Determining the outcomes of urethral construction in phalloplasty.

OBJECTIVE: To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history. MATERIALS AND METHODS: We conducted a single-centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans-male patients undergoing gender-affirming surgery and cis-male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision-anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri- and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires. RESULTS: The mean (±sd) follow-up duration was 5.5 (±3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis-male vs 71.8% for trans-male patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public. CONCLUSIONS: Urethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results.

Functional and surgical outcomes after phalloplasty in cis men.

PURPOSE: Evaluate the surgical outcomes along with a comprehensive assessment of functional outcomes in cis men (non-trans) who underwent phalloplasty. METHODS: All consecutive cis men who underwent phalloplasty from 2008 to 2018 for penile insufficiency due to various causes were included. These underwent phalloplasty by either a radial forearm free flap (RFFF) or suprapubic phalloplasty (SPP). Data were collected from medical files. A questionnaire was sent a minimum of 1 year after surgery to each patient to evaluate sexual function and self-esteem, satisfaction with genitals, and urinary function. RESULTS: Among the 19 patients included, 12 underwent RFFF and 7 SPP; 25% of those who had RFF and 14.3% of those with SPP had a Clavien-Dindo ≥ 2 complication. A total of 16 patients had a urethroplasty procedure, 50.0% of whom had a Clavien-Dindo ≥ 2 complication. Penile prostheses were implanted in 14 patients; 64.3% of whom had a complication. Seven patients answered the questionnaire (36.8%); the relationship satisfaction score was 89.5/100 and the confidence score was 100/100. Among the 5 patients who had a sexual relationship, all reported having a lot of pleasure during sexual intercourse and reached orgasm at least "regularly". At least 66.7% of the patients were "satisfied" or "very satisfied" about the size and the appearance of genitals. Among the 5 patients who answered questions regarding urinary function, 60.0% had standing micturition, and 80.0% reported being comfortable in public toilets. CONCLUSION: Despite the high frequency of complications and the need for revision surgery, phalloplasty seems to allow a satisfying psychosexual and urinary functions for cis men suffering from penile insufficiency.

Suprapubic phalloplasty in transmen: surgical results and critical review.

This article presents the surgical outcomes of a consecutive series of 71 transmen undergoing pre-expanded suprapubic phalloplasty (SPP) in a specialized center. The median [IQR] duration to finalize this three-stage phalloplasty procedure was 7 months [6-7]. Median [IQR] follow-up was 39.4 months [19.7-81.2]. Among those included, 25 (35.2%) had a urethroplasty, and 40 (56.3%) a penile prosthesis as additional procedures. Complications were the result of disorders of wound healing (dehiscence, infection, partial necrosis) or tissue expander (migration, infection). Sixty patients (84.5%) experienced at least one complication during the phalloplasty procedure, mostly minor complications Clavien < IIIa (81.8%). Among these, 16 (22.5%) underwent at least one reintervention, 2 of whom underwent two reinterventions (18 reinterventions in total for Clavien ≥ IIIa complication). There was no loss of phalloplasty. Among the wide variety of techniques developed for phalloplasty, the suprapubic technique seems to be a valuable option for transmen on the path to genital gender affirming surgery.