[Introduction of the anterior sagittal trans-ano-rectal approach (ASTRA) as a technical variation of the Passerini-Glazel clitoro-vaginoplasty: preliminary results].

A variant technique to the 1-stage clitorovaginoplasty in severely masculinized female pseudohermaphrodites is presented. The new variant consist of an anterior sagittal trans-ano-rectal approach (A.S.T.R.A.) with the patient placed in the prone position after that a clitoroplasty was performed by the Paserini-Glazel procedure. A.S.T.R.A. permit to perform the dissection between the vagina and the urethra, the suture of the vaginal stump and the anastomosis between the neo-introitus vaginalis and the vagina under direct vision. A.S.T.R.A. with a protective colostomy was performed in two patients with normal rectum. The anorectal sphinteric mechanism was divided in the anterior midline, and the rectum was opened just in the anterior rectal wall. This provided excellent exposure to urogenital sinus. The vagina was then easily and fully separated from the urogenital sinus, the vaginal stump sutured and the anastomosis between the mucocutaneous cylinder (neo-introitus vaginalis) and the vagina performed. The rectum, perineal body and the anterior sphinteric mechanism were reconstructed. The postoperative course was uneventful. The patients had normal fecal control after the colostomy closure. No urinary incontinence was encountered. An anterior sagittal midline incision provides excellent exposure to the urogenital sinus and assure the preservation of the anorectal innervation and the sphinteric mechanism.