A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the “Ideal” Neophallus an Achievable Goal?

Abstract

Introduction:The complex anatomy and function of the native penis is difficult to surgically replicate. Metoidioplasty and radial forearm flap phalloplasty (RFFP) are the 2 most commonly utilized procedures for transgender neophallus construction.Methods:A MEDLINE search for metoidioplasty and RFFP in female-to-male genital reconstruction was performed. Primary outcome measures were subsequently compared. A systematic review was planned in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the quality of evidence.Results:Using Population, Intervention, Comparison and Outcomes tool criteria, a total of 188 articles were identified; 7 articles related to metoidioplasty and 11 articles related to RFFP met inclusion criteria. The GRADE quality of evidence was low to very low for all included studies. In studies examining metoidioplasty, the average study size and length of follow-up were 54 patients and 4.6 years, respectively (1 study did not report [NR]). Eighty-eight percent underwent a single-stage reconstruction (0 NR), 87% reported an aesthetic neophallus (3 NR), and 100% reported erogenous sensation (2 NR). Fifty-one percent of patients reported successful intercourse (3 NR), and 89% of patients achieved standing micturition (3 NR). In studies examining RFFP, the average study size and follow-up were 60.4 patients and 6.23 years, respectively (6 NR). No patients underwent single-stage reconstructions (8 NR). Seventy percent of patients reported a satisfactorily aesthetic neophallus (4 NR), and 69% reported erogenous sensation (6 NR). Forty-three percent reported successful penetration of partner during intercourse (6 NR), and 89% achieved standing micturition (6 NR). Compared with RFFP, metoidioplasty was significantly more likely to be completed in a single stage (P < 0.0001), have an aesthetic result (P = 0.0002), maintain erogenous sensation (P < 0.0001), achieve standing micturition (P = 0.001), and have a lower overall complication rate (P = 0.02).Conclusions:Although the current literature suggests that metoidioplasty is more likely to yield an “ideal” neophallus compared with RFFP, any conclusion is severely limited by the low quality of available evidence.

Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence

“…These seeming decreases in rates over time could be cause for celebration, but the reality is that when the recently‐reported low stricture rate of 21% is added to that group's reported fistula rate of 15% and their meatal stenosis rate of 14%, an “all cause” urological complication rate of 36% is seen even in the best hands (Ascha et al, in press)—not very different from the 35 to 41% rate reported in the past (Doornaert et al, ; Frey et al, ). This high rate of complication must be well understood by patients and practitioners alike.…”

Transgender Health Simplified: A Concise Guide to the Gynecologist

“…Patient who undergo a metoidioplasty can achieve erections without a prosthesis. Metoidioplasty is associated with less complications, better patient aesthetic satisfaction, more orgasmic sensations, and higher patient report of standing micturition [40] Male-to-female SRS Feminizing augmentation mammoplasty for transwomen involves the placement of an implant either below the subcutaneous tissue or under the pectoralis muscle [41]. Feminizing cross hormone therapy is recommended prior to breast augmentation; some experts recommend at least 6 months [42].…”

What Is the Ideal Neophallus? Response to Frey et al. (2017): An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature

“…With great interest we have read the literature reviews on genital reconstructive techniques applied to female-to-male transgender individuals by Frey et al 1 , 2 Over time, many different surgical techniques have been developed for male genital reconstruction and a comprehensive overview of these techniques is currently lacking. Hence, we applaud the authors for providing an overview of literature on this topic.…”

“…Nevertheless, we would like to put these outcomes into a different perspective. Frey et al 1 , 2 state that the notion of an “ideal” bottom surgery outcome has not been articulated from the perspective of patients. By lack of an up-to-date standard, they revert to a definition of the “ideal neophallus” as described by Hage and De Graaf 3 in 1993.…”