Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications

Background: Phalloplasty with urethral lengthening is the procedure of choice for female-to-male transgender patients who desire an aesthetic phallus and standing micturition, but is associated with complications, including urethral stricture and fistula formation. Horizontal urethra construction can be accomplished with labia minora flaps covered with additional vascularized layers of vestibular tissue when vaginectomy is performed concomitantly with phalloplasty. However, vaginectomy is not a requisite step in Phalloplasty, and some individuals may choose to retain their vagina. In these cases, extra layers of vascularized vestibular tissue are not used for horizontal urethra coverage. This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates.
Methods: A single-center retrospective study of 224 patients who underwent phalloplasty with urethral lengthening was performed. Patients were sorted into vaginectomy and vaginal preservation cohorts and complication rates were assessed.
Results: Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non–urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41).
Conclusion: Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue. (Plast. Reconstr. Surg. 140: 551e, 2017.)
Phalloplasty is one of the primary reconstructive options available to transgender patients seeking female-to-male genderconfirming surgery. Regardless of reconstructive technique, the goals of phalloplasty include creating an aesthetic neophallus with tactile and erogenous sensation, allowing penetrative intercourse, and enabling micturition while standing.1 The latter is often a priority for transgender men,2 which requires phalloplasty to include urethral lengthening from local or distant tissues.3 Phalloplasty has very high satisfaction rates1; however, it can present several well-documented challenges to the reconstructive surgeon.4,5 Specifically, urethral strictures and fistulas occur with complication rates quoted at 30 percent, and as high as over 50 percent.1,4,6,7 Urethral complications are often a result of mechanical stress on From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center; the Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine; and Brownstein and Crane Surgical Services. Received for publication December 29, 2016; accepted April 5, 2017.
 Disclosure: The authors have no financial disclosures to declare and there was no funding obtained for the production of this article