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Page 2 of 10 Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113

neophallus with metoidioplasty and phalloplasty, however, is a complex procedure prone to urinary
complications, including urethral stricture.

In the general population, the rate of urethral stricture disease can reach 0.6% and is more prevalent in
[1]
patients older than 55 years old . Both metoidioplasty and phalloplasty patients face a much higher risk of
post-operative urethral stricture, ranging from 18%-58% . After surgical treatment, they also have a higher
[2-7]
rate for stricture recurrence than in cis-gender urethroplasty and may require multiple additional
procedures.

The reasons for the high rate of stricture disease after metoidioplasty and phalloplasty are numerous and
involve the complex anatomy of the neo-urethra. Current techniques of metoidioplasty with urethral
lengthening carry a lower risk of strictures than phalloplasty . Variations in phalloplasty type and surgical
[5]
technique have also been shown to affect complication rates.

In this review, we will address the magnitude, etiology, treatment options and outcomes for urethral
stricture disease after metoidioplasty and for phalloplasty in patients undergoing gender affirmation surgery
and describe our experience with managing these complex patients.

Differences in the urethral anatomy between cisgender and transgender men
The anatomy of the neourethra includes the native urethra, the fixed part (pars fixa), anastomotic part,
phallic part (pendulous urethra) and the meatus [Figure 1]. The most common sites for stricture are the
anastomosis followed by the phallic urethra . In contrast to cis-males, there are no corpora providing a rich
[8]
vascularized bed for the neourethra or for any repair of the urethra. The healthy cis-gender urethral
vascularity has significant redundancy and a rich network feeding the urethra from distal branches
emanating from both the internal and the external iliac artery. In contrast, depending on the type of
phalloplasty, the blood supply for the neourethra typically relies on a single vascular source or survival from
the vascularity from adjacent tissue. Another consideration is that many patients desire a longer phallus
which may result in longer segments of neo-urethra with a potentially increased risk of stricture disease.

Another factor absent in cis-gender men that can affect the neo-urethral flow dynamics is the presence of a
vaginal remnant. This vagina-like tissue can remain or regrow after gender-affirming surgery in transmen
who have had their vagina surgically removed and have had either inadequate resection of the vaginal tissue
or stricture that increases pressure on the proximal urethra and causes one to enlarge. This remnant can be
a source of infection, residual urine causing post-void dribbling and fistula.

Metoidioplasty
Metoidioplasty is one of the primary surgical options for creating a neophallus in male transgender patients.
A hypertrophied clitoris after systemic testosterone therapy is utilized for the creation of the neophallus,
and the urethra is tubularized, typically using local flaps alone or augmenting them with free grafts.
Metoidioplasty permits urination while standing but does not allow for penetration during intercourse in
[9]
most patients. Hage and van Turnhout presented in 2006 the first long-term outcome for a series of 70
patients undergoing metoidioplasty. Complication rates were high, including 35% urethral stricture rate and
[5]
37% fistula rates . Djordjevic et al. reported their outcome of a single-stage metoidioplasty with urethral
[9]
lengthening with combined buccal mucosa graft and local genital skin flaps. They reported only 2 cases
(2.4%) of urethral strictures and 7 cases (8.5%) of urethral fistulas that required surgery .
[5]