Abstract
Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty.
Highlights
For many female-to-male (FtM) transgender persons, construction of a neophallus is a crucial culminating step in the gender transition
Though many techniques have been described, the radial forearm free flap remains the most common for phalloplasty due to its long, reliable vascular pedicle, multiple nerve innervations, and pliability [1]. Despite regarding it as the preeminent technique, urological complications remain the ubiquitous challenge of radial forearm phalloplasty
A biopsy was taken of the distal-most aspect of the urethra and demonstrated endometrial tissue, as was expected given the original placement of the uterine mucosal graft
Summary
For many female-to-male (FtM) transgender persons, construction of a neophallus is a crucial culminating step in the gender transition. Though many techniques have been described, the radial forearm free flap remains the most common for phalloplasty due to its long, reliable vascular pedicle, multiple nerve innervations, and pliability [1]. In the largest published series, 41% of patients suffered urological complications, mostly urethral strictures and fistulae; complications have been reported as high as 80% [2, 3]. These sequelae arise in the FtM patient because the natal female urethra must first be lengthened to build the pars fixa of the neourethra, which is subsequently anastomosed to the pars pendulans within the constructed radial forearm free flap. Vaginal mucosa, which possesses properties similar to buccal mucosa, is often used to construct the pars fixa in the FtM patient [5, 6]
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