Dr Seghers Speach
Part3 Question & Answer Sesion
I think... Thank you for your attention and...
**A** Dr. Seghers, can I ask you a couple of questions?
**S** Couple? One.
**A** Let me ask you, when you create the tunnel, the corpora tunnel of the penile flap or graft do you take it up to the base of the peritoneum [perineum], do you take it as high as the peritoneum [perineum], or do you make a judgement on the basis of the length of the plug?
**S** I go almost at the perineum. I think if I go to the perineum, I will go through.
**A** I understand.
**S** But I am about... the only difference you see, I used to feel where the bladder with my thumb on the bladder catheter and I feel where it balloons. Now, but I go far away, but I have a small fingers and short fingers I use 6 and a half for a glove. So I have to use instruments to do it the best because my fingers are too short.
**A** I understand.
**A** Let me ask one or two other things too. How long before you start to advance the drains? If this is right, isn't that about the second or third day? How soon before you begin to start to advance the drains? The ???? drains that you have there?
**S** I remove them out complete. I remove completely out after 48 hours.
**A** After 48 hours, that's what I wanted to know.
**S** In one stage, sometimes there is still some bleeding tendency. I can left 1 but usually I remove it completely. And once I started some bleeding when I had removed in one stage. In one stage.
**A** And last thing, not last thing but rather did I understand that you don't create a pseudo cervix. Did I see on one of the specimens that you had taken the glans and you don't place...
**S** No, No, No, No.
**A** You do not?
**S** I had that years [ago]. I think I can but I don't have the right to make test or experimental surgery on Americans travelling long distances. They have to be well to be able to leave after 8 or 10 days even if they don't have they have to stay longer. They will be trouble with the airlines. Because they don't keep the appointment. But I have done some tests with Belgianss or locals that I can check myself and see after 2 weeks, 3 months, repeatedly. I try to make some kind of cervix. I read the literature and I have a temptation to try something and it fails. And so I did it anyway. I had to be sure it would work before doing it especially on people travelling long distances.
**A** I agree.
**A** Last question, do you take a terminal urine for culture and sensitivity after, just before you take the catheter out, are you?
**A** You don't do that?
**S** No, no. For common complications maybe I skip that phase. Common complications is a bladder infection urinary infection.
**A** That's right.
**S** Especially a few patients. They like to play a little with their catheter because it's stiff, it cannot be pulled out because there is a self retaining balloon. But they play, pushing it a little inside. That's not good.
**A** I wonder if you did it in the fact that it's in for so long, there might be some bacteria there that had cultures that they would know at least that they would have overt cystitis.
**S** Yes they are. This means some more, some use of antibiotic later on through the mouth so they are under strong antibiotic during 48 hours, ZYNACEF I.V. during 3 times 1.5 gram during 2 days and after that I give BACTERIN, strong, twice a day.
**A** Ah OK, fine. That certainly helps some.
**S** Then we depart you from the hospital when they leave the hospital they stop. And if I hear that they have to urinate too often and the usual sign, in fact told them to drink a lot, to drink a lot, in order to wash their inside and to have to try to avoid an infection, an ascending infection from the outside to the inside. But it happens.
**A** Once in a while.
**A** Thank you very very much indeed.
**S** Some other questions?
**A** How long does the surgery last?
**S** About 3 hours, but now I say it's 2, 2 hours 30. It's average 3 hours. Rarely more than that, that's why I am able to do 2 in a row. I never did 3, but maybe it will happen eventually. That brings out another factor which you have nothing to do with that but when we keep appointment for some surgery to patients who have their surgery at the end of the month we do that 3 months in advance and I am not sure if I will be in perfect shape at that time. That's sometimes difficult. Sometimes I think tired or without any reason I get flu sometimes and I told you that you had the flu and that you had to fly back home. But if I have patients coming and I have the flu, I cannot do your surgery before next week, this is a difficult question. I work with the flu when it happens. Sometime when I do 2 cases, at the end of the second case I feel ready to start the third 1 and I joke with nurses she can go to take the third patient and there is no third patient, not even a minor case. Sometimes 1 surgery is too much. You never know. This is never a feel for anywhere. On a better day I don't sleep, somebody asks if I would do a favor, generally 7 at night...
**Moderator** We have time for probably, we will extend this session probably for about 15 minutes. For those that want questions, and make sure that they we get them in I want to use the mike in the center of the room and we'll probably keep it to about 4 people or so. So if you have questions then go to use that mike and line up please.
**A** Dr. Seghers, can you tell me if there are unique complications for patients having surgery that have already had a bilateral orchiectomy?
**S** Its not real complications, but I think it's also the case it doesn't help the surgery because there's shrinkage of the scrotum and shrinkage of the penis. So there is less tissue. Most of the patients have not enough tissue or 2 pieces of just [enough]. So it can be done if the patient has all the reasons to have the orchidectomy done before such as not operating the female hormones and being obligeded and cannot go for surgery early. Maybe it can be done, but I don't advise that. But you can say yes I did it to a girl who came with pus running from her buttocks, I tried to do something maybe somebody would say something to take her money. I had removed testicles, it's to please her for little. Otherwise she would do a trick with us who have done nothing but I think I know some do that because it's available it can be paid by insurance, but I don't think that it can be done but... it's not so helpful, and it's not shortening the main procedure that I say between 2 hours and 3 hours. The fact that to remove the testicles happens you save in the maximum maybe 3 minutes.
**A** If you don't have any skin atrophy and other than that there's no other complications?
**S** We have less, less skin atrophy, but somebody told me if I require to stop the female hormones maybe 2 weeks or 3 weeks before surgery it's not to enlarge the penile skin during that time, it's to shorten the time that you recuperate some reflex and some possible extension but it's to avoid the risk of the female hormones with blood clots being circulating in the large veins and to try to avoid the pulmonary embolism which can kill patients almost certainly without the surgery too. But since it's not necessary surgery, we can be in trouble. And there's a possibility with hormones, with the first case in Belgium which died, this, I didn't have yet but it can happen.
**A** Pardonne ma question mes Mon ami, DR. Seghers. Je vous avant cours. Merci beaucoup pour la visit.
**S** Le visit.
**A** I have couple of questions, why you find that hair growth is a frequent complication at the vaginal opening and if so is there anything that can be done about that?
**S** For me, it's not a complications, but the patient argued about that. That it was a complication and the main reason and if she was true, I didn't tell her enough. She felt I was responsible for that not to tell her. I don't ask patients to sign a written consent because if you do that you have to add all complications even that they could die. They have to sign that one. So in Belgium, we are not obliged to do that. With the documents I have that they come for that, that's enough. But maybe that one said she had a rough time with that. To my surprise.
**A** But is it usually serious or is it just something that's a personal problem that people reach?
**S** A more personal problem.
**A** Also where do you recommend having z-plasty done, do you recommend coming back to Belgium?
**S** NO, no. I think it will be done by any plastic surgeon who is willing to take care of that. I used to do that under general anesthesia because with the local I do since I worked at central Africa, we used a lot of local anesthesia and it's possible to do a lot, but American patients it's not so easy for the question of pain.
**A** And finally do most of your patients seem to have sufficient sensation?
**S** Not for the time they are in Brussels because I used to say that the clitoris or what I call the pseudo clitoris that's asleep for 3 months. And after that if you are lucky it can get awake, it gets awake it means you can have pain. Pain and feeling this is a link, the same thing but it's a good sign. When you start to have some pain it means all nerves are growing back again and that the sensitivity is gaining in in importance. In my opinion, it's not the clitoris that I make which is subcutaneous at the beginning. If it is so important somebody, some curious gentleman can eventually feel something there, but the feeling is not exactly the same thing. Some patients say they urinate through their clitoris. This statement is incorrect because they urinate through the urinary opening of the pee hole and it's swollen around because that's the rest of the corpus spongiosum which increases in size when they are excited. This is not so, some think it's the clitoris, but it isn't. When they have a good feeling or some kind of orgasm and many they write me about that they are so proud and so happy, some time they get it when they have when they are doing their dilation, it's coming from the prostate. Because the prostate is staying in place, this is very delicate. This shrinks a little because of the female hormones, but the orgasmic sensation that they get is contraction of the seminal glands which stays in place and at the same time they have some fluid coming out of the urethra, not in the vagina. Vagina is always going to be dry and you have to use lubricant, but the feeling, the orgasm that they get is coming from, in my opinion, from the prostate.
**A** Dr. seghers I have two questions. One is, what general type of insurance do you require or do you accept?
**A** Do you accept any insurance for surgery if there is insurance that will cover it?
**S** I can give receipt and what have been paid for. Insurance, that's your problem. I'm not billing the insurance company.
**A** Yes, I just was wondering.
**S** But I can't get from some perhaps they're going in a rough time because the insurance, medicare and so they are very reluctant to say, to pay anything for reassignment surgery and especially when it's done abroad. And it's... They write that the form that they give the receipts is not correct and after that they want a copy of the operating room report. I send a copy, I have written that an operating report since I am French speaking and the operation is doing in Brussels ... the surgical report is made in French in my chart.
**Moderator** Insurance will be covered in the next section.
END OF RECORDING