Overview of Surgical Techniques in Gender-Affirming Genital Surgery

Mang L. Chen; Polina Reyblat; Melissa M. Poh; Amanda C. Chi


Transl Androl Urol. 2019;8(3):191-208. 

In This Article

Urethral Reconstruction After Phalloplasty and Metoidioplasty

Urethral strictures and fistulas are relatively common, averaging around 50% in phalloplasty patients and 25% in metoidioplasty patients.[20,23–27,55–57,59,62–64] In metoidioplasty patients, most fistulas are ventral to the shaft of the phallus and are seen more frequently in patients without abundant labia minora tissue. The second most common location is behind the scrotum at the perineum-scrotum junction. Strictures in metoidioplasty patients are less common, and when present, are usually of the proximal portion of the labia minora urethroplasty—just distal to the native urethral meatus. In phalloplasty patients, the areas at highest risk for urethral fistula or stricture formation are at the PF-PP urethral anastomosis and the neophallus urethral meatus. These are the vascular watershed areas. For patients with prolonged neophallus swelling, fistulas can occur along the ventrum of the shaft several months after phalloplasty. They have a natural history of opening and closing; if they don't close by around 4 months, repair is required.

Fistulas that are small (5 mm or less) and persist beyond 4 months postoperatively can be repaired primarily. Patients who are at risk of fistula formation often have minimal labia minora tissue, which then leads to minimal sub-epithelial flap availability for urethral suture line closure during the initial metoidioplasty. Therefore, the primary strategy for fistula repair is separation of the urethral epithelium from the phallus epithelium, with interposition of additional tissue. The urethral epithelium can be closed with inverting sutures followed by coverage with a dermal interposition graft, which can be harvested from the groin. The phallus skin is then closed over the graft. Proximal fistulas with often have dartos equivalent tissue for closure and don't require an interposition graft. Larger fistulas (>5 mm) may require an epidermal autograft from the groin or mouth depending on the fistula location to cover the defect. Urethras made from labia minora have mucosal like epithelium and may respond better to oral grafts; skin urethras from a neophallus respond about equally well to skin or oral grafts. Exceptionally large defects, or defects without sufficient neighboring vascularized tissue, may require a staged approach: the first stage is creation of a vascularized sufficiently wide urethral plate followed 6 months later by urethral tubularization.

Some patients desire urethral lengthening without vaginectomy. This is not a commonly desired surgery, but it frequently leads to urethrovaginal fistulas.[62] Patients are counseled appropriately prior to undergoing this procedure and understand the expected need for fistula repair postoperatively. Treatment for this is similar to fistula repair at other urethral locations. The main difference is that definitive treatment may require vaginectomy, as this allows the development of local flaps to cover the urethrovaginal fistula repair site.

Strictures of the proximal labia minora urethra in metoidioplasty patients are frequently short and can be treated with anastomotic or Heineke-Mikulicz type repairs. Strictures associated with phalloplasty are commonly seen at the PF-PP anastomosis or distal urethra. Strategies for treatment are similar to strategies utilized for cis-men urethroplasties: it depends on length and location of the strictures.[65] Distal strictures with minimal scar tissue can be treated with staged Johanson urethroplasty or Asopa type urethroplasty.[56,66,67] Short PF-PP urethral strictures are amenable to anastomotic or Heineke-Mikulicz urethroplasties;[65] longer strictures require substitution urethroplasty with oral or skin grafts; long and obliterative strictures benefit from staged urethroplasties, and on rare occasion, a free flap urethroplasty.[68–70] The appropriate timing of repair is usually about 3–4 months from initial metoidioplasty or phalloplasty to allow tissue maturation and vascularization. For stricture recurrences after urethroplasty, 3–4 months is suggested prior to repeat urethroplasty. When patients have recurrences before the 3–4 month period, SP tube urinary diversion is recommended until the appropriate time.