Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty.

OBJECTIVE: To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). METHODS: A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. RESULTS: Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. CONCLUSION: UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty.

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

Incidence, Complications, and Long-term Outcomes of Gender-affirming Phalloplasty: Analysis of a Large Statewide Population-based Dataset.

OBJECTIVE: To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset. METHODS: Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. RESULTS: We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. CONCLUSION: This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy.

Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips.

BACKGROUND: Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex. OBJECTIVE: This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty. MATERIALS AND METHODS: A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical. RESULTS: A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement. CONCLUSION: Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.

Topographic and Structural Anatomy of the Suspensory Ligament of the Penis: Implications for Phalloplasty.

BACKGROUND: The suspensory ligamentous system of the penis supports the penis when erect and plays a key role during coitus. These ligaments, which are prone to injury during coitus, are clinically important in penile reconstruction procedures. OBJECTIVES: The current study investigated the macro- and microanatomy of the suspensory ligamentous system of the penis to determine the origin, course, insertion, dimensions, and tissue composition of these ligaments, knowledge of which is vital for successful penile reconstruction procedures. METHODS: The study utilized a total of 49 cadavers. Gross anatomy dissection, MRI, and histological staining were performed to elucidate the topography, dimensions, and tissue composition of the suspensory ligaments of the penis. RESULTS: Three ligaments were observed to form the suspensory ligamentous system of the penis. The most superficial is the fundiform ligament, which consists of superficial bundles and deep median bundles, with the former arising from the Scarpa's fascia and the latter arising from the linea alba of the anterior abdominal wall; both inserted into the superficial fascia of the penis. The suspensory ligament of the penis arose from the pubic symphysis and inserted into the deep fascia (Buck's fascia) of the penis. The arcuate ligament arose from the body of the pubis and pubic symphysis and inserted into the Buck's fascia. The ligaments were determined to consist of adipose tissue, collagen fibers, elastic fibers and reticular fibers, in varying proportions. CONCLUSIONS: The suspensory ligaments of the penis exhibit a fan-like structure on the penis that allows the forward movement of the penis as a result of engorgement of the erectile bodies while simultaneously offering support.

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Erectile device insertion following phalloplasty in transgender and non-binary individuals assigned female at birth: a narrative review.

Genital gender affirmation surgery (gGAS) for individuals assigned female at birth (AFAB) is complex and requires the staged insertion of an erectile device to permit penetrative intercourse. This final stage of gGAS is challenging, owing to the variable anatomy and lack of supportive structures within the neophallus when compared with erectile device insertion for individuals assigned male at birth. There is a paucity in the literature at present regarding erectile device insertion in trans-sex AFAB patients. Hence, a narrative review following a literature review and supplemented by expert opinion from a high-volume centre of expertise is presented. The choices available for erectile device in this patient cohort are discussed. Principle surgical steps required for this complex surgery is outlined along with the recommended postoperative management of the patient. Postoperative outcomes and complications are also summarised in this fast-developing surgical procedure.

Deep inferior epigastric vessels for free scapular flap phalloplasty.

We aimed to present our 20-year experience of using the deep inferior epigastric vessels as recipient vessels for free scapular flaps phalloplasty and evaluate the outcomes. Penile reconstruction was performed using a free scapular flap between 2000 and 2020 by the same surgical team. Deep inferior epigastric vessels were used in all the cases. The surgical techniques and outcomes were described. Overall, 73 patients used the deep inferior epigastric artery (DIEA) as the recipient artery. Regarding the recipient veins, 2 veins were anastomosed in 72 (98.6%) patients, 1 deep inferior epigastric vein (DIEV) was used in 1 patient, 2 DIEV in 14, 1 DIEV + superficial inferior epigastric vein (SIEV) in 13, 1 DIEV + superficial circumflex iliac vein (SCIV) in 38, great saphenous vein (GSV) + SCIV in 4, and GSV + SIEV in 3. The mean age and body mass index of the study cohort was 28 years and 24.3 kg/m2, respectively. The shortest follow-up time was 7 months. Eleven patients had flap-related complications. Three patients were readmitted to the operating room within 24 hours, and 2 of them underwent salvage procedures with venous revision. Two patients lost the entire flap. One patient with 3-cm distal portion necrosis required surgical intervention. Three patients experienced urethral necrosis. DIEA is a suitable receptor artery for inflow. The DIEV, SIEV, and SCIV are available options for venous drainage according to the patient anatomical characteristics. The GSV can be an excellent backup for outflow and salvage procedures.

[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]. / Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme.

AIMS: The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. METHODS: In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. RESULTS: The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. CONCLUSION: Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study.

OBJECTIVE: To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization. METHODS: A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention. RESULTS: Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12). CONCLUSION: The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.

Urethroplasty Methods for Stricture Repair After Gender Affirming Phalloplasty: High Failure Rates in a Hostile Surgical Field.

OBJECTIVE: To report our experience with 71 postphalloplasty urethral strictures in order to discuss the performance characteristics of different urethroplasty techniques in urethral stricture after phalloplasty. METHODS: We conducted a retrospective chart review of 85 urethroplasties performed for stricture repair in 71 patients with phalloplasty for gender affirmation between August 2017 and May 2020. Stricture location, urethroplasty type, complication rate, and recurrence rate were recorded. RESULTS: The most common stricture type was distal anastomotic (40/71, 56%). The most common initial repair type was excision and primary anastomosis (EPA) (33/85, 39%), followed by first-stage Johanson urethroplasty (32/85, 38%). The stricture recurrence rate after initial repair of all types was 52% (44/85). The recurrence rate of stricture after EPA was 58% (19/33). The recurrence rate after staged urethroplasty was 25% (2/8) for patients who successfully completed a first and second stage. 30% (3/10) of patients who completed a first stage and opted out of a second stage required a revision to achieve successful lifetime voiding from the surgical urethrostomy. CONCLUSION: EPA after phalloplasty has a high failure rate. Nontransecting anastomotic urethroplasty has slightly lower failure rate, and staged Johanson-type surgeries have the highest success rates after phalloplasty.

Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study.

BACKGROUND: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. AIM: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. METHODS: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. OUTCOMES: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. RESULTS: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. CLINICAL IMPLICATIONS: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. STRENGTHS AND LIMITATIONS: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. CONCLUSIONS: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes.

OBJECTIVE: 1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS: Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS: Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION: ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.