Introduction: High rates of urological complications are seen after phalloplasty with Urethral Lengthening (UL). To provide a treatment alternative with a reduced risk of complications, phalloplasty without UL has been offered in our institution since 2009. To create clear expectations for physicians and transmen in the choice for or against UL, an overview and comparison of clinical outcomes is useful. Therefore, the aim of this study was to compare the surgical outcomes and urinary functioning after phalloplasty with versus without UL.
Methods: A single center, retrospective chart review was conducted among transmen who underwent phalloplasty with or without UL between 01-2013 and 01-2021. Since 01-2013, standardized voiding assessments (e.g. International Prostate Symptom Score, frequency volume chart, and uroflowmetry with post-void residual volume) have been performed pre and post phalloplasty. Primary outcomes were comparison of complications and reoperations. Secondary outcomes were the end-stages of voiding at follow-up and the comparison of voiding analyses.
Results: Of 136 included transmen, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Mean operation time (381 vs. 272 minutes) and median length of hospital stay (7 vs. 5 days) were significantly longer in the group with UL (both p<0.001). Of the surgical complications, partial necrosis (40% vs. 16%, p=0.005) and genital wound infection (35% vs. 18%, p=0.05) were seen more frequent after UL. In the group with UL, 43% urethral fistulas and 60% urethra strictures were observed, relative to only one patient without UL who had a urethral fistula (both p<0.001). Meatal stenosis was seen in 29% with versus 11% without UL (p=0.02). A reoperation for a surgical or urological complication was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 75% of the patients with UL who reached end-stage of voiding were able to void while standing, with on postoperative uroflowmetry a significant decrease in maximum flow rate (27 vs. 19 mL/s, p=0.001). After phalloplasty without UL, all patients had a definitive perineostomy and no differences were seen in the voiding analyses pre- and postoperatively.
Conclusions: The choice for or against UL has become more relevant over the years, with currently one third of transmen opting for phalloplasty without UL in our center. This comparison of clinical outcomes after phalloplasty with versus without UL can be of added value in the shared decision making process for transmen, to come to the most suitable choice of gGAS for each individual.