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Page 6 of 10 Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113

Urethral dilation, CIC or internal urethrotomy may be considered as an option for patients who do not
want or are not candidates for more definitive treatment with the understanding that there may be a higher
failure rate than reconstructive options. However, complex false passages and long-term worsening of their
strictures after repeated dilations may occur. For this reason, we rarely perform repeat dilations,
urethrotomy or recommend CIC without first offering urethroplasty as a more definitive option.

Urethral reconstruction for metoidioplasty strictures
Repair of metoidioplasty strictures has not been well described in the literature. Depending on the location
and the length of the stricture, we prefer to repair them in either one stage or two stages using buccal
mucosal grafts [Figures 4 and 5]. Local skin flaps may also be an option, but the vascularity of the skin flap
can be unpredictable. Similar to cisgender patients’ urethroplasty, for short strictures (< 2 cm), we prefer to
repair in one stage using a buccal mucosal graft or a Heineke-Mikulicz nontransecting urethroplasty. For
longer strictures (> 2 cm), we repair them in two stages in a Bracka style repair with the first stage involving
placement of buccal mucosal grafts. We wait until the graft and adjoining tissue is soft and supple, which
[16]
typically takes six months and then tubularize the urethral plate in the second stage . At this time adjacent
vascularized tissue can be used to provide tissue coverage to minimize the risk of fistula. Occasionally,
residual vaginal remnant may be present, and this can provide additional flap tissue for a urethroplasty.

Urethral reconstruction for strictures after phalloplasty
Open surgical treatment options for neo-phallic strictures can be divided into single-stage vs. staged repairs.

Single-stage repairs
Nontransecting urethroplasty, based on the Heineke-Mikulicz surgical principle for stricturoplasty, can be
used for short (< 1 cm) strictures in cis-male patients. With this technique, a longitudinal incision is made
through the ventral aspect of the stricture and then closed with interrupted sutures horizontally. This
[8]
technique is typically used for short, non-dense strictures and confers the benefit of preserving any
residual vascularity.

Excision and primary anastomotic (EPA) urethroplasty involves excision of the fibrotic stricture and
anastomosing the better vascularized proximal and distal segments of the urethra. EPA can have a high
success rate in cis-gender patients, but there is little data on its use in the transgender population .
[17]
[18]
Verla et al. had 43% failure rate in a series of 44 patients. We reserve this option for patients with short
and dense strictures . These patients should have a segment of the urethra that can be mobilized proximal
[8]
and distal to the stricture without compromising the appearing of the phallus. The SPY Portable Handheld
Imager (SPY-PHI) is a handheld instrument that uses fluorescence Imaging technology in combination with
indocyanine green to check for adequate tissue vascularity in reconstructive surgery. The use of the SPY
imaging system can augment intra-operative visualization of the viability of the transected urethral ends.

Another option is the use of local skin flaps for reconstruction of the urethra. Because of the
unpredictability of the vascular supply of the local skin, we do not routinely use this option for patients.

Among cis-male patients, complex urethral reconstruction is mostly performed with oral buccal mucosal
grafts (BMG). The reason for the wide acceptance of BMG as graft tissue to fix urethral stricture disease is
due to its inherent properties which include: readily availability, a concealed donor site, a non-keratinized
elastic epithelium with rich pan-laminar vascular plexus, which normally resides in moist surroundings and
is resistant to skin infections .
[19]