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
    **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?
    **S** NO.
    **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.
    **S** YES.
    **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
    **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
    **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?
    **S** Insurance?
    **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.

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