nine patients whose chromosomes were examined were found to suffer from Klinefelter's Syndrome. From the personal history it was apparent that 8 of the 12 male transsexuals had difficulty in identifying with an absent, alcoholic or brutal father. The wish to be a member of the opposite sex could be traced in 10 of the 12 male and all 6 female transsexuals to the first five years of life. 7 of the 12 male transsexuals and 3 of the 6 female transsexuals were found to have attempted suicide or to have had suicidal tendencies in the past. In 9/12 male transsexuals and 5/6 female transsexuals the "change of sex" operation was considered to be indicated. The average age at operation was 28 for the male transsexuals and 26 for the female transsexuals. The follow-up studies were done 2 months to 3 years after operation for the male transsexuals (average 1, 7 years) and 2 to 3 3/4 years post operatively (average 2, 9 years) for the female transsexuals. 7/8 of the male transsexuals from whom we have katamneses and both female transsexuals reported that they felt subjectively better than before the operation. The present legal situation concerning the registration of change of name and sex in various countries is described.

Sexual differentiation normally proceeds in a series of consecutive steps including sex determination, gonadal differentiation, genital development, and the realization of somatic and psycho-social sex characteristics. Deviations from the normal course are known at each level of this process, resulting in sex reversal and intersexuality. Many of these abnormalities can be traced to genetic mutations. From the level of the differentiated gonad onwards, further sexual development is largely controlled by endocrine functions which are fairly well understood. By contrast, the development of the as yet undifferentiated gonad into either testis or ovary is hormone-independent, and is now believed to be due to the presence or absence of a cell surface component, the H-Y antigen. While the exact mechanism of H-Y antigen action is still under study, its biological function in testicular differentiation is well established. There are a number of mutations which interfere with normal primary gonadal differentiation, and it can be concluded from these mutations that several different genes are involved in this basic step of sexual development. Of these genes comprising the H-Y antigen system, some have regulatory, others structural functions. The H-Y antigen system promises to become a model for the understanding of the genetic control of cellular differentiation.

Complete left ovariectomy of female chicken results in a phenotypic sex-reversal accompanied by the development of a right fertile or sterile testoid. Incomplete left ovariectomy can induce either a sterile or fertile ovariotestoid or a sterile testoid. In comparison with the normal testis the right testoid of sex-reversed hens shows many abnormalities: The size of the testoid of juvenile sex-reversed hens is only about 10 x 2 mm and those of the adults about 20 x 10 mm. First signs of maturation division are visible 25 weeks after hatching, i.e. a retardation of 8 weeks. The histology of the testoids is very heteromorphic and considerably different from that of a normal testis. The spermatogenic parenchyma consists of supporting-cell-areas (SERTOLI-cell only tissue), sterile testis-cords (SERTOLI-cell only cords) and of fertile testis-cords. According to the differentiation of the germ cells and supporting cells respectively, the testis cords are subdivided into 4 stages. Spermatogenesis is stopped in the spermatid stage and it is impossible to enforce further maturation by utilizing the direct spermatogenic effect of high androgen doses. The ultimate component of the blood-testis barrier, the inter-SERTOLI-cell junctions, is visible neither in the sterile nor the fertile testis-cords. Thus, as far as the immune system is concerned, the haploid germ cells are acting like endogenic foreign-body cells. This becomes apparent by severe cell death and finally by a total destruction of testis-cords. The interstitial-glandular parenchyma consists of testicular single-interstitial-cells (LEYDIG-cells), ovarian interstitial-cell-nodules and interstitial-cell-areas. Statements concerning the qualitative and quantitative ability of the interstitial cells are made using morphological criteria and by consideration of test data in steroid-hormones. As to the atypical cytomorphology of interstitial-cells (4 types are distinguishable) distinct deviations in the hormonal status are visible in comparison with male controls: The testosterone concentration in plasma is decreased by the factor or 8.4, while the estradiol concentration is increased by the factor of 4.3. Attempts at normalizing the testosterone concentration by experimental stimulation with gonadotrophins failed. It is obvious that the interstitial-cell-nodules, the interstitial-cell-areas as well as the supporting cells originate from epithelial cells of the medullary cords (Chordae medullares) and from the epithelial cells of the distended medullary cords (Lacunae medullares). In other words the above mentioned cells are of epitheliogenic origin.

One has to distinguish masculine sex behavior and estrogens alone or in combination with gestagens evoke feminine sex behavior. The central integrator for the induction of sex behavior is located in diencephalic nuclei. If sex hormones are lacking, the sex drive is fading off, except in women. Sex hormones are also responsible for the determination of those neutral centres controlling male or female sex behavior later in life in most species. Based on animal datas and on retrospective inquiries of homosexuals or mothers of homosexuals, a hypothesis for the etiology of homo-, bi- and hyposexuality has been developed by Dorner. Absence or deficiency of androgens in the critical phase of "brain differentiation" leads to male homo-, bi- or hyposexuality, respectively. If androgens become active in the critical phase of female differentiation, then the result will be female homo-, bi- or hyposexuality, respectively. This hypothesis will be critical evaluated.

Transformation of the rete ovarii into a rete testis and of the epoophoron into an epididymis after experimental sex reversal in Gallus domesticus is described. After castration of female chicks, the medulla of the left ovary and/or the right gonadal rudiment develop into a testoid or an ovotestis. From general view, this is observed as sex reversal. In case of formation of a testoid, the epoophoron develops into an epididymis and the rete ovarii develops into a rete testis which consists of intra- and extratesticular and intracapsular parts. Thus, a luminated duct system is developed which allows the transport of semen. In case of formation of an ovotestis, the discontinuously side-by-side located parts of the rete ovarii and of the epoophoron are maintained.