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Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience

D’Arpa, Salvatore M.D., Ph.D.; Claes, Karel M.D.; Lumen, Nicholas M.D., Ph.D.; Oieni, Sebastiano M.D., Ph.D.; Hoebeke, Piet M.D., Ph.D.; Monstrey, Stan M.D., Ph.D.

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 382e-392e
doi: 10.1097/PRS.0000000000005278
Reconstructive: Trunk: Original Articles
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Background: Urethral reconstruction in anterolateral thigh flap phalloplasty cannot always be accomplished with one flap, and the ideal technique has not been established yet. In this article, the authors’ experience with urethral reconstruction in 93 anterolateral thigh flap phalloplasties is reported.

Methods: Ninety-three anterolateral thigh phalloplasties performed over 13 years at a single center were retrospectively reviewed to evaluate outcomes of the different urethral reconstruction techniques used: anterolateral thigh alone without urethral reconstruction (n = 7), tube-in-tube anterolateral thigh flap (n = 5), prelaminated anterolateral thigh flap with a skin graft (n = 8), anterolateral thigh flap combined with a free radial forearm flap (n = 29), anterolateral thigh flap combined with a pedicled superficial circumflex iliac artery perforator flap (n = 38), and anterolateral thigh flap combined with a skin flap from a previous phalloplasty (n = 6). Seventy-nine phalloplasties were performed for female-to-male sex reassignment surgery. The others were performed in male patients with severe penile insufficiency.

Results: Urethral complication rates (fistulas and strictures) were as follows: tube-in-tube anterolateral thigh flap, 20 percent; prelaminated anterolateral thigh flap, 87.5 percent; free radial forearm flap urethra, 37.9 percent; superficial circumflex iliac artery perforator urethral reconstruction, 26.3 percent; and skin flap from previous phalloplasty, 16.7 percent.

Conclusions: When tube-in-tube urethra reconstruction is not possible (94.2 percent of cases), a skin flap such as the superficial circumflex iliac artery perforator flap or the radial forearm flap is used for urethral reconstruction in anterolateral thigh phalloplasties. Flap prelamination is a second choice that gives high stricture rates. If a penis is present, its skin should be used for urethral reconstruction and covered with an anterolateral thigh flap. With these techniques, 91.86 percent of patients are eventually able to void while standing.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ghent, Belgium; and Palermo, Italy

From the Departments of Plastic and Reconstructive Surgery and Urology, Ghent University Hospital; and the Department of Surgical, Oncological and Oral Sciences, Plastic and Reconstructive Surgery Section, University of Palermo.

Received for publication August 22, 2017; accepted July 23, 2018.

Disclosure:The authors have no financial interests to disclose in relation to the content of this article.

Salvatore D’Arpa, M.D., Ph.D., Department of Plastic and Reconstructive Surgery, Ghent University Hospital, De Pintelaan, 185, B9000 Ghent, Belgium, salvatore.darpa@uzgent.be

Copyright © 2019 by the American Society of Plastic Surgeons