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Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113 Page 3 of 10

Figure 1. Neo-phallus urethra illustrated with native urethra, pars fixa, pars pendulous, and meatus.

Techniques in phalloplasty and urethral construction
The urethra is constructed in different ways with different phalloplasty techniques [Table 1]. One option,
includes construction of the urethra at the time of the phalloplasty typically occurs during the radial
forearm free flap phalloplasty (RFFF) and the anterior lateral thigh flap (ALT) phalloplasty. The second
option for construction of the urethra with the phalloplasty is in a staged fashion which occurs with the
abdominal phalloplasty, the musculocutaneous latissimus dorsi (MLD) phalloplasty and others such as the
Superficial circumflex iliac artery perforator flap. These can impact the type and location of the stricture.

Tube within tube techniques
RFFF is the most commonly utilized surgical technique for phalloplasty . Advantages of the RFFF include
[10]
a thin flap and relatively skinless ulnar surface for construction of the urethra using the tube within a tube
one-stage technique. Nonetheless, the patient is left with a visible scar on his forearm and a scar from the
[2]
skin donor site to cover the forearm scar. Monstrey et al. described a series of 287 patients using a one-
stage RFFF technique for all patients. The overall rate of urethral stricture or fistula requiring urethroplasty
was 18%. The RFFF utilizes the radial artery with its venae comitantes and the cephalic vein for urethral
vascularity. Typically, this anastomosis is formed at the proximal portion of the neo-phallic urethra. One
might expect to find a higher incidence of the strictures in the distal edges of this pedicle.

Though not common, the urethra can be constructed using a radial artery-based forearm free flap
urethroplasty. Garaffa et al. reported their experience for a two-stage procedure where they reconstructed
[11]
a neo-urethra from RFFF, and incorporated it in a previously constructed pedicled pubic phalloplasty. This
technique resulted in 4% stricture rate and 5% fistula rate in 27 patients.

[12]
Salgado et al. reported their outcome on a series of 21 transgender male patients undergoing two-stage
radial forearm phalloplasty, using a flap neourethra prelamination with buccal, vaginal, or uterine mucosa.
The urethral stricture rate was 19%.

ALT (Anterior lateral thigh flap) is another tube-within-a-tube technique commonly used for phalloplasty.
In comparison with the RFFF, the main advantages are a less clearly visible donor site scar and a neophallus
[3]
with a skin color more resembling the groin area. Ascha et al. reported a 21% incidence of urethral