Page 48 - Read Online

Page 8 of 10 Zisman et al. Plast Aesthet Res 2022;9:15 https://dx.doi.org/10.20517/2347-9264.2021.113

Staged repairs
Staged urethral repairs in cis-male patients are needed in case of complex cases such as long strictures, prior
failed attempts, lichen sclerosis or failed hypospadias surgery. It is based on Bracka’s technique for two-stage
[16]
hypospadias surgery . In the first stage, following ventral urethrotomy, the strictured segment of the
urethra is incised or excised and a neo-urethral plate is constructed using a graft - typically a BMG. The
patient will void through a proximal urethrostomy for about six months until the second stage. This period
of time will give the neo-urethra and graft time to develop neo-vascularity. In the second stage, the neo-
[8]
urethral plate graft edges will be tabularized [Figure 6]. Lumen et al. described that staged repair
urethroplasty is superior to non-staged repair urethroplasty for stricture disease after phalloplasty.

Perineal urethrostomy
The creation of a perineal urethrostomy may be an option for patients who have failed multiple attempts at
stricture repair and/or who want the procedure with the highest chance for success. In addition, the perineal
urethrostomy may be a temporary or permanent option for transgender men in whom standing to void is
not bothersome, men with significant co-morbidities or those with co-existing conditions such as infections
that preclude complex reconstruction. We perform a modification of the Blandy inverted U-shape flap with
a midline anterior extension. If a vaginal remnant is present, it can be removed concurrently. We have
found that patients who undergo a perineal urethrostomy have significantly improved quality of life after
surgery.

OUR EXPERIENCE
We retrospectively evaluated our experience with urethral reconstructive surgery performed for stricture
disease in transgender men after phalloplasty. Treatment outcome was evaluated on follow-up using
cystoscopy or retrograde urethrogram. Treatment failure was defined by the recurrence of stricture or
fistula requiring additional reconstructive surgery. We performed 18 reconstructive surgeries for 14
transgender men after phalloplasty from March 2018 to February 2021 at our institution. Median patient
age was 42 years (26-64 years). Surgeries included one-stage or staged urethroplasty (n = 11), perineal
urethrostomy as temporary or definitive treatment (n = 5) and DVIU in 2 patients [Table 2]. Of those
undergoing urethroplasty, 3 patients underwent staged urethroplasty using BMG and 8 underwent non-
staged ventral onlay urethroplasty (6 with local vaginal flap and 2 using BMG). The median time to
reconstructive procedure from initial phalloplasty was 15.7 months. At a median follow up of 8 months, 5
urethroplasty procedures had failed (45%). The median time from treatment to failure was 6.3 months.
Because this is a relatively small cohort of patients, it was difficult to assess for statistical significance. Future
research with larger sample size is needed.

Lessons learned given our experience:

1. Repair of transgender patients’ strictures has a higher recurrence rate than that of cisgenders’ strictures.

2. A perineal urethrostomy may be an option for patients with recurrent strictures.

3. Staged repairs may be considered for more complex strictures.

CONCLUSION
There is significant risk for urethral stricture and fistula after metoidioplasty and phalloplasty. There is an
absence of long-term quality data on optimal techniques to manage this. Urethral dilation and internal
urethrotomy are prone to failure. Urethroplasty after phalloplasty or metoidioplasty is a challenging