VS-1-7 Female-to-Male Gender Affirming Surgery: The Pedicled Pubic Phalloplasty and Radial Artery Free-Flap Urethroplasty

Abstract

The goal of genital female-to-male (FTM) gender affirming surgery is to create an aesthetically acceptable phallus to allow voiding while standing and penetrative sexual intercourse. The radial artery free flap phalloplasty accomplishes these goals but results in significant donor site scarring. The visible scarring can be minimised by incorporating a radial artery free flap urethroplasty inside a previously formed pedicled pubic phalloplasty. This technique combines the less technically challenging phalloplasty with a well-vascularised and stable urethra for voiding. The combined procedure is performed in 4 stages: 1) phallus formation 2) creation of neourethra by free flap microvascular transfer to the recipient site 3) laparoscopic hysterectectomy and bilateral salphingo-oopherectomy, vaginectomy, join-up urethroplasty, burying of clitoris, scrotoplasty and glansplasty 4) penile and testicular prosthesis insertion. Each stage is performed at 6-monthly intervals. Steps: 1) a 13cm by 14cm pedicled pubic flap is raised preserving the superficial epigastric vessels. 2) a 4cm x 17cm free flap neourethra based on the radial artery is raised from the relatively hairless medial forearm and tubularised. A disc of skin is excised at the phallus tip and space dilated to size 20 Hegar. The neourethra is tunnelled through the phallus and a spatulated urethral anastomosis is performed followed by microsurgical vascular and neural anastomoses. The donor forearm is resurfaced with a split thickness skin graft. 3) Modified Norfolk technique glansplasty with urethral lengthening using inner labial and anterior vaginal flaps. 4) Penile prosthesis prepared with polyethylene terephthalate cap and sock and testicular prosthesis inserted via separate groin incisions with placement of the reservoir in an extraperitoneal position.