Staged Urethroplasty for Reconstruction of Long Complex Pendulous Strictures of a Neophallic Urethra.

BACKGROUND: Post-phalloplasty, patients may present with urologic complications, including strictures, urethrocutaneous fistulas and vaginal cavity remnants.1-3 OBJECTIVE: To demonstrate the feasibility of staged repairs for long complex neophallus strictures. METHODS: All post-phalloplasty patients who underwent pendulous (pars pendulans) or panurethral urethroplasty for strictures >7 cm were identified. In preparation for surgery patients were co-managed with their local providers, whenever possible, in treating symptomatic infections with culture-specific antibiotics, draining abscess and managing suprapubic catheters. During Stage-1, a ventral incision through the perineum and neophallus was created to expose remnants of the neo-urethral plate. Additional findings (fistula/remnant cavity) were treated at this stage if found, along with re-mobilization of a previously placed gracilis flap. The neourethral plate was augmented with buccal mucosal graft (BMG) with a goal of achieving an approximately 3-cm-wide plate. The lateral neourethral edges were sutured to the edges of the skin incision creating a temporary perineal urethrostomy. Stage-2 was performed in a delayed fashion and included mobilization and tubularization of the neourethra, with additional oral mucosa inlay (BMG or lingual), if needed, followed by a multi-layer closure. Postoperatively, patients were assessed in clinic when possible, or via telemedicine appointments for urethral patency, and queried using patient-reported outcome measures. Failures were defined as need for additional revisions or urethral instrumentation. RESULTS: Twenty-one patients presented between December 2013 and July 2021 with urinary obstruction due to long penile strictures. Seventeen patients, mean age 33 (22-58), elected to undergo staged reconstruction. Prior phalloplasty techniques included radial forearm flap phalloplasty in 15/17 and anterolateral thigh flap in 2/17. In 11/17 patients BMG was previously used during phalloplasty for urethral prelamination.4 Mean stricture length was 12 cm (7-17). Concurrent procedures during Stage-1 included re-harvesting BMG (11/17), gracilis flap re-mobilization (7/17) and redo-vaginectomy (5/17).5 During Stage-2, 14 patients (82%) required additional oral graft inlays: lingual 6/14 (including 2 bilateral), BMG 5/14 (including 1 bilateral) and lingual+BMG in 3/14. At a mean follow-up of 24 months (4-77), there were 2 failures (12%). Thirteen patients completed follow-up questionnaires and all reported upright voiding and at least a moderate improvement in their condition on Global Response Assessment: +3 (markedly improved) in 11/13 (85%), and +2 (moderately improved) in 2/13 (15%). CONCLUSION: A staged urethroplasty is a feasible option for transgender men with long complex penile strictures of the neophallus. This technique demonstrates promising early functional outcomes and high patient satisfaction.

A buccal mucosal graft subcoronal resurfacing technique to treat recurrent penile adhesions: the buccal belt.

OBJECTIVE: To outline our step-by-step surgical technique using a subcoronal buccal mucosal graft (BMG) resurfacing technique for the treatment of recurrent penile adhesions. METHODS: To perform the 'buccal belt' procedure a subcoronal circumferential segment of diseased skin was excised. An appropriately sized BMG was circumferentially secured subcoronally with a proximal and distal anastomosis to the edges of the wound. Quilting stitches were also placed to allow proper graft fixation. A petroleum jelly bolster was secured as a tie-over dressing. Patients were discharged with a Foley catheter and the bolster dressing in place. The bolster and Foley catheter were removed 7 days postoperatively. The patients were then seen for follow-up at 4- to 6-month intervals. A retrospective, international multi-institutional review was conducted to include all patients who underwent this procedure. Surgical complications, evidence of recurrence, and patient-reported outcome measures including visual analogue scale (VAS) and global response assessment (GRA) questionnaires were reviewed. RESULTS: Thirty-one men underwent the procedure across six institutions between March 2014 and September 2020. The mean (range) surgical time was 59 (25-95) min. At the mean (range) follow-up of 27 (4-79) months all patients reported resolution of presenting symptoms and no recurrence of adhesions. The mean VAS score was 8.9 and 9.0 for aesthetics and functional outcomes, respectively. On GRA, overall improvement was reported by all patients (61%, +3; 25%, +2; 14%, +1). CONCLUSION: There are limited options for the treatment of recurrent penile adhesions. A subcoronal BMG resurfacing is feasible, with no recurrence and overall high satisfaction seen in an initial patient cohort.