Urologic Complications After Phalloplasty or Metoidioplasty

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Key points

  • Urethral stricture and urethrocutaneous fistulae are common after phalloplasty and metoidioplasty.

  • Strictures commonly occur at anastomotic sites and fistulae commonly occur at suture lines proximal to strictures.

  • Reconstruction should be tailored with respect to the type of complication, patient’s preferences, and available tissue for reconstruction.

Anatomy of metoidioplasty

Transgender male patients are presented with 2 options for genital reconstruction: metoidioplasty or phalloplasty. Metoidioplasty involves extension of the native urethra by tubularization of labial and vaginal flaps to produce a phallus sufficient for urination in standing position. The surgical steps of metoidioplasty are analogous to techniques for repairs of proximal hypospadias repair in pediatric patients.9 Specifically, the vaginal cavity is resected and obliterated, the labia minora is

Anatomy of phalloplasty

Phalloplasty is preferred by patients who want to attain both upright voiding and the ability to perform penetrative intercourse. A more invasive option, phalloplasty usually involves a combination of local and distant tissue flaps. Following phalloplasty, the urethra of the transgender male patient can be divided into separate, interconnected segments.10, 11 Proximally, the native (female) urethra is connected to the fixed urethra (pars fixa), which in turn is connected by a circumferential

Urethrocutaneous Fistula

The most common urologic complication after phalloplasty or metoidioplasty is urethrocutaneous fistula. Several studies reported on outcomes of radial forearm flap phalloplasty with fistulae rates ranging from 22% to 75%.14, 15, 16, 17 Although fistulae can occur anywhere along the neourethra, they generally originate at the suture line of the anastomosis between the pars fixa and pars pendulans, or at the junction between the native urethra and the pars fixa.15, 18 The most common location for

Preoperative planning and preparation

The initial assessment for revision urethroplasty should include an evaluation of medical records, specifically prior operative reports detailing previous surgeries. In planning reoperative surgery, it is important to understand the previous flap choice, how to avoid damaging vascular pedicles, and what tissue remains available for use as grafts or flaps. Placement of a suprapubic catheter is the initial step in treatment of a urinary fistula or a urinary obstruction due to a urethral

Surgical techniques

If a buccal graft is needed, general anesthesia is preferred and the endotracheal tube is positioned to the side opposite the potential graft site. Positioning the patient in lithotomy allows access to the genitalia and the thighs, in case there is needed for skin graft, fasciocutaneous flap, or gracilis flap.

Results

The technique of reconstruction is based on the patient’s anatomy and the condition of the tissues. For example, the retrograde urethrogram in Fig. 1 demonstrates a patient with an anastomotic urethral stricture extending proximally into the fixed urethra and distally into the phallic urethra. A stricture of this length cannot be reconstructed by a Heineke-Mikulicz technique or by EPA. Therefore, substitution with a flap or graft is necessary. In this case, the urethra was opened on the ventral

Problems and complications

There are several challenges to urinary reconstruction in transmen following phalloplasty.11 Preputial and penile skin flaps commonly used in standard penile urethral reconstruction are not available20; there is no native corpus spongiosum to cover the urethral reconstruction; and the neophallus is composed of skin, fat, and fascia, which may not be an ideal recipient bed for a graft.15

Even after successful reconstruction, urinary incontinence is common due to trapping of urine in the fixed and

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    Disclosures: The authors have nothing to disclose.

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