Treatment of Urethral Strictures in Transmasculine Patients

Abstract

Background. Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods. We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results. Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions. Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.

Determining the outcomes of urethral construction in phalloplasty

“…[9] in their major case series on urethroplasty for stenosis after phalloplasty. Despite the poor quality of the phalloplasty urethra, the success rate after secondary urethroplasty (excision and primary anastomosis or augmented graft urethroplasty) was satisfactory and consistent with the other case series [24].…”

“…Almost all strictures required surgical revision, which was generally performed in two stages as recommended by Lumen et al [9] in their major case series on urethroplasty for stenosis after phalloplasty. Despite the poor quality of the phalloplasty urethra, the success rate after secondary urethroplasty (excision and primary anastomosis or augmented graft urethroplasty) was satisfactory and consistent with the other case series [24]. Some studies have suggested that prelaminated skin graft for urethral reconstruction was much more associated with complications compared to free flap urethra [5,25], although one of these studies included very few cases of skin graft urethra [5].…”

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

“…Urethral strictures are among the major complications associated with both metoidioplasty and phalloplasty. Urethral strictures typically present later in the postoperative course, which range between 6 and 36 months [33], and may occur concomitantly with urethral fistula. In metoidioplasty, the strictures are typically found at the anastomotic site in the proximal pars fixa whereas in phalloplasty, it is the site between the pars fixa and pars pendulans.…”

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

“…We recommend that Dr D remain grounded in what is known rather than addressing the unknowns inherent in the initial request: the patient's anatomy differs from the majority of urethroplasty patients from our own practice and in the literature, as UAP relies on collateral blood supply rather than a robust vascular pedicle. 10,11,12 Although the exact outcome of such a surgery is debatable, what Dr D knows is that UAP is not as safe and reliable as urethral lengthening after other types of phalloplasty.…”