[The radial forearm phalloplasty with prelaminated urethra: a report of our learning curve during the last 6 years]

Surgical techniques of phalloplasty in transgender patients: a systematic review

Gender confirmation surgery has a crucial role among transgender individuals. Phalloplasty is a procedure that uses flaps for phallic shaft creation. Flaps can be classified in free flaps or pedicle flaps and can be obtained from different donor sites such as forearm, thigh, abdomen, groin, and leg, and upper back. We conducted a systematic review about surgical flaps for phallic shaft creation in transgender patients. A systematic review was conducted on PubMed/MEDLINE, Cochrane Clinical Answers, and Cochrane Central Register of Controlled Trials databases without timeframe limitations. Exclusion criteria included articles that reported phalloplasty on patients other than transgender, as well as other surgical techniques such as urethroplasty, vaginectomy, hysterectomy and studies focused on psychosocial outcomes. Two hundred twenty-eight potential articles were identified in the initial search. Forty-one studies fulfilled the inclusion and exclusion criteria. Surgical flaps for phallic shaft creation in transgender patients were reported on 1,391 cases. Microsurgical flaps were the most common (24 of 33). The flap technique most frequently described was radial forearm flap (15 of 33) followed by Anterolateral thigh flap (7 of 33), Latissimus dorsi flap (5 of 33), abdominal flap (4 of 33), fibular flap (3 of 33), and groin flaps (3 of 33). The literature on surgical flaps for phallic shaft creation in transgender patients reflected how challenging the reconstruction of the phallus is. In summary, there is no universal choice of flap that could be applied to every patient. Therefore, the surgical approach must be chosen considering surgeon experience, physical examination, and patient desire. We hope this review supports future studies on surgical flaps for phallic shaft creation in transgender patients.

[Gender reassignment from female to male : Phalloplasty]

BACKGROUND

The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals.

OBJECTIVE

The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty.

MATERIAL AND METHODS

Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years.

RESULTS

Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%.

CONCLUSION

Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

Excision and Primary Anastomosis for Isolated, Short, Anastomotic Strictures in Transmen

Background:

Since the recommendation to perform excision and primary anastomosis (EPA) for isolated, short, anastomotic strictures in transmen, there have been no further reports about its results. This study aims to provide an updated and extended report about the results of EPA for the aforementioned indication.

Methods:

Since 2002, data of all transmen in whom an EPA urethroplasty has been performed at Ghent University Hospital were collected in a database. Exclusion criteria for this analysis were age <18 years old, nonanastomotic strictures, and stricture length >3.0 cm. Postoperative complications were analyzed with descriptive statistics. Failure-free survival (FFS) was analyzed with Kaplan–Meier statistics. Need for further urethral manipulation was used as definition for failure. Potential predictors for failure were entered in a univariate Cox regression analysis.

Results:

In total, 44 patients were included with a median (interquartile range) follow-up of 40 months (7–125 months). Complications after EPA urethroplasty were present in 12 (27%) of the patients and mainly involved low-grade complications (11/44, 25%). After 1, 2, and 5 years, the estimated FFS rate (SD) was 61% (7.8), 61% (7.8), and 47% (9.1). Stricture length (hazard ratio [HR], 2.11; P = 0.03), prior urethroplasty (HR, 3.53; P = 0.008), and extravasation at first voiding cystourethrography (HR, 3.00; P = 0.047) were identified as predictors for failure.

Conclusions:

EPA for an isolated, short, anastomotic stricture in transmen is associated with low complication rates, but high failure rates. After 5 years, the estimated FFS rate is 47%. Stricture length, prior urethroplasty, and extravasation at first voiding cystourethrography are predictors for failure.

Das Radialispenoid mit präformierter Harnröhre – Eine Analyse der Komplikationen anhand der Clavien-Dindo Klassifikation

Das Radialispenoid hat sich im Rahmen der geschlechtsangleichenden Operationen (gaOP) Frau zu Mann (FzM) etabliert. Neben den Verfahren nach Chang und Gottlieb gibt es jedoch für die Variante mit präformierter Harnröhre ein Erfahrungsdefizit. Diese Arbeit soll die Komplikationen der verschiedenen Operationsteilschritte aufführen und anhand der Clavien-Dindo Klassifikation einteilen.

Patienten und Methoden Eingeschlossen wurden alle Patienten, die vom 01.01.2011 bis 30.06.2017 eine Radialislappenplastik mit präformierter Harnröhre im Rahmen der gaOP in unserer Klinik erhalten haben. Es konnten 39 Patienten in diese retrospektive Studie eingeschlossen werden. Erfasst wurden die Komplikationen der Kolpektomie, der Harnröhrenpräformierung, der Penoidkonstruktion, der Hodenprothesenimplantation und der Glansplastik. Der Nachbeobachtungszeitraum vom Datum des Penoidaufbaus betrug zwischen 6 und 80 Monaten, im Durchschnitt 32 Monate. Die Komplikationen wurden nach Clavien Dindo eingeteilt.

Ergebnisse Die Penoidkonstruktion verlief bei 5 von 39 Patienten (12,8 %) ohne Komplikation. Bei 22 Patienten (56,4 %) kam es zu einer Grad I Komplikation. Bei vier Patienten (10,3 %) kam es zu einer Grad II Komplikation. Bei 16 Patienten (41,0 %) trat eine Komplikation Grad IIIb auf. Ein Patient erlitt eine Grad IV Komplikation (2,6 %).

28 der 39 Patienten (71,8 %) hatten postoperativ eine Fistel. Jedoch mussten diese Fisteln nur bei acht der 28 Patienten chirurgisch verschlossen werden (20,5 % des Gesamtkollektivs). Bei 5 Patienten kam es zu einer Stenose (12,8 %), bei zwei Patienten mehrfach (insgesamt 8 Stenosen). Unter den 16 Patienten mit einer drittgradigen Komplikation kam es bei zwei Patienten (5,1 %) zu einem Lappenverlust.

Schlussfolgerung Das Radialispenoid mit präformierter Harnröhre stellt mittlerweile ein etabliertes Verfahren zur Penoidkonstruktion bei FzM-Transidenten Patienten dar. Im Rahmen unserer Lernkurve und aufgrund einer technischen Modifikation mit einer Visierlappenplastik i. B. der Harnröhrenanastomose konnte die Quote der urologischen Komplikationen im Hinblick auf die Fisteln deutlich gesenkt werden. Die vorliegende große Serie liefert eine Datenbasis an klassifizierten Komplikationen nach Clavien-Dindo für zukünftige Vergleiche zu neuen Techniken oder Innovationen bekannter Verfahren.

Use of a fibrovascular tube in creation of neo-urethra during penile reconstruction

INTRODUCTION

There are several techniques employed in the surgical treatment of total or partial penile reconstruction, hypospadias surgery, and urethral stricture. Urethral reconstruction is performed in different ways applying these techniques.

OBJECTIVE

We evaluated use of a fibrovascular sheath to create a neo-urethra formed around a silicon tube.

MATERIAL AND METHODS

We used nine male New Zealand rabbits for this study. In the first step, we placed a silicone tube under the skin in the lower abdomen of the rabbits and waited for the formation of a fibrovascular sheath to totally surround the tube. In the second step, the silicone tube was removed and the formed fibrovascular sheath was anastomosed with penile urethra over a silicone 8F Foley catheter. Ten days after the second step, the silicone Foley catheter was removed. Twenty days after the second step, we evaluated the newly created neo-urethra with a retrograde urethrogram. Thirty days after the second step, the rabbits were sacrificed and the bladder, urethra, and neo-urethra were removed for histopathological examination.

RESULTS

Six of the rabbits completed the study. After the first operation, in the third month, formation of the fibrovascular sheath was observed around the silicon tube. After anastomosis and removal of the silicon Foley catheter, urine was seen to pass through the neo-urethral meatus. Urethrocystography showed that the neo-urethra and penile urethra were aligned and urine flow was regular. Histopathological evaluation showed that the structural integrity of the newly formed urethra was comparable with the structure of the regular urethra (Table) and the calibration did not change over time, although the newly formed urethra was not covered with uroepithelium.

CONCLUSIONS

In this study, we achieved promising results with use of a newly formed fibrovascular sheath as a neo-urethra.

[Phalloplasty: Microsurgical options and management algorithm]

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube-in-tube phalloplasty with radial forearm flap: a report of two cases

We present a salvage procedure to reconstruct the neo-urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube-in-tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo-urethra and a strip of the outer lining of the neo-phallus. Neo-urethra-reconstruction was performed with a second RFF from the contralateral side providing well-vascularized tissue. No flap-related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo-phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo-urethra and reconstructed the outer lining of the neo-phallus