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

Abstract

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.

Spatial distribution of smooth muscle tissue in the male pelvic floor with special reference to the lateral extent of the rectourethralis muscle: Application to prostatectomy and proctectomy

“…Furthermore, such morphological knowledge is also useful for anorectal surgeons to avoid urethral injury during proctectomy, especially in perineal approaches such as transanal total mesorectal excision (Uchimoto et al, ; Martin et al, ; Denost et al, ; Saito et al, ; Penna et al, ). In addition, understanding the detailed anatomy around the urethra is also important in radial forearm free flap phalloplasty (RFFP), which is the current standard of care for most FTM gender conformation surgeries (Santucci, ).…”

Gender affirmative care of transgender people: a single center's experience in Korea

“…A total of 30 (9.0%) patients required a second operation [21]. However, with respect to SRS for FTMs, most such surgeries are associated with a rate of urethral stricture as high as 51%, which decreases only to 23–35% even among the most experienced contemporary surgeons [22]. As such, postoperative complications may be related to differences in the use of genital plastic surgery between MTFs and FTMs.…”

One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

“…Cross-sex hormones are associated with cardiovascular complications, including a fourfold increased risk of heart attacks in biological females, and a threefold increase in the incidence of venous thromboembolism in biological males (Alzahrani et al, 2019;Nota et al, 2019). "Gender-affirming" surgeries can cause urethral stricture, neo-vaginal stenosis and prolapse, and long-term post-mastectomy pain (Larsson, Ahm Sørensen, & Bille, 2017;Manrique et al, 2018;Rashid and Tamimy, 2013;Santucci, 2018). The effects of "genderaffirmative" care on fertility have not been adequately studied, but infertility is a likely outcome, depending on the specific treatments pursued.…”