New concepts in feminizing genitoplasty--is the Fortunoff flap obsolete?

We retrospectively evaluated the results of an original technique that combines mobilization of the urogenital sinus with the creation of urogenital flaps to enlarge the vaginal introitus for 1-stage feminizing genitoplasty in children with urogenital sinus anomalies, thus, avoiding the use of posteriorly based perineal flaps.

A total of 11 patients with urogenital sinus anomalies have undergone a modified Fortunoff technique combining total urogenital mobilization with the creation of urogenital sinus flaps by a single surgeon (RG) since 1998. Patient age at surgery ranged from 3 months to 13 years (mean 3.8 years). Diagnoses included congenital adrenal hyperplasia in 7 patients, cloacal malformation in 2 and urogenital sinus malformation in 2. Eight patients underwent a perineal approach and 3 underwent a posterior sagittal approach.

Followup ranged from 3 months to 5 years (mean 2.5 years). The cosmetic appearance was considered superior to that achieved with previous techniques. The vagina had a more physiological position in all patients except 1, and no patient had development of vaginal stenosis. One patient had development of a mild mid urethral stricture that required a single dilation using anesthesia. In this patient cystourethroscopy performed 3 years later was normal.

We believe that the redundant urogenital sinus tissue must not be discarded, but rather incorporated into the reconstruction of the posterior vaginal wall, thus, avoiding the use of perineal skin flaps. This modification allows placement of the vaginal opening in a more physiological position with a better cosmetic appearance than previous techniques.