Introduction: The most common strictures after gender-affirming phalloplasty are the anastomotic strictures. Stricture treatment after phalloplasty have a high recurrence rate due to the poor vascularization of the neo-urethra. Despite, different techniques of stricture treatment described in the literature, there is no medical evidence to prefer one technique over the other. Methods: We analyzed retrospectively 80 transmasculine patients diagnosed with an anastomotic stricture post phalloplasty between 2002 and 2022. Comparison of surgical outcome between excision and primary anastomosis (EPA) (n=53) and staged urethroplasty (n=16) was analyzed. Differences in stricture length were measured for both groups. The primary outcome was recurrence rate between both groups. Secondary outcomes were previous interventions , complications and type of phallus. Results: The median follow-up after stricture treatment was respectively 24 and 10 months for EPA and staged urethroplasty. There were no significant differences for age, type of phallus and smoking habits. After EPA, recurrence rate was seen in 51% of patients (27/53) in comparison with 38% of patients after staged urethroplasty (6/16). The median stricture length was twice as long for staged urethroplasty, respectively 2 cm and 1 cm was measured in patients for staged urethroplasty end EPA. This difference was significant (p <0,001). Half of the patients who underwent EPA have had no previous interventions in the past (29/53) in comparison with 6 out of 16 patients for staged urethroplasty. Previous surgery was divided into endoscopic treatment, urethroplasty and perineostomy. For EPA, respectively 9 (17%) , 9 (17%) and 6 (11%) patients underwent endoscopic treatment, urethroplasty or perineostomy whereas this was respectively the case in 1 (6%), 9 (56%) and no patients (0%) for staged urethroplasty (p= 0,012). No postoperative complications were seen in 41 patients (77%) and 6 patients (38%) after respectively, EPA and staged urethroplasty. Most of the complications were low grade. Only 1 patient had a grade 3 complication, this was seen after staged urethroplasty (p =0,003). Conclusions: EPA is an optional treatment for short anastomotic strictures after phalloplasty. These patients had less previous stricture surgeries in comparison with patients for staged urethroplasty. Staged urethroplasty is a preferable treatment for strictures > 1cm and in patients after multiple attends of other stricture therapies but more complications must be taken into account. SOURCE OF Funding: No funding.
