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Page 4 of 10 Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113

Table 1. Phalloplasty types and reported rates of urethral stricture
Flap type Technique Vascular blood supply Reported rate of urethral stricture
RFFF [2,6,7] Tube within tube Radial artery 18%-58%
[3]
ALT Tube within tube Branch of lateral femoral 21%
circumflex artery
[4]
Abdominal phalloplasty One or two stage Superficial Epigastric artery 44%-94%
[13]
MLD Two stage thoracodorsal vascular bundle 25%
RFFF: Radial forearm free flap phalloplasty; ALT: anterior lateral thigh flap; MLD: musculocutaneous latissimus dorsi flap.

stricture among 64 patients who underwent a single-stage ALT. Total urethral complications, including
meatal stenosis and fistulas were 32.8%.

Phalloplasty without concomitant urethral construction
Abdominal phalloplasty typically uses a tubularized segment of subcutaneous tissue from the anterior
abdominal wall to construct the neo-phallus. Bettocchi et al. published their experience with 80 patients
[4]
undergoing phalloplasty using a flap of anterior abdominal wall skin, while constructing the neourethra
with skin from the clitoris and labia majora. Out of which, 32 patients underwent a 1-stage procedure, and
48 had a 2-stage procedure. In the 2-stage technique, neourethra was fashioned after the neophallus had
been given time to heal. The total urethral stricture rate was very high, but even significantly higher in the 1-
stage than the 2-stage technique (94% vs. 44%). The authors reported transitioning from 1-stage to 2-stage
[4]
technique due to the high rate of complications in the 1-stage procedure .
MLD phalloplasty relies on a flap whose blood supply originates from the thoracodorsal vascular bundle.
[13]
Djordjevic et al. reported the largest experience in a series of 129 patients. In the first stage of urethral
reconstruction after the MLD, local flaps including from the labia or from tissue available from a
metoidioplasty were used to lengthen the urethra to reach the middle of the neophallus, and in the second
stage, buccal mucosa was used to lengthen the urethra distally. Thirty-three patients (25%) developed
urethral stricture that required dilation or surgical revision.

EVALUATION OF NEO-PHALLIC STRICTURES
Symptoms
Patients with neo-phallic strictures typically present with worsened storage symptoms, including urinary
urgency and frequency as well as increasing voiding symptoms such as slowed urinary stream, which can be
assessed by uroflow and post-void dribbling. In addition, patients may report recurrent urinary infections,
retain urine, have a urethrocutaneous fistula from increased proximal pressure on the urethra [Figure 2],
and/or a sizable vaginal remnant. In terms of patient reported outcomes, there is a lack of data and great
variability between patients in terms of symptoms and needs for additional intervention.

Cystoscopy can help diagnose the stricture, but utility may be limited by the inability of the cystoscope to
pass through the distal-most extent of the stricture. Because of this, to evaluate the urethra proximal to the
stricture or the presence of complicating factors such as a fistula or vaginal remnant, we have found a
retrograde urethrogram (RUG) and/or voiding cystourethrogram to be critical prior to corrective surgery.
The length, location, density of the stricture as well as the presence of complicating factors such as vaginal
remnant can usually be determined from the RUG. Ideally, this should be done by the surgeon who is most
aware of the important pre-operative questions that need to be answered [Figure 3].