Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men

Rooij, Freek P. W. de; Peters, Femke R. M.; Ronkes, Brechje; Sluis, Wouter B. van der; Al-Tamimi, Muhammed; Moorselaar, R. Jeroen A. van; Bouman, Mark‐Bram; Pigot, Garry L.S.

doi:10.1111/bju.15500

Cited by 9 publications

(5 citation statements)

References 22 publications

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“…It seems that the urethral part mainly involved in complications is the skin (pars pendula), regardless of its type (free flap skin or skin graft). Based on these findings, we believe that the outcomes of urethral lengthening of metoidioplasty and phalloplasty should not be reported together, as has been done in some series [10,26,27].…”

Section: Discussionmentioning

confidence: 97%

Determining the outcomes of urethral construction in phalloplasty

et al. 2022

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To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history. Materials and MethodsWe conducted a single-centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans-male patients undergoing gender-affirming surgery and cis-male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision-anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri-and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires. ResultsThe mean (AESD) follow-up duration was 5.5 (AE3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis-male vs 71.8% for transmale patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public. ConclusionsUrethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results.

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Section: Discussionmentioning

confidence: 97%

Determining the outcomes of urethral construction in phalloplasty

et al. 2022

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“…The European Urological Association has written guidelines on treating urethral strictures in transgender men [48]. Other treatment algorithms have used stricture length to determine repair technique [47,49]. Surgeon preference and experience should also be considered when deciding on the treatment.…”

Section: Managementmentioning

confidence: 99%

Gender‐affirming care in urology: emergency care of the gender‐affirming surgical patient—what the primary urologist needs to know

Krakowsky,

Shah,

Nguyen

et al. 2023

BJU International

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ObjectiveTo present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender‐affirming surgery (GAS).MethodsA narrative review was performed using the following keywords: ‘gender‐affirming surgery’, ‘complications’, ‘emergency’, ‘postoperative’. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis.ResultsThe most common feminising genital GAS performed is a vaginoplasty. The main post‐surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure.ConclusionGenital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow‐up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender‐inclusive environment for all patients.

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“…Heineke-Mikulicz urethroplasty has been successful for short strictures, 2,10 involving a longitudinal urethrotomy and a horizontal closure. 10 Small fistulas are similarly treated by primarily excising the fistula tract, closing the urethral defect, and buttressing the repair with local adipofascial flaps followed by skin closure (commonly with local flaps [eg, rhomboid]).…”

Section: Potential Problems and Solutionsmentioning

confidence: 99%

“…Previous studies have extended known principles to develop algorithms for handling common complications, such Volume 154, Number 2 • Revision Phalloplasty 363e as urethral fistulas and strictures. 2 However, there is a paucity of literature on the evaluation and management of this growing population seeking correction of multiple problems after phalloplasty (ie, salvage of the troubled phalloplasty).…”

mentioning

confidence: 99%

“Revision Phalloplasty: Evaluation, Algorithms and Techniques for Salvage After Major Complications”

Keller

Chen²,

Ovadia

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Background: Phalloplasty is among the most complex and technically demanding reconstructive surgeries. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There is little published on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap. Methods: A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of two high-volume phalloplasty teams (Johns Hopkins/Brigham & Women’s Hospital and GU Recon/Buncke Clinic) in treating patients with severe post-surgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision. Results: Common complications of phalloplasty include urethral strictures and fistulae, diverticula, excess bulk, phalloplasty malposition, hypertrophic/keloidal scarring, and partial/total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus. Conclusions: Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications following phalloplasty.

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Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men

Cited by 9 publications

References 22 publications

Determining the outcomes of urethral construction in phalloplasty

Determining the outcomes of urethral construction in phalloplasty

Gender‐affirming care in urology: emergency care of the gender‐affirming surgical patient—what the primary urologist needs to know

“Revision Phalloplasty: Evaluation, Algorithms and Techniques for Salvage After Major Complications”

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