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Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?

Remington, Austin, C., B.A.; Morrison, Shane, D., M.D., M.S.; Massie, Jonathan, P., M.D.; Crowe, Christopher, S., M.D.; Shakir, Afaaf, M.D.; Wilson, Stelios, C., M.D.; Vyas, Krishna, S., M.D., Ph.D., M.H.S.; Lee, Gordon, K., M.D.; Friedrich, Jeffrey, B., M.D.

Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 220e–229e
doi: 10.1097/PRS.0000000000004061
Cosmetic: Original Articles
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Background: Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.

Methods: A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.

Results: A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.

Conclusions: Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

Stanford, Calif.; Seattle, Wash.; New York, N.Y.; and Rochester, Minn.

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Washington School of Medicine; the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, Mayo Clinic.

Received for publication April 24, 2017; accepted August 25, 2017.

The first three authors contributed equally to this work.

Disclosure: The authors have no financial disclosures. There was no funding for the production of this article.

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Jeffrey B. Friedrich, M.D., Division of Plastic Surgery, University of Washington Department of Surgery, 7CT73.1 Harborview Medical Center, 325 9th Avenue, Mailstop 359796, Seattle, Wash. 98104, jfriedri@uw.edu

©2018American Society of Plastic Surgeons