Introduction: An ideal solution for phalloplasty in transgender men still does not exist, and urethroplasty results in high rate of complications. We have evaluated outcomes of staged urethral reconstruction in musculocutaneous latissimus dorsi (MLD) free flap phalloplasty.
Methods: Between January 2007 and January 2020, 147 transgender men, aged 18 – 53 years (mean 27 years) underwent total MLD phalloplasty. In 111 patients phalloplasty was performed as a primary procedure, while in 36 patients it was done after previously performed metoidioplasty. Urethral reconstruction was performed as a staged procedure. In the first stage, simultaneously with total phalloplasty, urethra was lengthened to the maximum extent using all available vascularized hairless tissue (vaginal flap, labia minora flaps and clitoral skin flap) and incorporated into the neophallus. Additional urethral lengthening was achieved in the following stages using buccal mucosa grafts.
Results: Follow-up period in our series ranged from 18 to 175 months (mean 96 months). Total length of the neourethra reconstructed during the first stage was measured during the surgery, and ranged from 11.1 to 20.7 cm (mean 14.8 cm). Neophallic urethral lengthening by either one or two-stage buccal mucosa graft tubularization was performed in 92 patients (62.6%). Satisfactory voiding in standing position was achieved in totally 95 patients (64.6%). Urethral fistula occurred in 28 patients (19%) and healed spontaneously in 8 patients, while the remaining patients required revision surgery. Urethral stricture developed in 33 patients (22.4%), and there were 13 strictures in the neophallic segment and 20 cases of bulbar strictures. All strictures required surgical repair, in 22 patients urethroplasty with buccal mucosa graft was performed. Fistula between remnant vaginal cavity and neourethral lumen was noted in 21 patients (14.3%). Vaginal remnant was excised through perineal approach and urethral opening was closed and covered with local vascularized tissue to prevent fistula formation.
Conclusions: The musculocutaneous latissimus dorsi (MLD) phalloplasty combined with urethral lengthening can provide satisfactory esthetic and functional outcomes. Although urethral complication rate is still high, use of vascularized flaps for neourethra has satisfactory outcomes.
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