No progress was made, unsurprisingly, during the dark days of World War II, but soon after the close of hostilities a French surgeon called Georges Burou (1910–1987) set up a pioneering clinic that provided Genital Reconstruction Surgery (GRS) and other plastic surgeries that transwomen required. He treated many of the most famous transwomen to appear in the 1950s and 60s. He carried out over 3000 GRS surgeries and advanced the surgical techniques enormously.
Burou’s work laid the foundation of the modern practice of Genital Reconstruction Surgery. While such surgeries had been carried out before, for example in Germany under Magnus Hirschfeld, these had really been at the limit of the surgical techniques then available. Without anti-biotics particularly, surgeons were reluctant to carry out major surgeries for conditions they thought were not life threatening.
World War 2 stopped the development of GRS techniques in Germany and, unfortunately, Hirschfeld’s notes were all destroyed by the Nazis. Burou was beginning again, but he had bidg advantages.
The war had seen tremendous progress in all forms of surgery, largely as a result of treating battlefield injuries that only a decade or so earlier might have been fatal or have led to limb amputation. Although a grisly thought, the war gave surgeons an opportunity to develop surgical technique beyond compare with pre-war standards. This was what gave Burou his chance.
He set up shop in Casablanca, because it was a French territory, but one in which genital surgeries of this type were permitted. In mainland France they
were seen as castration, which was illegal a that time. Before long Burou had perfected his technique and by 1950 his clinic was attracting clients from all over the world, including Coccinelle from France, April Ashley from the UK and Christine Jorgensen from the USA.
Although surgical techniques of GRS have continued to improve in the decades since Burou was in practice, most of this is in regard to improving the cosmetic appearance of the neovagina and the depth of penetration it can accommodate. The basic principles of using the penile skin or sheath, inverted, as the inner lining of the vagina and relocating the glans to approximate the location of a natural clitoris, while preserving nervous integrity and sensation, were all established by Burou.
The Interdisciplinary Symposium on Gender Dysphoria Syndrome was held at the Stanford University School of Medicine, February 2-4, 1973.
The purpose of the meeting was to provide a forum for the exchange of scientific information about the patient who desires and is considered for gender re-identification.
The symposium was sponsored by the Divisions of Urology and Plastic and Reconstructive Surgery at the Stanford School of Medicine. Its principal architect and chairman was Donald R. Laub, M.D., Chief of the Division of Plastic and Reconstructive Surgery.
In addition to the United States, numerous representatives from Canada, Mexico, England, Morocco and Australia were present. Below is a translation of Burou’s presentation.
Male to Female Transformation
Georges Burou, M.D.*
Dr. Burou is a gynecologist from Morocco who had previous experience making a neo-vagina in cases of vaginal atresia. He treated a male patient who insisted upon sex reassignment surgery and went into this field. When Dr. Burou created the operation, he was totally unaware of previous such work in the world. He thought at the time that the best thing to do was to utilize the live graft which can be made from the penile skin when properly dissected. this is what he is going to describe now. This is the first report on this new technique.
Dr. Burou want to thank very much many American physicians who supported him in this work, referring many American patients, and who have been extremely helpful in corresponding with him.
The entire surgical operation is done in one stage, consisting of two successive steps. All of the patients who under go surgery have been prepared, undergo psychiatric care, on hormones, and made quite feminine. The first step is made on a very narrow surgical field and the goal of this first step is to create a space between the rectum and the prostate. The fist incision is made posteriorly between the anal area and the scrotal ridge. This first part is extremely important, because you can determine at any time by intrarectal inspection that there is no lesion to the rectal wall. This is very important to avoid any further complications during the dissection in the rectum in the prerectal space.
Figure 1 shows the first incision going from the anal area through the ridge of the scrotum. On the left of the figure is the first dissection of the bulb and both corpora cavernosa. The cleavage between the rectum and the prostate is made by cutting all the ligaments between the bulb and the rectum. Then Dr. Burou positions the cleavage with his finger in the natural space which is between the rectal wall and the prostate. The cleavage is done when you admit easily two fingers of a vaginal retractor. One can meet at the end of this new space a natural formation which makes you feel that you are really meeting the natural vaginal cul-de-sac, Douglas space. The first step is over.
The first step is in fact the most important and most dangerous. The second one is relatively easy. One enlarges the surgical field in the most usual way, taking all the usual precautions. The initial incision is now prolonged under the scrotum to the root of the penis. The surgical field is widened by retracting and widely exposing the scrotal skin on both sides. On the neocolporrhaphy we have both the corpora cavernosa, spongiosa, and the two testes. The testes and its beaker will be cleaved by cleavage of the fiberous tunica.
Figure 2 shows that the high testes has been dissected through the fat pad attached to it. It is separated on the inside from the corpora cavernosa, and it is also freed from the lateral wall. Once the testes and all the surrounding pedicle have been freed, the spermatic chord is cut and ligated, as can be seen in Figure 3. Removing the section of the testes and all the mass surrounding it, requires very careful hemostatis and the right sectioning of the bulb, corresponding to the future urethra. The right of Figure 3 shows where both corpora cavernosa will be sutured; the needle is visible. On the right the corpora cavernosa is shown firmly sutured with the future urethra pending on the right. Above are the erectile bodies of the penis. The left side of Figure 4 shows the erectile bodies being pushed out and dissected from the penile skin. Figure 5 shows that practically all of the skin of the penis now has been completely freed from the erectile bodies. Figure 6 shows the complete dissection of the penile skin; you even keep the foreskin when available. It is at this stage that the end of the penile skin is being sutured and closed. This will constitute later on the neovagina.
Figure 6 shows the neovagina quite ready to be inserted in the prerectal space which was created. On the lower abdominal skin is a slight skin slit which will allow the future urethra to be passed through. The figure also shows an important feature coming through the skin near the anal area – two threads which are being inserted on the anterior ani muscle.
These two threads will serve to support a bougie of Eggar, a prosthetic instrument known in obstetrics. This bougie of Eggar will be placed in the neovagina to provide support. Figure 7 shows a drain with aspiration which is being placed in the posterior commissure. The bougie of Eggar is in place, and the two threads coming from the skin are tightening very closely and very firmly that bougie of Eggar into the neovagina. It is easy to regulate or test the firmness and tension on the two threads. At this stage excess skin flap must be removed in order to obtain a good appearance. Figure 7 shows the exit of the levator cannula with catheter. There is no skin suture. The urethra is being sutured on the catheter, about .5 cm from the skin. Some kind of retraction must always be foreseen. Figure 7 also shows the drainage at the posterior commissure.
Eight days after surgery, the bougie of Eggar was maintained for 48 hours. The aspiration is also removed after 48 hours. The urethral catheter is maintained for four days. The management of the new vagina is being made by frequent and daily introductions of small vaginal retractors. In the next few days permeability of the urethra must also be maintained by daily introduction of the catheter and making sure that there is no stenosis that it is completely patent. With the catheter, the urethra is immediately introduced at the appropriate place during the final step.