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.

High Surgical Complication Rates after Silicone Implant Use for Improvement of Glans Ridge Appearance.

Background: Construction of the glans is an important aspect of gender-affirming phalloplasty. In these surgeries, the glans ridge is commonly constructed using the Norfolk technique or a similar technique. In cases of glans ridge flattening after creation, we generally recommend a redo/revision glansplasty, which is often curative. However, in situations when the glans ridge flattens again, we developed a silicone glans implant technique in an effort to create a satisfactory and lasting glans ridge. Methods: We conducted a pilot study of our first 12 glans implant cases. A retrospective chart review and brief, ad-hoc patient survey measured patient demographics, implant status, and patient satisfaction. Results: A total of 12 patients received a silicone glans implant between November 2017 and February 2020. One patient had the glans implant removed before the survey, and also could not be contacted. Three patients did not respond to the survey. Of the eight patients who responded, only five (5/8, 63%) patients still had the silicone implant at the time of the survey. The average satisfaction score was 3.25 (range 1 = very satisfied and 5 = very dissatisfied). Common complaints cited included dissatisfaction with implant appearance, as well as infection, discomfort, and pain. Conclusions: Patients and surgeons should be aware of the possibility of a novel silicone implant technique to create a glansplasty in those with failed/flattened previous glansplasty surgery. However, the technique is in development: patient satisfaction remains spotty and complication rates are high, although technical improvements may increase future success rates.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications.

BACKGROUND: Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. AIM: To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. METHODS: Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). OUTCOMES: Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). RESULTS: There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. CLINICAL IMPLICATIONS: Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated STRENGTHS & LIMITATIONS: Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. CONCLUSION: We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641-649.

Optimization of Second-stage Metoidioplasty.

OBJECTIVE: To describe a planned 2-staged metoidioplasty. Metoidioplasty is a genital gender-affirmation surgery aimed at creating a neophallus, scrotum (if desired), and flat male-type perineum (if desired) from natal tissues. It generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. The details of this procedure are sparsely mentioned in the literature. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis. MATERIAL AND METHODS: We conducted a retrospective chart review of patients after metoidioplasty between August 2015 and June 2020, and isolated those that underwent second-stage metoidioplasty. Each procedure was done by 1 of 4 surgeons in a single practice in 2 locations, San Francisco, CA, and Austin, TX. Details of procedures required, complications, and demographic information were recorded. RESULTS: Out of the 75 patients that had undergone metoidioplasty, 37 (37 of 75, 49%) underwent a second-stage metoidioplasty. Reduction of upper scrotal blocking tissue was the most common procedure performed during a second-stage metoidioplasty (31 of 37, 84%), followed by escutcheonectomy/penile lift (30 of 37, 81%), bilateral implant placement (20 of 37, 54%), chordee repair (13 of 37, 35%), and unilateral implant placement (1 of 37, 3%). 6 of the 37 patients (16%) developed major complications. 5 of the 37 (5 of 37, 15%) second-stage patients required a redo second-stage metoidioplasty. CONCLUSION: Second-stage metoidioplasties are commonly performed on patients to optimize results of phallic lengthening and release, and to repair complications that arise after single-stage metoidioplasty. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty.

BACKGROUND: Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications when compared with previously reported complication rates of undelayed single-stage ALT phalloplasty in our practice. METHODS: A retrospective medical record review was performed on all phalloplasty patients in our practice between January 2016 and September 2019. We found those patients who had completed delayed ALT flap phalloplasty with at least 6 months of delay and 12 months of follow-up. For these patients, we recorded postoperative complications, simultaneous surgeries, subsequent surgeries, and demographic characteristics. RESULTS: Five female-to-male transsexuals underwent delayed ALT flap phalloplasty (two were unplanned procedures, three were planned). Planned delay: The average time between Stage 1 and Stage 2 was 6.5 months. Complications for the planned delay cohort were as follows: partial loss of the neophallus not requiring repair (33%), urethral stricture requiring surgical repair (33%). Unplanned delay: The average time between Stage 1 and Stage 2 was 9.1 months. The following complication was seen in the unplanned delay cohort: urethral stricture requiring surgical repair (50%). CONCLUSIONS: Vascular delay of ALT flap phalloplasty is a successful emergency salvage procedure. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction.

Radial forearm free flap phalloplasty (RFFFP) is the most common surgery performed for genital reconstruction of female-to-male transgender patients. However, up to 19% require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFFFP was first reported in 1996 and has subsequently been reported by 1 high-volume center in Belgium. METHODS: Here, we present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation. RESULTS: In both cases, the creation of a distal AVF salvaged the neophallus. Importantly, the patient that had been transferred out of the operating room before reintervention suffered partial flap necrosis compared with no flap loss in the patient who had an AVF created during initial surgery. One AVF was ligated 18 days postoperative, whereas the other was never formally closed. CONCLUSIONS: These cases demonstrate that AVF can be reliably used for RFFFP salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss. Finally, in contrast with the prior explanation of this technique, timing of AVF ligation may be less critical than previously described. Microsurgeons are reminded that this technique may save complicated flaps in the uncommon case of microcirculatory flap obstruction.

Vaginoplasty tips and tricks

ABSTRACT Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

Vaginoplasty tips and tricks.

Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

What urologists need to know about female-to-male genital confirmation surgery (phalloplasty and metoidioplasty): techniques, complications, and how to deal with them.

Transmasculine gender-affirming surgery (GAS) is technically challenging, and in the past associated with a high but improving complication rate. Few surgical centers are performing this surgery, which can include metoidioplasty and phalloplasty, and patients often travel great distances for their surgery. While many will continue care with their original surgeons, others cannot due to social/geographic factors, or because emergencies arise. Thus, patients may seek care with their local urologist for relief of delayed complications, the most common of which include urethral stricture, penile prosthesis issues and urethrocutaneous fistula. This review will discuss the surgical elements behind metoidioplasty and phalloplasty, and the diagnosis and treatment for the most common postoperative issues.

Imaging Findings in Transgender Patients after Gender-affirming Surgery.

Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation. Online supplemental material is available for this article. ©RSNA, 2019.

The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series.

INTRODUCTION: Some transgender men express the wish to undergo genital gender-affirming surgery. Metoidioplasty and phalloplasty are procedures that are performed to construct a neophallus. Genital gender-affirming surgery contributes to physical well-being, but dissatisfaction with the surgical results may occur. Disadvantages of metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary phalloplasty after metoidioplasty. Literature on secondary phalloplasty is scarce. AIM: Explore the reasons for secondary phalloplasty, describe the surgical techniques, and report on the clinical outcomes. METHODS: Transgender men who underwent secondary phalloplasty after metoidioplasty were retrospectively identified in 8 gender surgery clinics (Amsterdam, Belgrade, Bordeaux, Austin, Ghent, Helsinki, Miami, and Montreal). Preoperative consultation, patient motivation for secondary phalloplasty, surgical technique, perioperative characteristics, complications, and clinical outcomes were recorded. MAIN OUTCOME MEASURE: The main outcome measures were surgical techniques, patient motivation, and outcomes of secondary phalloplasty after metoidioplasty in transgender men. RESULTS: Eighty-three patients were identified. The median follow-up was 7.5 years (range 0.8-39). Indicated reasons to undergo secondary phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had metoidioplasty performed as a first step toward phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). Each center had preferential techniques for phalloplasty. A wide variety of surgical techniques were used to perform secondary phalloplasty. Intraoperative complications (revision of microvascular anastomosis) occurred in 3 patients (5.5%) undergoing free flap phalloplasty. Total flap failure occurred in 1 patient (1.2%). Urethral fistulas occurred in 23 patients (30.3%) and strictures in 27 patients (35.6%). CLINICAL IMPLICATIONS: A secondary phalloplasty is a suitable option for patients who previously underwent metoidioplasty. STRENGTHS & LIMITATIONS: This is the first study to report on secondary phalloplasty in collaboration with 8 specialized gender clinics. The main limitation was the retrospective design. CONCLUSION: In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019;16:1849-1859.

Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender Confirming Surgery.

PURPOSE: Phalloplasty is a critical step in female-to-male (transmale) gender confirming genital surgery. We examined outcomes between transmales who underwent phalloplasty with vaginectomy and full-length urethroplasty using the anterolateral thigh pedicled flap or the radial forearm free flap. MATERIALS AND METHODS: We performed a single center, retrospective study of patients who underwent phalloplasty with vaginectomy and full-length urethroplasty using an anterolateral thigh pedicled flap or a radial forearm free flap from April 2013 to July 2016. All patients had at least 6 months of followup. Urethral and nonurethral complications were recorded. Complication rates were assessed using the OR of the anterolateral thigh pedicled flap and the radial forearm free flap groups. RESULTS: Of the 213 patients 149 and 64 underwent radial forearm free flap and anterolateral thigh pedicled flap phalloplasty, respectively. Patients with a radial forearm free flap had a significantly higher body mass index than those with an anterolateral thigh pedicled flap. The overall urethral complication rate for radial forearm free flap and anterolateral thigh pedicled flap phalloplasty was 31.5% and 32.8%, and the rate of partial or total neophallus loss was 3.4% and 7.8%, respectively. Patients in the pedicled flap cohort experienced significantly greater odds of urethral fistula (OR 2.50, p = 0.024), nonurethral complications (OR 2.38, p = 0.027) and phallus wound dehiscence (OR 5.03, p = 0.026). CONCLUSIONS: Anterolateral thigh pedicled flap phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup. Our findings can help guide surgical decision making when selecting a flap for phalloplasty.

Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications.

BACKGROUND: Phalloplasty with urethral lengthening is the procedure of choice for female-to-male transgender patients who desire an aesthetic phallus and standing micturition, but is associated with complications, including urethral stricture and fistula formation. Horizontal urethra construction can be accomplished with labia minora flaps covered with additional vascularized layers of vestibular tissue when vaginectomy is performed concomitantly with phalloplasty. However, vaginectomy is not a requisite step in phalloplasty, and some individuals may choose to retain their vagina. In these cases, extra layers of vascularized vestibular tissue are not used for horizontal urethra coverage. This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. METHODS: A single-center retrospective study of 224 patients who underwent phalloplasty with urethral lengthening was performed. Patients were sorted into vaginectomy and vaginal preservation cohorts and complication rates were assessed. RESULTS: Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non-urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). CONCLUSION: Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An overview of female-to-male gender-confirming surgery.

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

Phalloplasty: A Review of Techniques and Outcomes.

BACKGROUND: Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes. METHODS: A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. CONCLUSIONS: Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

Pre- and Post-Operative Care With Associated Intra-Operative Techniques for Phalloplasty In Female-to-Male Patients.

Phalloplasty, or creation of the penis, is one of the steps in gender confirming surgery for a female-to-male patient and for males with absence or malformation of the penis. Here, the most common techniques for phalloplasty, along with the pre-operative and post-operative care are discussed.

Analysis of free flap complications and utilization of intensive care unit monitoring.

We aimed to determine the optimal time for intensive care unit (ICU) monitoring after free flap reconstruction based on the timing of surgical complications. We reviewed retrospectively 179 free flaps in 170 subjects during an 8-year period at University Hospital. Thirty-seven flaps were reoperated due to vascular (n = 16, 8.9%) and nonvascular complications (n = 21, 11.7%). Vascular complications presented earlier relative to nonvascular complications (10.8 versus 99.3 hours). The flap survival rate was 93.2% with a mean ICU length of stay of 6.2 days. The lack of standardized monitoring protocols can lead to overutilization of ICU. Sometimes, flap monitoring is not the limiting factor, as patients with other comorbidities necessitate longer ICU stays. However, our study suggests that close monitoring of flaps seems most critical during the first 24 to 48 hours, when most thrombotic complications occur and prompt identification and re-exploration is critical. Some thrombosis and most hematomas present within 72 hours, and thus close monitoring is still warranted. We suggest close monitoring of free flaps in the ICU or dedicated flap monitoring unit where nursing can check the flap on an every-1-to-2-hour basis for the first 72 hours postoperatively to assure optimal surveillance of any potential problems.

Urethral reconstruction using a prefabricated pedicled gracilis flap.

This case study describes a patient who experienced an iatrogenic urethral injury because of a Fournier gangrene debridement. Because of the extent of the debridement, which resected all penile and scrotal dartos tissue, no local flaps that would typically be used to reconstruct a urethral disruption were possible. The authors chose to use a prefabricated pedicled gracilis flap to restore urethral continuity.