The aim of clitoral surgery is to achieve normal clitoral morphology without compromising sexual function. In this study, all patients were operated upon by a single experienced surgeon considering all the precautions to avoid neurovascular bundle damage and grossly the neurovascular bundle was preserved in all patients by careful dissection in the plane, utilizing fine instruments, using magnifying surgical loops.
We used the ventral approach suggested by Rajfer et al. to prevent damage to the neurovascular bundle in all cases in which we started dissection ventrally at 5’o clock position in the plane between the neurovascular bundle superiorly and the intact tunica albuginea inferiorly till the 7’o clock position on the other side encircling the corpus and lifting up the neurovascular bundle . Still, in four of six cases (66%) thick nerve fibers can be seen on the dorsal aspect of the clitoral bodies at the anatomical location of the neurovascular bundle imbedded in the fibrous tissue of the clitoris.
Being embedded in the fibrous tissue raises the concern that many penetrating nerves are present even inside the corpus under the tunica envelope which makes the preservation of the neurovascular bundle impossible without resecting a part of the corporal bodies with it as described by Kogan et al.  in the technique of subtunical reduction. The long-term evaluation of operated cases of CAH supports the possibility of inevitable neural damage with variable degrees of functional disabilities.
In another study, Melbourne group in 2007 utilizes the subtunical dissection with preservation of the neurovascular bundle through the last 30 years of practising feminizing genitoplasty in children with good outcome due to proper preservation of the nerve fibers of the glans .
Crouch et al. presented their experience after feminizing genitoplasty in London. They concluded that sensitivity was decreased in the genital areas where feminizing genitoplasty had been done. Surgery was also associated with sexual difficulties .
Creighton published her article under the title ‘London experience’ and concluded that there is very scanty evidence of a satisfactory post-pubertal cosmetic or anatomical outcome and it is unacceptable to claim that clitoral surgery does not affect sexual function, although the magnitude of this effect needs further evaluation .
Rieder and Hurwitz in their evaluation of the results of childhood feminizing surgery could have a complete evaluation in seven patients. Three patients (43%) had strong, three (43%) had moderate, and one (14%) had no sexual pleasure with clitoral stimulation. Three (43%) had strong, two (28%) had mild, and two (28%) had no orgasms with clitoral stimulation .
Lesma et al. evaluated the thermal and vibratory sensitivity of the clitoris, together with the psychosexual outcome of CAH patients operated upon with Passerini-Glazel feminizing genitoplasty. Their inclusion criteria were adult age and penetrative vaginal intercourse. A total of 12 patients (10% of their operated CAH cases) entered the study. Thermal and vibratory clitoral sensitivity was significantly decreased in all patients compared to healthy controls . Poppas et al. examined the erectile tissue removed from 27 female patient with CAH for the presence of nerves. In their methodology, they counted the nerves outside the tunica albuginea. In four of 27 patients (15%), no dorsal nerve branches were visualized in excised erectile tissue; in another 18 patients (67%), ten or fewer nerve branches were found. In patients who underwent nerve sparing ventral clitoroplasty, 92% of dorsal nerves detected were 90 μm or less. In their study, they counted the nerves outside the tunica albuginea; still, only four cases (15%) show no dorsal nerve branches in the excised specimen .
In our study, thick nerve fibers are encountered on the dorsum of the clitoris corporal body in four specimens and thin nerve fibers in the remaining two specimens. This means that even with careful dissection of the neurovascular bundle outside the tunica albuginea under the buck’s fascia, still there are nerves being injured and severed with the transected corpus clitoris.
These are peripheral nerves, whether they regrow again or not is unknown, the effect of cutting such nerves on the clitoral sensitivity is unknown so, and surgeon has to try to preserve such nerves to the maximum and utilize the technique that is more trustable in preserving such nerves. Whether the technique of ventral evacuation of the clitoris from erectile tissue is the best for preserving neurovascular bundle or not, we still have no answer for this question, but we are going to shift our surgical clitoroplasty from the lifting of neurovascular bundle above the tunica albuginea to start doing the ventral approach of just removing the erectile tissue leaving intact the tunica albuginea with all nerves outside the tunica intact.
One of the limitations of our study is that we used S100 stain which is a nonspecific stain by which we cannot distinguish between subtypes of nerve bundles, but we expected to deal only with sensory fibers. And also, we did not count the nerve fibers present in the specimens subjected to the study.
Our study is characterized by the presence of unified technique practised by a single surgeon for long time even before this study, pathology and staining were done by one expert pathologist and all children had congenital adrenal hyperplasia; however, the number of children is small and we need also to examine prospectively all specimens taken by subtunical technique of evacuation of erectile tissue to be more sure that nerves are being truly preserved on utilizing this procedure. This type of surgery needs special experience and a good team work which is achieved well in our work.