An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria. Phalloplasty is the most complex of these surgeries, and this complexity creates a wide range of potential complications. Some of the most common complications and therefore, targets for improvement in outcomes, concern neourethral fistula/stricture, efficacy of reinnervation of the phalloplasty flap, postoperative flap monitoring, and donor site morbidity. In the setting of no established “gold standard”, this review seeks to describe the components and staging of phalloplasty, with an emphasis on established and experimental solutions to the most common and vexing problems.

Authors: Carter EE, Crane CNSantucci RA.
Published in: Plast Aesthet Res. 2020 Jun 30.

Phalloplasty And Metoidioplasty: Techniques, Complications, and How To Deal With Them

Transmasculine gender-affirming surgery 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 discusses the surgical elements behind Metoidioplasty and Phalloplasty, and the diagnosis and treatment for the most common postoperative issues.
Authors: Jun MS, Crane CN, Santucci RA.
Published in: Minerva Urol Nefrol. 2019 Nov 4.

A Systematic Review of Penile Prosthetic Outcomes and Complications in Gender-Affirming Surgery

Penile Prostheses are commonly used to achieve erectile rigidity after Phalloplasty in trans masculine patients. Implantation poses significant challenges because of the delicate nature of the neophallus and lack of native erectile tissue. This is the first study to aggregate all reported Penile Prosthesis characteristics and outcomes in trans masculine patients. Prosthesis implantation in gender-affirming operations poses significant risk of complication, but it is still a reasonable and useful method to achieve rigidity necessary for sexual intercourse.
Authors: Rooker SA, Vyas KS, DiFilippo EC, Nolan IT, Morrison SD, Santucci RA.
Published in: J Sex Med. 2019 May.

Gender-affirming procedures for transgender women include Breast Augmentation using implants and genital reconstruction with Vaginoplasty. MRI is preferred over CT for post-Vaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men 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 fistulas and strictures. 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.
Authors: Stowell JT, Grimstad FW, Kirkpatrick DL, Brown ER, Santucci RA, Crane CN, Patel AK, Phillips J, Ferreira MA, Ferreira FR, Ban AH, Baroni RH, Wu CC, Swan KA, Scott SA, Andresen KJ.
Published in: Radiographics. 2019 Sep-Oct.

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. This is the first study to report on secondary Phalloplasty in collaboration with 8 specialized gender clinics. Transgender men who underwent secondary Phalloplasty after Metoidioplasty 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%). In high-volume centers specialized in gender affirming surgery, a secondary Phalloplasty can be performed after Metoidioplasty with complication rates similar to primary Phalloplasty.
Authors include: Santucci RA, Crane CN
Published in: J Sex Med. 2019 Nov.

Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications

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. 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.
Authors: Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML.
Published in: Plast Reconstr Surg. 2017 Oct.

Pedicled Anterolateral Thigh Flap Versus Radial Forearm Free Flap in Gender Confirming Surgery

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. Anterolateral Thigh Pedicled Flap Phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup.
Authors: Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML.
Published in: J Urol. 2018 Jan.

Strategies to Treat Them and Minimize Their Occurrence

Radial Forearm Free Flap Phalloplasty 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. 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.
Author: Santucci RA
Published in: Clin Anat. 2018 Mar.

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. 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.
Authors: Morrison SD1, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK.
Published in: Plast Reconstr Surg. 2016 Sep.

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