PD46-11 TECHNIQUES THAT REDUCE PARS FIXA AND PARS PENDULANS URETHRAL ANASTOMOTIC COMPLICATIONS DURING RADIAL FOREARM FREE FLAP PHALLOPLASTY

Abstract

INTRODUCTION AND OBJECTIVE: Transmasculine individuals interested in radial forearm free flap (RFFF) phalloplasty with full length urethroplasty are counseled on high urethral complication rates. The most common site for a postoperative urethral complication is the pars fixa (PF) and pars pendulans (PP) urethral anastomosis, which reportedly occurs in 40% to 50% of patients. Distal pars fixa urethral complications are rare; therefore, maximization of blood flow to the proximal PP urethral component of the RFFF may decrease urethral fistula and stricture formation. We describe our experience with flap harvest techniques that preserve blood flow to this region of the RFFF. METHODS: PF urethral reconstruction utilized labia minora flaps without use of any vaginal wall flaps. PP urethral reconstruction involved the volar portion of the RFFF with a 1-2cm proximal extension for the urethral component of the flap. Blood flow to and from this portion of the RFFF was maximized using the following techniques: 1) preservation of direct arterial perforators, when present; 2) keeping a dermal skin bridge to the proximal PP urethra; 3) wide dissection of an adipofascial layer; 4) preservation of a “urethral” vein. The added benefit of the adipofascial layer around the proximal PP urethra is tissue coverage over the PF-PP anastomosis. We retrospectively reviewed the outcomes of RFFF phalloplasty patients who underwent urethral reconstruction. RESULTS: From Oct 2017 to Oct 2019, 79 patients underwent RFFF phalloplasty with full-length urethroplasty. Mean followup is 12 months (range 0-23 months). Urethrocutaneous fistulas and/or urethral strictures developed at the PF-PP anastomosis in 27 (34%) patients: 7 patients had a PF-PP urethral stricture and fistula, 5 had an isolated anastomotic stricture, and 15 patients had a fistula with 11 patients spontaneously healing the fistula by 6 weeks. The total urethral revision rate for patients with a non-healing fistula and/or stricture at the PF-PP urethral anastomosis was 14% (11 patients). There are two patients with mild strictures and three with a fistula who are still being monitored and have not yet had urethral reconstruction. CONCLUSIONS: Techniques directed towards preservation of blood flow to the proximal urethral component of a RFFF phallourethroplasty reduces risk of urethral complications. More than half of the fistulas healed spontaneously, and most strictures required urethroplasty. Source of Funding: none