‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes

Shannon M. Smith, MD, MPH; Nance Yuan, MD; Grace Lee, PA-C; Jenna Stelmar, BS; Edward Ray, MD; Maurice M. Garcia, MD, MAS

Sexual Medicine (Apr 2022)

‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes

Shannon M. Smith, MD, MPH,
Nance Yuan, MD,
Grace Lee, PA-C,
Jenna Stelmar, BS,
Edward Ray, MD,
Maurice M. Garcia, MD, MAS

Affiliations

Shannon M. Smith, MD, MPH: Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
Nance Yuan, MD: Huntington Plastic Surgery Institute, Pasadena, CA, USA
Grace Lee, PA-C: Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
Jenna Stelmar, BS: Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA
Edward Ray, MD: Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; Cedars-Sinai Medical Center, Los Angeles, Division of Plastic Surgery, Los Angeles, CA, USA
Maurice M. Garcia, MD, MAS: Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; University of California San Francisco, Department of Urology and Department of Anatomy, San Francisco, CA, USA; Corresponding Author: Maurice M. Garcia, MD, MAS, Cedars-Sinai Medical Center, Los Angeles, Division of Urology, 8635 W. Third Street, Suite 1070W, Los Angeles, CA 90048, USA. Tel: 310-423-4700

Journal volume & issue: Vol. 10, no. 2
p. 100495

Abstract

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Background: Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL). Aim: To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL. Methods: We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date. Outcomes: Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries. Results: All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57). Clinical Implications: The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system. Strengths and Limitations: Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time. Conclusion: It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs.Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.

Published in Sexual Medicine

ISSN: 2050-1161 (Online)
Publisher: Oxford University Press
Country of publisher: United Kingdom
LCC subjects: Medicine
Website: https://academic.oup.com/smoa

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