Urethral Lengthening Research Articles

Functional outcomes after supra-pubic phalloplasty

BACKGROUNDA thorough evaluation of the functional outcomes resulting from supra-pubic phalloplasty (SPP) assessing different aspects of the phalloplasty has not been reported. PURPOSE OF THE STUDYTo report the outcomes on sexuality, urinary function, satisfaction, and regrets following an SPP performed at our centre. SUBJECTS STUDIEDAll consecutive patients who underwent the 3-steps technique of pre-expanded SPP between 2007 and 2018 and who had at least 1 year of follow-up. METHODSQuestionnaires were sent to analyse several domains of penile reconstruction: sexuality, urinary function, perceived sensitivity, and satisfaction. Sexuality was evaluated using the Self Esteem and Relationship (SEAR) questionnaire. Urinary function was analysed based on the urethral stricture surgery PROM (USS-PROM) questionnaire. MAIN FINDINGSA total of 77 patients were included, 92.2% were transmen, and 33 (42.9%) responded to the questionnaire. Urethral lengthening (UL) was performed in 28 (36.4%) procedures and erectile prosthesis was implanted in 42 patients (54.5%). The mean length of the neophallus was 15.3cm (SD 2.6) and the mean girth was 11.8cm (SD 2.1). The mean total SEAR score (/100) was 73.8 (SD 26.7). The mean six-item LUTS score (/24) was 8.4 (SD 4.6). The standing position was the usual voiding position reported by 11 patients (73.3%). CONCLUSIONPre-expanded SPP is a robust technique that can achieve substantial flap dimensions, leading to high satisfaction with neophallus appearance and the choice of the phalloplasty technique. Overall sexual outcomes are mostly favourable. UL is feasible and effective in terms of voiding in a standing position.

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty

ObjectivesTo determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening. MethodsA retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of urethral lengthening. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. ResultsBetween November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. ConclusionsUrethral lengthening during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

(040) Anterolateral Thigh Flap Phalloplasty: Outcomes Following Genital Gender Affirmation Surgery

Abstract Introduction Genital gender affirmation surgery (gGAS) is a key part of the management of patients with gender dysphoria. The anterolateral thigh (ALT) free flap was proposed as an alternative to the more common radial forearm free flap (RFFP) phalloplasty due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap offers greater security of vascular supply for suitable patients, and if suitable and desired the flap can be formed with an integrated urethra, facilitating voiding while standing. Objective The aim of the study is to report the contemporary surgical and functional outcomes of ALT phalloplasty. Methods All individuals undergoing ALT flap phalloplasty for genital gender affirmation surgery (GAS) between 2009 and 2023 nationwide were included. Individuals were managed in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care version 7. Data were extracted from a prospectively collected single surgeon database and medical records. Functional outcomes were assessed by non-validated questionnaire. Statistical analysis included Mann-Whitney, chi-squared, Fisher’s exact and unpaired T tests. Results Surgical outcomes: A total of 87 patients were included in the study. More than half (45, 51.7%) had an integrated urethra. The median length of stay following surgery was six days (IQR 6-7). Eleven patients (12.6%) had a 30-day Clavien-Dindo 3b complication or greater. Three patients (3.4%) experienced total flap loss. A further three patients (3.4%) had partial flap loss. Three patients (3.4%) required a salvage phalloplasty later. Thirteen patients (out of 42, 31.0%) without an integrated urethra went onto have a free flap urethroplasty. Functional outcomes: Thirty-nine individuals (44.8%) completed the patient reported outcomes questionnaire. Most patients (77%) were generally satisfied with their phalloplasty. More than half (56%) with an erectile device used their phallus for penetrative intercourse, while one in five reported experiencing orgasm using their phallus alone. Following urethral lengthening, all respondents were able to void standing. There was no significant difference in mean satisfaction scores for those with an integrated urethra compared to those without (4.18/5 vs 3.82/5, p=.45), as well as between those with or without an erectile device, respectively (3.78/5 vs 4.10/5, p=.26). Conclusions This study is one of the largest single centre cohorts of ALT flap phalloplasty reported to date. It further supports the use of the ALT flap as one of the main genital GAS options for transmen. Over half of the patients studied had an integrated urethra, the gold standard for urethral lengthening. Patient reported functional outcomes were promising, with similar scores regardless of urethral lengthening or erectile device insertion. Disclosure No.

(346) Simultaneous Bladder Drainage via Suprapubic and Urethral Catheters: Which Drains More Completely and Why?

Abstract Introduction Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. Objective We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients. Methods Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. UOP from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+). Results The aggregate number of 12-hour shift UOP observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml) (Table 1). Conclusions Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). The difference in urinary drainage is likely explained by the suprapubic catheter tip and drainage inlet residing in a more gravity-dependent location, within the funnel-shaped bladder neck (Figure 1). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter. Disclosure No.

Assessment of neophallus length following metoidioplasty.

An increasing number of gender diverse individuals are presenting for gender affirming care. An option for genital gender affirming surgery (gGAS) in transmasculine individuals is metoidioplasty, creating a small neophallus from enlarged clitoral tissue following prolonged testosterone exposure. The goal of this study is to understand factors which contribute to greater exposed neophallus length following metoidioplasty. We performed a retrospective chart review on patients presenting to a single academic institution who underwent a metoidioplasty. All operations were performed using the Belgrade technique with or without urethral lengthening depending on patient preference. Twenty-seven patients underwent metoidioplasty from 2017-2022. Sixteen had recorded stretched clitoral length (pre-operatively) and exposed neophallus length (post-operatively). The median length of time on testosterone therapy was 4.6 years. The median stretched clitoral length was 5.8 cm, and exposed neophallus length was 6 cm. There was a strong correlation between pre-operative length and post-operative length (ρ=0.9; P<0.0001). There were no correlations between pre-operative length or exposed neophallus length and BMI (ρ=-0.02, P=0.93; ρ=0.05, P=0.83, respectively). Time on testosterone does not correlate with stretched clitoral length nor exposed neophallus length (ρ=-0.28, P=0.15; ρ=-0.35, P=0.18, respectively). Patients considering metoidioplasty often wonder how large their neophallus will be. We found that patients can expect exposed neophallus length to be about 0.6 cm longer than their pre-operative stretched clitoral length. No evidence of association of time on testosterone nor BMI with exposed neophallus length was found. This information is crucial for gender diverse patients to make informed decisions about gGAS.

(277) Proposal for a Clearer Definition and Classification of Urethral Complications Following Transmasculine Gender Affirmation Surgery

Abstract Introduction The use of free flap microsurgical neophallus construction with integrated urethra have improved outcomes for transmasculine gender affirmation surgery (GAS) but there is no accepted gold standard. Many authors have described urethral complications but only in heterogenous and small cohorts. Anatomical nomenclature is also confusing. Objective We aim to describe urethral complications in the largest cohort of patients to date and propose a naming and classification system to improve reporting, research and management of this common problem. Methods All transmasculine individuals undergoing phalloplasty including a free flap urethroplasty, with staged urethral lengthening at our centre over five consecutive years (2014 – 2019) were retrospectively reviewed from a prospective database. Metoidioplasty was excluded. The incidence, timing and management of urethral complications were extracted from a prospective database. Statistical analysis was by Chi-squared test. Results Three hundred and seventeen individuals with median follow-up of 4.3 years (interquartile range 3.6– 5.0 years) were included. Types of phalloplasty include forearm flap, anterolateral thigh flap and abdominal flap with free flap urethroplasty. Almost half (43.5%) developed a urethral complication (fistula, stricture, severe post-micturition dribbling or urethral hair/stone); most commonly fistulae (48.5%) followed by strictures (37.4%). Complications were significantly higher in flaps with integrated urethra compared to staged combination free flap urethroplasty (39% compared to 10%, p&amp;lt;0.0003). Forty-four individuals (12.4%) developed more than one complication (31% of complications). Overall, complications were mostly in the phallus (flap-related) (72.2%) followed by scrotal and perineal urethra. Repairs before and during routine second stage urethral lengthening were for phallus complications comprising fistulas and strictures. Strictures were more common than fistulas in contrast to individuals before urethral lengthening (p&amp;lt;0.001). Staging the urethral lengthening allowed 81.6% of individuals to be asymptomatic while awaiting routine repair. Vaginectomy did not reduce the risk of urethral fistulae. Conclusions The largest series to date suggests that urethral complications continue to be common following phalloplasty and are mostly phallus or flap related. Complications may also be lower if a staged free flap urethroplasty is offered. We show that the nature of urethral complications in phalloplasty change depending on the stage of genital GAS and should be classified based on type, location and timing of occurrence. This classification standardises reporting and will help guide the approach for surgical correction. Complications in the phallus urethra relate to an issue with the free flap and requires a different approach compared to complications following urethral lengthening that are more likely in the scrotal or native urethra. Many complications occur prior to urethral lengthening (81.6%) and can be repaired routinely at that time. Furthermore, we propose that the urethral segments are called the phallus, scrotal and native urethra to allow for clear and concise nomenclature. Disclosure No

(280) Second Stage Surgery After Ring Flap Metoidioplasty: Technique and Outcomes

Abstract Introduction Metoidioplasty is an option for creation of external male-appearing genitalia in transmasculine individuals. Many individuals report good sensory, functional, and aesthetic outcomes following single-stage metoidioplasty with urethral lengthening and scrotoplasty. However, an average of 12% of patients require a second-stage surgery to improve aesthetic appearance, place testicular implants, address complications, and maximally lengthen the neophallus. These procedures are risky to perform at the time of initial metoidioplasty as this may disrupt the vascular supply to the neoscrotum via the anterior branches of the external pudendal artery. We report outcomes of second-stage ring-flap labial metoidioplasty involving monsplasty, upper labia majora dermatolipectomy, and scrotoplasty with testicular implant insertion. Objective Transmasculine individuals who have had metoidioplasty with rotational advancement labia majora flap and (Ghent style) scrotoplasty often desire monsplasty, upper labia majora tissue resection, and testis implant insertion to optimize aesthetics, reduce dysphoria and improve voiding function. We describe our technique and surgical outcomes with dermatolipectomy of the mons pubis (monsplasty) and upper labia majora with simultaneous testis implant insertion. Methods We retrospectively reviewed the outcomes of ring flap metoidioplasty patients who underwent second stage surgery involving monsplasty and upper labia majora dermatolipectomy, and testis implant insertion. Monsplasty is performed by excising excess skin and adipose tissue to better expose the penis and lift the genitals. Upper labia majora tissue is subsequently resected, followed by development of pockets into each hemiscrotum inferiorly. Silicone carving implants are then individually sized and inserted to serve as testicular prostheses. Results From November 2017 to January 2022, 13 patients underwent second stage metoidioplasty and scrotoplasty with testis implant insertion. Mean follow-up was 22 months. Monsplasty was not desired/necessary in two (15%) patients. Implant malposition occurred in one (7.7%) patient, and one (7.7%) patient was unhappy with the overall aesthetics prompting him to seek a second opinion. To date, no surgical revision was desired nor performed. There were no wound or implant infections, and no scrotal necrosis. Conclusions Monsplasty and upper labia majora dermatolipectomy with simultaneous testis implant insertion is a safe and reliable combination of surgeries after metoidioplasty with Ghent style scrotoplasty. Disclosure No

102. Post-void Urethral Residual Volume and Lower Urinary Tract Symptoms Improve up to One Year Post-phalloplasty: A Prospective Cohort Study

PURPOSE: Gender-affirming surgeries have been increasing considerably over the past decade, yet few studies report the functional outcomes after these surgeries. There were virtually no specific validated tools that assess the urinary outcomes following phalloplasty and flap-based neo-urethra reconstruction in transgender male patients. Patient outcome questionnaires adopted in cis-male urology have limitations in patients with flap-based neo-urethras. We therefore initially developed a Post-Phalloplasty Urinary Function Test (PP UFT) to better assess the lower urinary tract symptoms (LUTS) in this patient population following urethral lengthening surgery and found that many patients do suffer from LUTS. Post-void dribbling due to post-void urethral volume (PVUR) was responsible for most of the patient dissatisfaction and poor quality of life. In this study, we prospectively investigated the time course of urinary dysfunction using PP UFT and PVUR measurements in transmen during the first 12 months following urethral lengthening. METHODS: A pilot study of 15 adult trans-men who had undergone phalloplasty with urethral lengthening surgery was done to validate the PP UFT scale. We then conducted a prospective cohort study of nine transmen who underwent phalloplasty with urethral lengthening surgery between 2019 and 2021 at a single institution. Patients were followed at 2, 4, 6, and 12-month intervals after their stage-two phalloplasty procedure. To assess lower urinary tract symptoms, patients were asked to complete the PP UFT, and PVUR was recorded at each visit by measuring residual urine after voiding via “milking technique”. Significance was assessed using Wilcoxon Signed-Rank tests with a cutoff set at 0.05. RESULTS: Nine patients were included in the study. Average PP UFT score improved from 7.9 out of 40 points at two months (IQR 6,8) to 4.6 points by six months (p<0.05; IQR 2,6) with a net improvement of 4 points by 12 months. Average PVUR improved from 7.6 mL at two months (IQR 4.5-12.5) to 4.4mL at six months (p<0.05; IQR 3.3-4.5), with a net improvement of 4.5mL by 12 months. Two of eight patients who reported incontinence at two months after surgery claimed to no longer suffer from incontinence at six months. CONCLUSION: Combination of PP UFT and PVUR measurements up to one-year following second- stage phalloplasty offer promise for quantifying urinary function and quality of life, although larger studies are needed to validate these instruments. Future directions include multi-institutional prospective studies with greater than one-year follow-up and the addition of PVUR and PPUFT questionnaires with cross-comparison to CT imaging protocols.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy.

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes

1) To describe the authors' technique of ALT phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. Following IRB approval, retrospective chart review identified all patients undergoing primary three stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least one urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). ALT phalloplasty with split thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender affirming phalloplasty.

3D CT Urethrography With Cinematic Rendering (3DUG): A New Modality for Evaluation of Complex Urethral Anatomy and Assessment of the Postoperative Phalloplasty Urethra

To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging. Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening. Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging. We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients.

Simultaneous Bladder Drainage via Suprapubic and Urethral Catheters: Which Drains More Completely and Why?

Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients. Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. Urine output from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+). The aggregate number of 12-hour shift urine output observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, Suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml). Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter.

Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review.

There is currently a paucity of data on urethral-related outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) with urethral lengthening (UL)and vaginectomy. A systematic review was performed utilizing MEDLINE, Web of Science, Cochrane Library, Europe PMC, OSF Preprints, and EMBASE. Methodologic quality was scored using Methodological Index for Non-Randomized Studies (MINORS) criteria. Four independent reviewers performed the article evaluation, data extraction, and methodologic quality assessment. Primary outcomes included standing to urinate/pee (STP), penile length, glanular meatus, urethral stricture, fistula, and flap necrosis. Results were summarized qualitatively with descriptive statistics. A total of 2,881 articles of which 11 retrospective reviews of 13 cohorts met criteria; 4.3/16 average (avg) MINORS score. Six metoidioplasty cohorts had an average penile length of 6 cm, 74% reported successful STP, and a quarter developed stricture or fistula. Phalloplasty cohorts included radial forearm flap (RF) and Anterolateral Thigh flap (ALT). Of the 4 RF studies nearly a third developed a stricture or fistula and only one study reported 99% STP with a glanular meatus. Three ALT studies reported no length but had 80-90% STP with a glanular meatus and a quarter with stricture or fistula. Urethral complications in MaPGAS-UL in a cohort with prior vaginectomy are common and variably reported. Patient centered outcome measures as well as clearly defined outcome metrics created in partnership with community members are needed.

Updates on metoidioplasty.

Metoidioplasty presents a variant of phalloplasty in transmen who require simple and safe genital gender affirmation surgery (GAS). The aim is to evaluate updates on the technique, as well as personal experience. The surgical steps of metoidioplasty are removal of the vagina, clitoral straightening and lengthening, urethral lengthening using available flaps and grafts, and creation of the scrotum with testicular prostheses implantation. The surgical goal is to achieve appearance of male genitalia, voiding in standing position, and full erogenous sensitivity. Modifications of the technique have developed due to recent advances in anatomy and new requests from transmen. Besides full metoidioplasty, other variants include metoidioplasty before, after or simultaneously with total phalloplasty. Each variant has its' own advantages, which must be discussed with the candidate preoperatively. A total of 938 transmen with the mean age of 29 years underwent one-stage metoidioplasty between January 2004 and January 2022. In majority of cases (65%) metoidioplasty was performed as a final option, and the length of the neophallus ranged between 4and 10 cm. Urethral complications occurred in 143 cases, dislocation and rejection of testicular implant in 55 and vaginal remnant in 92 cases. Voiding in standing position was reported in almost all cases (99%), and 12.5% of transmen requested phalloplasty after metoidioplasty. Metoidioplasty is a safe, one-stage procedure with good esthetic and functional outcomes. It includes a wide spectrum of variants that can be offered to transmen as a part of genital reconstruction, with goal of achieving patients' satisfaction.

Microsurgical Gender Affirmation Surgery.

Phalloplasty in the female to male transgender patient is a complex operation aimed at creating a functional and aesthetic phallus, external genitalia, and perineum. Functional goals include standing micturition and sexual function with erogenous and tactile sensation as well as the ability to participate in penetrative intercourse. Functional genital reconstruction relies on creating of a fully lengthened urethra from local tissues as well as the provision for additional length via tissue transplantation. This manuscript will review techniques for the creation of perineal urethral segment as well as primary flaps available for the creation of neophallus. Particular emphasis is given to our preferred method of reconstruction: single-stage urethral lengthening with radial forearm flap phalloplasty including a review of surgical techniques and complications.

The effect of colpectomy on lower urinary tract function in transgender men

Background: In transgender men, effects of colpectomy on voiding function are unknown, except for the incidence rates of urinary tract infections and urinary retention. Aims: To provide insight into the effect of colpectomy on Lower Urinary Tract Function (LUTF) in transgender men. Methods: A retrospective chart review was conducted among transgender men who underwent colpectomy between January 2018 and October 2020. Primary outcomes were objective and subjective changes in voiding. Secondary outcomes were transurethral catheterization length and the need for clean intermittent self-catheterization (CISC). Results: Of 132 men, 89 (67%) underwent Robot-assisted Laparoscopic Colpectomy (RaLC) and 43 (33%) Vaginal Colpectomy (VC). Maximum flow rate on uroflowmetry decreased following RaLC (mean of 29.1 vs. 38.3 mL/s, p = 0.002) and VC (mean of 29.2 vs. 40.3 mL/s, p < 0.001) after a median of four months postoperatively. An increase in total International Prostate Symptom Score was seen more frequently following VC compared to RaLC. Subjective changes were indicated by 39%, more often by men who underwent VC, of which the majority improved during the first months postoperatively. Trial without catheter (TWOC) on the first postoperative day was more successful after RaLC (79/89, 89%) than VC (24/43, 56%). Secondary TWOC was successful in 22/132 (17%) patients after a median of eight days postoperatively. In 5/132 (4%) men (three VC and two RaLC), temporary CISC was necessary for a period ranging from 5 to 21 days. The last 2/132 (2%) men after RaLC were still performing CISC at end of follow-up. Eventually, 5% (two VC and four RaLC) had to refrain from genital gender-affirming surgery with urethral lengthening due to voiding dysfunction. Discussion: After colpectomy, most objective and subjective worsening in LUTF is of a temporary nature, however, 5% had to refrain from genital gender-affirming surgery with urethral lengthening due to persistent voiding dysfunction, despite the desire to void while standing.

A Novel Technique of Urethroplasty Could Reduce Urethra-Related Complications in Phalloplasty With Urethral Lengthening.

Urethral lengthening in phalloplasty could bring many postoperative complications, such as urethra fistula and stricture, which greatly affects the patient's mental health and quality of life. To describe a novel technique of vaginal mucosal graft for prelamination urethra (VMGPU) combined with modified urethral anastomosis (MUA) for the reconstruction of a neourethra. A retrospective study of transgender men between January 2006 and March 2021 was conducted. Patients were divided into three groups according to the surgical methods : traditional group（TG，VMGPU group（VG） and VMGPU+MUA group (VMG). The main outcomes measures were demographics, surgical characteristics, complications, International Prostate Symptom Score（IPSS，Quality of Life（QOL） score，and voiding frequency conditions. Of 80 eligible transgender men（TG:n = 39，VG:n = 31, VMG:n = 10), the urethral fistula developed in 19/39 (49%) patients in TG, 8/31 (26%) in VG, and 1/10 (10%) in VMG (P = 0.034). The urethral stricture formed in 15/39 (38%) patients in TG, 4/31 (13%) in VG, and 1/10 (10%) in VMG (P = 0.028). Compared with TG, the VG got more favorable IPSS. The QOL scores showed that patients in VG or VMG were more satisfied with their postoperative status. VMGPU combined with MUA may help reduce urethral complications for transgender men who wish to undergo phalloplasty with urethral lengthening. VMGPU combined with MUA focuses on reducing the urethra-related complications in the anastomotic stoma between the fixed and the penile urethra, which has not been noticed in the past. The limitations of this study are that the retrospective study design is prone to bias; the study using VMGPU+MUA technique is only in the preliminary stage, and more cases are needed to prove its effectiveness; the median follow-up in VMG was only 2 years, and longer-term follow-up results are inconclusive; the IPSS, QOL, and the voiding frequency chart were not validated in transgender men. Our pilot study suggests that VMGPU combined with MUA may reduce the urethra-related complications, especially the urethral fistula in the anastomosis stoma between the fixed and the penile urethra. Gao H, Wu D, Kong X, et al. A Novel Technique of Urethroplasty Could Reduce Urethra-Related Complications in Phalloplasty With Urethral Lengthening. Sex Med 2022;10:100571.

Modification of the single‐tube radial forearm phalloplasty technique to allow for urinary meatal reconstruction: A report of two cases

The free radial forearm flap is the gold standard technique for transgender phalloplasty due to superior complication rates compared to other methods. However, reconstruction of the urinary tract, including urethral lengthening and creation of a pars pendula urethra within the flap, carries a high rate of complications. The risk of complications and a lack of desire for standing urination are reasons patients elect for single-tube phalloplasty. However, to date, single-tube phalloplasties lack creation of a urinary meatus, which affects the aesthetics of the reconstruction. The purpose of this report is to describe a technique for creating an aesthetic urinary meatus in single-tube phalloplasty. We herein describe the technique in the use of two healthy transgender males (ages 31 and 39). Both patients did not desire micturition through the neophallus, but still desired the appearance of a meatus at the tip of the neophallus. Single-tube radial forearm phalloplasty was performed for both patients. The radial forearm flaps for each patient were 14 × 15 cm. Meatoplasty was performed at the time of flap elevation utilizing an intact 1 × 4cm intact strip of ulnar sided skin during flap tubularization. This strip of skin was then invaginated to create a neomeatal pouch. The postoperative course was uncomplicated for both patients following at 5-day hospital stay for flap monitoring. Follow up time was 7 and 8 months. The neomeatal pouch persisted in both patients and the patients were satisfied with the appearance of the tips of the neophalluses.

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men

Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0–6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.

The Montréal Classification of urethral lengthening for phalloplasty in transmasculine patients—surgical techniques and urethral complications

Introduction Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes. Materials and methods All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student’s T-test, Chi-squared test, Fisher’s exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction. Results Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively. Conclusions We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results.