‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes

Abstract

Background Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL). Aim To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL. Methods We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date. Outcomes Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries. Results All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57). Clinical Implications The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system. Strengths and Limitations Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time. Conclusion It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs.

How Should Surgeons Approach Gender-Affirming Surgery Revisions When Patients Were Not, Perhaps, Well Informed in Prior Counseling?

“…Considering the less robust blood supply after local tissue transfer and decreased pliability of the abdominal tissue, Dr D suggests that an additional donor site, such as the forearm, is needed and believes that urethral lengthening on the abdominal phalloplasty would result in an unacceptably high rate of stricture and fistula above the already high rate expected in standard procedures such as RFFP. 1 First, Dr D should clarify the goals of surgical treatment with T. Potential goals that can be addressed without urethroplasty to the tip of the phallus should be elucidated, such as creating the appearance of a urethral meatus 2,3 or closure of the vaginal canal. 4 If T desires these non-urologic changes in addition to standing micturition, treatments to meet these goals should also be discussed.…”