Staged Urethroplasty for Reconstruction of Long Complex Pendulous Strictures of a Neophallic Urethra

Abstract

Post-phalloplasty, patients may present with urologic complications, including strictures, urethrocutaneous fistulas and vaginal cavity remnants.1-3 OBJECTIVE: To demonstrate the feasibility of staged repairs for long complex neophallus strictures. All post-phalloplasty patients who underwent pendulous (pars pendulans) or panurethral urethroplasty for strictures >7 cm were identified. In preparation for surgery patients were co-managed with their local providers, whenever possible, in treating symptomatic infections with culture-specific antibiotics, draining abscess and managing suprapubic catheters. During Stage-1, a ventral incision through the perineum and neophallus was created to expose remnants of the neo-urethral plate. Additional findings (fistula/remnant cavity) were treated at this stage if found, along with re-mobilization of a previously placed gracilis flap. The neourethral plate was augmented with buccal mucosal graft (BMG) with a goal of achieving an approximately 3-cm-wide plate. The lateral neourethral edges were sutured to the edges of the skin incision creating a temporary perineal urethrostomy. Stage-2 was performed in a delayed fashion and included mobilization and tubularization of the neourethra, with additional oral mucosa inlay (BMG or lingual), if needed, followed by a multi-layer closure. Postoperatively, patients were assessed in clinic when possible, or via telemedicine appointments for urethral patency, and queried using patient-reported outcome measures. Failures were defined as need for additional revisions or urethral instrumentation. Twenty-one patients presented between December 2013 and July 2021 with urinary obstruction due to long penile strictures. Seventeen patients, mean age 33 (22-58), elected to undergo staged reconstruction. Prior phalloplasty techniques included radial forearm flap phalloplasty in 15/17 and anterolateral thigh flap in 2/17. In 11/17 patients BMG was previously used during phalloplasty for urethral prelamination.4 Mean stricture length was 12 cm (7-17). Concurrent procedures during Stage-1 included re-harvesting BMG (11/17), gracilis flap re-mobilization (7/17) and redo-vaginectomy (5/17).5 During Stage-2, 14 patients (82%) required additional oral graft inlays: lingual 6/14 (including 2 bilateral), BMG 5/14 (including 1 bilateral) and lingual+BMG in 3/14. At a mean follow-up of 24 months (4-77), there were 2 failures (12%). Thirteen patients completed follow-up questionnaires and all reported upright voiding and at least a moderate improvement in their condition on Global Response Assessment: +3 (markedly improved) in 11/13 (85%), and +2 (moderately improved) in 2/13 (15%). A staged urethroplasty is a feasible option for transgender men with long complex penile strictures of the neophallus. This technique demonstrates promising early functional outcomes and high patient satisfaction.