Urethral stricture after phalloplasty

Abstract

Phalloplasty is a critical step for many transgender men who seek relief from gender dysphoria; however, phalloplasty is a difficult and complex surgery with many potential complications. The most common complications are urinary, mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures. Improvements in surgical technique have driven down complication rates over the past few decades. Despite these innovations, complication rates remain high, and transgender surgeons must be well versed in their diagnosis and treatment. Over the same time period, gender affirming surgery has seen unprecedented growth in the United States. Transgender surgeons are few, and their patients often travel great distances for their index surgery. As such, locally available reconstructive urologists will be called upon to treat these complications with greater frequency and must be proficient in diagnosis and treatment to help these patients achieve a good outcome.

Keywords: Gender confirming surgery; gender dysphoria; phalloplasty; transgender; urethral stricture; urinary fistula.

Figure 1

Neourethra anatomy. (A) Schematic of neourethra anatomy shows the native urethra, fixed urethra, and pendulous urethra; (B) retrograde urethrogram of a healthy urethra after phalloplasty shows native urethra (green), pars fixa (orange) and pars pendulous (blue).

Figure 2

Anastomotic urethra anatomy. (A) The pars fixa is created from paravaginal mucosal flaps that are mobilized to midline and tubularized to create a long urethral tube. The tissue quality of these flaps is variable and dependent on patient anatomy instead of surgeon technique. (B) The pars fixa is covered with a robust second layer of bulbospongiosus muscle which is freed up laterally and closed across the midline.

Figure 3

Urethrocutaneous fistula repair. (A) Mature urethral fistula at the base of a phalloplasty. Usually these are caused by relative necrosis of the fat over the urethra combined with fusing/healing of the urethral suture line to the phallus skin ventral suture line. A “T” shaped incision includes the fistula, the penile shaft suture line and the penile base suture line where it is sewn to the upper scrotum. (B) Successful primary closure of the fistula (not seen) followed by coverage with a local random tissue flap. (C) Final closure of skin over fistula repair with efforts to offset the skin suture lines with the previous fistula location/suture lines.

Figure 4

The edges of the flap that are used to create the phallus necessarily has the least robust blood supply as it is logically the furthest from the main vessel trunk on which the phalloplasty is based. Distal urethral necrosis or dehiscence of the meatus (connection of the urethra to the skin edges), once healed, can cause meatal stenosis.

Figure 5

Distal urethral stricture after phalloplasty treated with a dorsal split thickness skin graft and single-stage urethroplasty.

Figure 6

Second stage Johanson urethroplasty for long penile urethral stricture in an early technique “nonmicrovascular” phalloplasty. Two previously placed buccal grafts in the center have almost completely contracted. Because of this poor take of buccal grafts, we have abandoned their use in phalloplasty strictures.

Figure 7

First stage Johanson urethroplasty of a long penile stricture with split thickness skin grafts.

Figure 8

Second stage Johanson urethroplasty of a long penile stricture. The future urethra is marked (A) and incised (B). The inner later is tubularized (C), and the outer layer is closed (D).