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Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113 Page 7 of 10

Figure 4. Two-stage repair of Metoidioplasty urethral stricture. (A) BMG 6 months after the first stage urethroplasty. (B) Neo-urethra
tubularized over catheter. (C) Metoidioplasty after repair. BMG: Buccal mucosal grafts.

Figure 5. RUG images of metoidioplasty stricture repair. (A) Neo-urethral stricture. (B) Post urethroplasty image. RUG: Retrograde
urethrogram.

One stage substitution urethroplasty can also be used for transgender men with neo-phallic strictures. One
stage repairs with BMG can be performed in a variety of ways, including using the graft as a dorsal inlay
urethroplasty, ventral onlay urethroplasty or a combined dorsal inlay and ventral onlay graft urethroplasty.

In dorsal inlay urethroplasty using BMG (Asopa technique), a ventral longitudinal midline urethrotomy is
made to expose the stricture and a dorsal urethrotomy and mucosal planes developed. The BMG is quilted
and anastomosed to the dorsal urethral plate in an inlay fashion. In dorsal onlay urethroplasty the urethra is
dissected free from the underlying tissues and a urethrotomy is performed. The BMG is then sutured to the
dorsal urethra with the expectation that the underlying dorsal tissue has a rich enough vascularity to
maintain the graft.

Ventral onlay techniques involve performing a ventral urethrotomy followed by augmentation with BMG
ventrally. In cisgender patients, the ventral component may be supported by adjacent vascularized tissue,
but the use of these techniques is challenging in transgender patients due to poor vascular bed and scar
tissue in the neophallus. Optimal techniques in single-stage urethroplasty after phalloplasty are not well
described but failure rates are high with single-staged techniques with up to 40%-50% with recurrent
stricture. Combination techniques can also be used in a single stage. Beamer et al. has noted improved
[20]
results for a single-staged technique combining dorsal inlay and ventral onlay BMG urethroplasty. With 1-
year follow up, they reported an 80% success rate for transgender patients treated with phalloplasty
strictures.