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

Massie, Jonathan P.; Morrison, Shane D; Wilson, Stelios C.; Crane, Curtis; Chen, Mang L.

doi:10.1097/prs.0000000000003697

Cited by 80 publications

(23 citation statements)

References 15 publications

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“…Using the aforementioned inclusion criteria, 25 full-text articles were included for analysis. 13 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 A full flow diagram with all screening and exclusion decisions is available in Fig. 1 .…”

Section: Resultsmentioning

confidence: 99%

“…20 34 35 39 Less commonly used flap types were free thoracodorsal artery perforator, 29 tensor fasciae latae island, 38 and combinations of flap types. 33 Within the identified flap types, there was substantial variation in flap subtype of the RFF, including the fasciocutaneous, 28 sensate free, 22 35 39 free radial artery forearm flap, 13 24 27 30 31 32 36 40 and osteocutaneous free RFF. 23 26 37…”

Section: Resultsmentioning

confidence: 99%

“…As is standard for masculinizing phalloplasty, all studies reported completing two steps for urethral lengthening: the creation of the pars fixa, or the portion of the urethra between the native urethra and the base of the phallus, and the creation of the pars pendulans which extends throughout the neophallus. The pars fixa, or proximal urethra, was completed with a variety of different flaps including the anterior vaginal wall, 20 24 25 26 28 29 31 32 34 37 39 labia minora, 13 25 26 27 30 31 32 33 35 36 37 40 vaginal flap, 23 33 36 39 vaginal mucosa, 41 bladder, 21 urethral plate, 36 metoidioplasty, 33 35 and vestibular and infundibular skin strips 18 19 20 22 38 40 ( Table 2 ). The pars pendulans, or distal urethra, was typically created with the same flap used to create the body of the phallus, but other options included vaginal graft, 31 a full-thickness skin graft from the median forearm, 29 and subcutaneous island flap from the preputial apron.…”

Section: Resultsmentioning

confidence: 99%

“…Studies also reported on a variety of factors thought to have affected complication rates within their samples beyond flap type and number of stages. Factors hypothesized to reduce urethral stricture and fistula included procedure standardization, 27 experience levels of the surgical team, 27 prelamination of the pars pendulans, 22 31 34 vaginectomy, 30 flap rotations and shaping, 24 26 and reinforcement of the urethral anastomosis between the native urethra and pars fixa and between the pars fixa and pars pendulans. 37 40 Complications and the factors theorized to have impacted them have been qualitatively synthesized in Table 3 , stratified by phallus flap type and number of stages.…”

Section: Resultsmentioning

confidence: 99%

“…RFF was the most commonly reported flap choice, representing 64% of identified cases 13,[22][23][24][26][27][28][30][31][32][35][36][37]39,40 (►Table 2). Other commonly used flap types were ALT, 13,18,30,41 abdominal, 19,21,25,41 and fibular flaps.…”

Section: Surgical Techniques: Flap Choice and Number Of Stagesmentioning

confidence: 99%

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A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty

Jolly

Boskey

et al. 2022

J Reconstr Microsurg Open

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Background As phalloplasty becomes more routinely performed, there is a growing need for an evidence base to guide surgical decision-making. Recent reviews have suggested that flap type and number of stages may affect the high rates of urethral complications seen with phalloplasty, but no rigorous comparison of both has been performed. Methods A systematic review was conducted across PubMed, Google Scholar, and ScienceDirect (PROSPERO #158722). All included studies examined urethral complications following gender-affirming phalloplasty in transgender men. Data were extracted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. All searches, extractions, and grading were completed by two authors. Results Twenty-five studies were included with a total of 1,674 patients. Identified flap types included radial forearm, anterolateral thigh, abdominal, and fibular flaps. Surgical techniques varied widely within the flap types. Number of stages ranged from one to four. Stricture and fistula were the most frequently reported complications with considerable variation in the reported rates between studies, even within singular flap types. Data extraction indicated serious quality issues with the published literature, with the majority of studies at high risk of bias due to short follow-up times, inconsistent and incomplete reporting of outcomes, and inconsistent reporting of surgical technique. Conclusion To date, there is insufficient data to support a preferred flap type to minimize the urethral complication rates of phalloplasty. Further high-quality literature is required to determine the impact of potential factors affecting complications of gender-affirming phalloplasty. Improved literature quality may be facilitated by a standardized set of reporting guidelines.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Surgical Techniques: Flap Choice and Number Of Stagesmentioning

confidence: 99%

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A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty

Jolly

Boskey

et al. 2022

J Reconstr Microsurg Open

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

Santucci¹

2018

Clinical Anatomy

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Radial forearm free flap phalloplasty (RFFP) is the current standard of care for most FTM gender confirmation surgeries. This procedure is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required. Patient and physician knowledge regarding the high burden and poor treatment options for urethral stricture after phalloplasty is incomplete, and patient acceptance of this reality is crucial for honest understanding of the potential complications of this increasingly common but extremely complex surgery.

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Evaluation and management of urologic complications following transmasculine genital reconstructive surgery

Elyaguov

Isakov

Nikolavsky

2022

Neurourology and Urodynamics

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Aims Transmasculine genital reconstructive surgery involves the creation of a neourethra by way of metoidioplasty or phalloplasty. We aim to describe approaches in identifying complications associated with these procedures as well as the various reparative techniques that can be utilized to reestablish the neourethral tract. Methods We prepared a guide to diagnostic and procedural interventions for urologic complications following transmasculine genital reconstructive surgery based on our clinical experience as well as those of our colleagues. We reviewed all current peer‐reviewed publications based on this topic. Results These procedures have a considerable revision rate for urologic complications, which include urethrocutaneous fistulae, persistent vaginal remnant, and urethral strictures. These complications often present simultaneously and require appropriate workup and treatment. Conclusions Several reconstructive techniques can be employed to restore the neourethral tract, as we describe in detail.

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

Abstract: Therapeutic, III.

Cited by 80 publications

References 15 publications

A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty

A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty

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

Evaluation and management of urologic complications following transmasculine genital reconstructive surgery

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