metic and anatomical outcomes at adolescence of feminisingsurgery for ambiguous genitalia done in childhood. Lancet,358: 124, 2001

20. Passerini-Glazel, G.: Feminizing genitoplasty. J Urol, 161: 1592,1999

EDITORIAL COMMENT

The authors report their large series of Passerini-Glazel clitoro-vaginoplasty procedures in 66 children, of whom 46 were availablefor extended followup. Outcome information was limited to the ana-tomical results of the vaginoplasty portion of the procedure (stenosisvs no stenosis) and the cosmetic results of the overall procedure(mother and surgeon subjective opinion).All patients were judged to have good cosmetic outcomes. None

had introital stenosis. Of the prepubertal group 45.5% and of thepostpubertal group 25% had vaginal stenosis at the anastomosis ofthe mucocutaneous cylinder and the true vagina based on the defi-nition of stenosis of the authors (16 Hegar caliber or less). All ste-noses were cured by Y-V plasties.In the early 1990s Passerini-Glazel told me that he had stopped

creating the complete mucocutaneous cylinder before attaching it tothe true vagina as he originally described. His modified approachinvolves using the same UGS and phallic skin components but tai-

loring them and assembling them individually after first inserting aposterior flap into the true vagina. This approach gave a moreexacting fit and avoided the circular anastomosis that seemed tooccur with a premade cylinder. The modified approach may furtherreduce the anastomotic stenosis.I think it is unlikely that persistence of dysplastic distal vaginal

tissue is a significant cause of stenosis. Although the distal vagina isnarrow as it enters the UGS, once it is disconnected and the posteriorvaginal wall is adequately opened what was originally the distalnarrow/dysplastic area becomes an insignificant percentage of thetotal vaginal circumference. It is more important to avoid a circularanastomosis than to excise the distal vaginal tissue.The authors should be congratulated for showing that a modern

feminizing genitoplasty technique performed by a single experiencedsurgeon can yield good anatomical results with easily correctablestenosis when it occurs and with good cosmetic results as judged bythe surgeon and mother in primary and secondary cases. I hope thatin the future the authors will be able to provide us with long-termfollowup about all the needed outcome parameters (anatomical, cos-metic, sexual sensation and sexual function) from the point of view ofthe patient.

Richard S. HurwitzKaiser Permanente Medical CenterLos Angeles, California

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