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NEW: Phalloplasty in Transgender Men With and Without Urethral Lengthening
Christopher Salgado, Kerstin Yu, Stefan Kenel-Pierre, Edward Gheiler and Tony Shao. Transgender Health Advances and New Perspectives, edited by Carlos Miguel Rios-González, February 25, 2022.
The decision to undergo urethral lengthening is considered early in this surgical process. However, urethral complications are among the most common problems we see in phalloplasty, and surgical techniques have evolved to decrease these complications. We have developed an advanced two-stage mucosa-only prelaminated neourethra phalloplasty technique to address these issues. We also discuss the perineal urethroplasty in patients opting for no urethral lengthening in phalloplasty.

NEW: Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations [FULL TEXT]
Christopher J Salgado, Kerstin Yu, and Maria J Lalama. J Surg Case Rep. 2021 Dec; 2021(12).
Preservation of the vaginal canal with reproductive organs is uncommon though becoming increasingly discussed in trans men. In cases where the vagina is preserved, the method with least complications is to maintain the native urethral orifice. Urethral lengthening requires modification of the anterior wall of the vagina, which may narrow the vaginal canal and risk urethral sequelae. In cases where the reproductive organs or vaginal canal with the cervix have been preserved, screening for cancer is best followed by both a urologist and gynecologist so that surveillance is adequately maintained by physicians knowledgeable of this particular anatomy.

Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging
Berli JU, Monstrey S, Safa B, Chen M. Plast Reconstr Surg. 2021 May 1;147(5):801e-811e.
Neourethra reconstruction is the most challenging aspect of phalloplasty, with widely varying techniques and staging between providers. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery. [FULL TEXT]
Carter EE, Crane CN, Santucci RA. Plast Aesthet Res 2020;7:33.
In the setting of no established "gold standard", this review seeks to describe the components and staging of phalloplasty, with an emphasis on established and experimental solutions to the most common and vexing problems.

The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series.
Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, van Moorselaar RJA, Mullender MG, Weigert R, Buncamper ME, Özer M, de Haseth KB, Djordjevic ML, Salgado CJ, Belanger M, Suominen S, Kolehmainen M, Santucci RA, Crane CN, Claes KEY, Monstrey S, Bouman MB. J Sex Med. 2019 Nov;16(11):1849-1859.
In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty.

Single-Stage Phalloplasty.
Chen ML, Safa B. Urol Clin North Am. 2019 Nov;46(4):567-580.
Single-stage phalloplasty may be accomplished by having both the microsurgical and the reconstructive urology team operate simultaneously. The single-staged approach is favored in patients whose ultimate goal is to have an aesthetic, sensate, and functional phallus and scrotum.

Staging in Phalloplasty.
Sara Danker, Nick Esmonde, Jens Urs Berli. Urol Clin North Am. 2019 Nov;46(4):581-590.
A phalloplasty may include some or all of the following: penile shaft, glans, shaft urethra, perineal urethra, scrotoplasty, vaginectomy, testicular implants, and erectile devices. The literature does not currently support a gold standard for how best to stage these procedures. This article reviews current techniques for phalloplasty staging and proposes that a staged urethral reconstruction is a reliable technique that allows for potential complications to be managed individually, while minimizing the severity of complications and their impact on the outcome of the final reconstruction.

Phalloplasty: techniques and outcomes. [FULL TEXT]
Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Transl Androl Urol. 2019 Jun;8(3):254-265.
As patient goals vary widely, it is helpful to think about phalloplasty as a modular set of procedures that can be combined, mixed and matched to meet the needs of each individual patient while also taking into account their anatomy. Each module-but particularly the shaft and penile urethra-can be performed using a variety of techniques. To date, there is no consensus among surgeons regarding the optimum staging of phalloplasty. Our primary goal is to outline the most frequently performed and reported options in phallic reconstruction and outline the various considerations that go into choosing a given sequence of procedures for the specific patient. The secondary goal of this article is to describe the complications common to each of those modules and how they interact when combined.

Preexpansion in Phalloplasty Patients: Is It Effective?
Elfering L, van der Sluis WB, Bouman MB, Buncamper ME, van de Grift TC, Lissenberg-Witte BI, Middelkoop E, Mullender MG. Ann Plast Surg. 2019 Jun 19.
Phalloplasty is performed as genital gender-affirming surgery in transmasculine persons. It requires the harvest of sizeable autologous fasciocutaneous flaps, which is associated with donor-site morbidity and extensive scarring. Flap preexpansion has been used to facilitate wound closure and reduce scarring, but the efficacy of flap preexpansion in phalloplasty is unclear. The objective of this study was to assess the safety and effectiveness of preexpansion before phalloplasty. Donor-site expansion before phalloplasty was associated with high rates of expander-related complications and expander failure. Primary closure of the donor site was achieved in less than a third of the cases. Primary closure may potentially lead to smaller scars and greater satisfaction; however, we concluded that the potential advantages of preexpansion do not outweigh the high risk of complications and lack of success.

Transmen's Experienced Sexuality and Genital Gender-Affirming Surgery: Findings From a Clinical Follow-Up Study.
van de Grift TC, Pigot GLS, Kreukels BPC, Bouman MB, Mullender MG. J Sex Marital Ther. 2019 Jan 23:1-5.
A clinical follow-up study was conducted in transmen at least one year after genital GAS in order to evaluate measures of experienced sexuality. The use and enjoyment of both chest and genitals during sexual activity increased after surgery. Other areas of improvement included arousability, sexual interest, and pleasure. In conclusion, genital GAS positively impacts transmen's sexuality, although possible issues with genital sensation or penetration may exist and should be communicated preoperatively.

Introduction to Phalloplasty.
Schechter LS, Safa B. Clin Plast Surg. 2018 Jul;45(3):387-389.
Phalloplasty represents the most complete genitoperineal transformation. Because it requires complex, staged procedures as well as the use of tissue from remote sites, patients must be well informed as to the nature of surgery. Surgical techniques for phalloplasty continue to evolve. Although many surgeons prefer the radial forearm free flap technique, a visible flap donor site makes this procedure less desirable for some patients. Other surgical options are available and include the anterolateral thigh flap, sometimes in conjunction with secondary flaps, and the musculocutaneous latissimus dorsi flap.

Phalloplasty Flap-Related Complication.
Esmonde N, Bluebond-Langner R, Berli JU. Clin Plast Surg. 2018 Jul;45(3):415-424.
This article focuses on flap-related complications after creation of a neophallus for transgender individuals. It outlines the most frequently used flaps for this procedure and how flap-related complications can affect the overall outcome of the phalloplasty. With surgeons staging the procedure in different stages, it is important to understand the different strategies and the implication a flap-related complication can have on the end result and how it may be prevented.

A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen.
van de Grift TC, et. al. J Sex Med. 2017 Dec;14(12):1621-1628.
Genital dissatisfaction is an important reason for transmen to undergo genital gender-confirming surgery (GCS; phalloplasty or metoidioplasty). However, little is known about motives for choosing specific techniques, how transmen benefit postoperatively, and whether psychosexual outcomes improve. This study evaluates the motivations for and psychosexual outcomes after GCS.

Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications.
Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Plast Reconstr Surg. 2017 Oct;140(4):551e-558e.
This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non-urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue.

Mystery and realities of phalloplasty: a systematic review. [FULL TEXT]
Sarikaya S, Ralph DJ. Turk J Urol. 2017 Sep, epub 2017 Aug 3.
This comprehensive review of literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016 includes 191 FTM transgender patients and concluded that phalloplasty is a reliable and useful operation with good functional and aesthetical results.

An overview of female-to-male gender-confirming surgery
Morrison SD, Chen ML, Crane CN. Nat Rev Urol. 2017 May 16.
Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients

Gender Confirmation Surgery: Guiding Principles
Schechter LS, D'Arpa S, Cohen MN, Kocjancic E, Claes KEY, Monstrey S. J Sex Med. 2017 May 03
At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. This article represents the first step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures.

Phalloplasty: Microsurgical options and management algorithm
Boucher F, Brosset S, Mojallal AA, Braye F, Chateau J, Morel Journel N. Ann Chir Plast Esthet. 2017 Apr 26
The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

Free Flap Phalloplasty For Female To Male Gender Dysphoria
Garaffa G, Ralph DJ. J Sex Med. 2016 Dec.

Phalloplasty and Urethral (Re)construction: A Chronological Timeline [FULL TEXT]
Samuel Golpanian, Kenneth A Guler, Ling Tao, Priscila G Sanchez, Klara Sputova and Christopher J Salgado. Anaplastology 5:159. (September 2016)
In this article we present the methods of phalloplasty and urethral (re)construction that have been developed in chronological order, starting from the initial reports in the literature to the most recent and commonly used techniques.

Phalloplasty: A Review of Techniques and Outcomes.
Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Plast Reconstr Surg. 2016 Sep;138(3):594-615.
Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes. Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

Laser hair removal for genital gender affirming surgery. [FULL TEXT]
Zhang WR, Garrett GL, Arron ST, Garcia MM. Translational Andrology and Urology. 2016;5(3):381-387. There is limited data regarding hair removal practices in preparation for genital gender affirmation surgery and notable variation in hair removal techniques. This article presents a literature review, recommendations, and a practical laser hair removal (LHR) approach to hair removal prior to genital gender affirmation surgery.
Also see: Patients' Guide to Pre-Operative Hair Removal for Phalloplasty

Difference In Outcomes After Total Phallic Reconstruction In the Transgender and Non-Transgender Population
Oscar Suarez Fernandez De Lara, Jack M. Zuckerman, Ramon Virasoro, Jeremy Tonkin, Jessica Delong, Kurt A. McCammon. The Journal of Urology , Volume 195 , Issue 4 , e790 (April 2016)
Researchers from Norfolk, Virginia set out to compare total phallic reconstruction outcomes, for both transgender (TG) and non-transgender (NTG) individuals, via data analysis of those who underwent total phallic reconstruction (at their institution) between the years of 1983 to 2015. Based on indication of surgery, 47 percent of the nearly 100 who underwent the procedure were assigned as transgender and 53 percent were assigned as non-transgender. Additionally, most opted for a procedure known as the "forearm free flap;" however, three selected a local pedicled flap.

Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study.
Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. J Sex Med. 2016 Feb 24.
The first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period.

Pre- and Post-operative Care With Associated Intra-operative Techniques for Phalloplasty in Female-to-male Patients
Shane D. Morrison, Marcelina G. Perez, Cayden K. Carter, Curtis N. Crane. Urol Nurs. 2015;35(3):134-138.
The most common techniques for phalloplasty, along with the pre-operative and post-operative care are discussed.

Postoperative Imaging of Phalloplasties and Their Complications
Blaschke E, Bales GT, Thomas S. AJR Am J Roentgenol. 2014 Aug;203(2):323-328.
A review of imaging techniques used in postoperative evaluation of the neophallus and and complications associated with phalloplasty.

Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience
Maurice M. Garcia, Nim A. Christopher, Francesco De Luca, Marco Spilotros, David J. Ralph. Translational Andrology and Urology, Vol 3, No 2 (June 2014), doi: 10.3978/j.issn.2223-4683.2014.04.10.
Assessment of patient satisfaction, regret, pre/post-op sexual function, genital preferences, and genital measurements post-op. Overall, FTM Phalloplasty is associated with exceedingly high overall satisfaction and, in this series, without any overall regret.

Sexual Desire in Trans Persons: Associations with Sex Reassignment Treatment.
Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, Weyers S, Hoebeke P, T'sjoen G. J Sex Med. 2013 Oct 24. doi: 10.1111/jsm.12365.

Phalloplasty: The Dream and the Reality
Mamoon Rashid, Muhammad Sarmad Tamimy. Indian Journal of Plastic Surgery, 46:2, 283-293, Sept 21 2013.
Review of the various methods used for phalloplasty, including common complications and how they can be avoided.

Penile Reconstruction [Full PDF]
Christopher J Salgado, Sarah Eidelson, Rachael Madalon and Zhongyi Sun (Oct 2012) Anaplastology 1:e105.

Quality of Life and Sexual Health after Sex Reassignment Surgery in Transsexual Men [Full Text PDF]
Katrien Wierckx, Eva Van Caenegem, Els Elaut, David Dedecker, Fleur Van de Peer, Kaatje Toye, Steven Weyers MD, Piet Hoebeke MD, Stan Monstrey MD, Griet De Cuypere MD, Guy T'Sjoen MD .The Journal of Sexual Medicine, Volume 8, Issue 12, pages 3379–3388, December 2011

Is It Worth It? What Trans Healthcare Providers Should Know About Phalloplasty [PDF]
Adams, N.; & Grenier, F. (2011, September). Poster session presented at the 2012 Canadian Professional Association for Transgender Health conference, Winnipeg, Manitoba. Retrieved from www.noahjadams.com/downloads.

Sex Reassignment Surgery in the Female-to-Male Transsexual
Stan J. Monstrey, M.D., Ph.D., Peter Ceulemans, M.D., and Piet Hoebeke, M.D., Ph.D. Semin Plast Surg. 2011 August; 25(3): 229–244.

Bioengineered corporal tissue for structural and functional restoration of the penis
Kuo-Liang Chen, Daniel Eberli, James J. Yoo, and Anthony Atala (Proceedings of the National Academy of Sciences, Vol. 106 No. 45, November 9, 2009)

Evaluation of surgical procedures for sex reassignment: a systematic review
P.A. Sutcliffe, S. Dixon, R.L. Akehurst, A. Wilkinson, A. Shippam, S. White, R. Richards, C.M. Caddy (Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 62, Issue 3 , Pages 294-306, March 2009)

Phalloplasty: a valuable treatment for males with penile insufficiency.
Lumen N, Monstrey S, Selvaggi G, Ceulemans P, De Cuypere G, Van Laecke E, Hoebeke P. Urology. 2008 Feb;71(2):272-6.

Gender Identity Disorders: Diagnostic and Surgical Aspects
Michael Sohn, and Hartmut Bosinski, MD (Journal of Sexual Medicine, Volume 4 Issue 5, Aug 2007)

Genital sensitivity after sex reassignment surgery in transsexual patients.
Selvaggi G, Monstrey S, Ceulemans P, T'Sjoen G, De Cuypere G, Hoebeke P. Ann Plast Surg. 2007 Apr;58(4):427-33.
To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential.

Severe Penile Injuries: Etiology, Management and Outcomes
Sava V. Perovic, Urologia Polska (Polish Journal of Urology) 2005/58/3, ISSN 0500-7208.

Gender Reassigment - Dan Greenwald and Wayne Stadelmann (eMedicine Journal, Volume 2 Number 7, July 6, 2001)

Peniplastica Totalis to Reassignment Surgery of the External Genitalia in Female-to-Male Transsexuals.
Hage, J. Joris. 1992. ISBN 9053831150

Radial Forearm Flap Phalloplasty

Immediate Lymphovenous Bypass Treated Donor Site Lymphedema during Phalloplasty for Gender Dysphoria [FULL TEXT]
Walter Lin, Bauback Safa, Mang Chen, Ming-Huei Cheng. Plast Reconstr Surg Glob Open. Sept 17 2021;9(9):e3822.
The extended radial forearm flap phalloplasty remains one of the most commonly performed gender-affirming phalloplasty techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting of preventative or immediate lymphovenous bypass (LVB) with axillary lymph node dissection for the treatment of breast cancer, it is possible that a subset of patients undergoing gender-affirmation surgery would benefit from immediate lymphatic reconstruction at the time of primary phalloplasty. Lymphography showed no dermal backflow at 5 months follow-up; at 13 months, the patient demonstrated no signs or symptoms of lymphedema in the left forearm or hand.

NEW: Two-Stage Prelaminated Mucosal Neourethra Radial Forearm Flap Phalloplasty for Transgender Men [FULL TEXT]
Christopher J. Salgado MD, Ajani Nugent MD, Josef Hadeed MD, Maria Lalama BS, Jorge Rey MD & Carlos Medina MD. Global Journal of Medical Research: I Surgeries and Cardiovascular System, Volume 21, Issue 1, 2021.
A retrospective review of transmen patients from June 2016 to June 2018 was performed on patients undergoing a two- stage mucosa only prelaminated neourethra radial forearm flap phalloplasty. Using a two-stage approach for the construction of the transman phalloplasty, we have been able to show acceptable complication rates while accomplishing the goals in our surgical endeavor.

An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap. [FULL TEXT]
Miller TJ, Safa B, Watt AJ, Chen ML, Lin WC. Clin Case Rep. 2020
Jul 15;8(11):2191-2194.
An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction
Richard A Santucci, Keeley D Newsom, Galen S Wachtman, Curtis N Crane. Plast Reconstr Surg Glob Open, 2021 May 21;9(5):e3595.
Up to 19% of RFF Phalloplasty patients require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFF Phalloplasties was first reported in 1996. AVF can be reliably used for salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss.

The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature
Falcone M, Preto M, Timpano M, Ciclamini D, Crosio A, Giacalone F, Battiston B, Tos P, Gontero P.   Int J Impot Res. 2021 Feb 18.
The aim of this study and literature review is to analyse and focus on the surgical technique and its postoperative vascular complications.  To optimize the surgical outcomes, venous vascular drainage should be recommended.

Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap [FULL TEXT] [PDF POSTER]
Alexandra Kovar, MD, Susie Choi, BS, and Matthew L. Iorio, MD. Plast Reconstr Surg Glob Open. 2019 Sep; 7(9): e2442.
The RFF donor site is large in comparison to other applications of the flap which may increase the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength. This study systematically reviewed the current literature to assess the donor site morbidity associated with RFF Phalloplasty.

Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty.
De Wolf E, Claes K, Sommeling CE, Opsomer D, Cherubino M, Vieni S, Monstrey S, D'Arpa S. J Sex Med. 2019 Jul;16(7):1111-1117. doi: 10.1016/j.jsxm.2019.03.270.
The free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion. The aim of this study is to describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty. A total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups. Arterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan.

Radial Forearm.
Gottlieb LJ. Clin Plast Surg. 2018 Jul;45(3):391-398.
The radial forearm free flap phalloplasty provides a thin, potentially sensate, minimally hair-bearing cutaneous flap. Since its initial description, several modifications of the technique have emerged. The earliest dimensions described needed to be increased because of the increase amount of subcutaneous fat in the Western population. Incorporating a centrally placed neo-urethra with a distal extension that gets folded over to create a semblance of a neoglans eliminates the distal/meatal stenosis. Performing a urethral extension at a preliminary surgery and extending the neourethra proximally has improved the position of the neophallus and minimized proximal urethral strictures and fistulas in transgender men.

The anatomy of forearm free flap phalloplasty for transgender surgery. [FULL TEXT]
Kim S, Dennis M, Holland J, Terrell M, Loukas M, Schober J. Clin Anat. 2018 Mar;31(2):145-151. doi: 10.1002/ca.23014. Epub 2017 Dec 18.
Surgical text descriptions enhanced by new anatomic illustrations. Note: Surgical description is based on a 2011 study about a variation of RFF phalloplasty developed in Singapore that includes prelamination of the urethra, an abdominal graft for the neourethra and a section of radius bone for rigidity.

Aesthetic Refinements after Radial Free Flap Phalloplasty: Optimizing the Donor Site and the Phallus [FULL TEXT]
Mañero, Iván; Labanca, Trinidad; Triviño, José M. Plastic and Reconstructive Surgery, December 2017, Vol 5, Issue 12
8 patients underwent forearm fat grafting with localized laser, and 7 patients micropigmentation of the neophallus after radial flap phalloplasties. All Patient and Observer Scar Assessment Scale parameters showed a statistically significant reduction between preoperative and postoperative values. Male Genital Self-Image Scale survey showed that all patients felt positively about their genitals after micropigmentation. Patients who underwent refinement procedures were highly satisfied with the aesthetic outcome and felt more confident.

Minimising the donor area morbidity of radial forearm phalloplasty using prefabricated thigh flap: A new technique. [FULL TEXT]
Aggarwal A, Singh H, Mahendru S, Brajesh V, Singh S, Ghag N, Khazanchi Rk. Indian J Plast Surg 2017;50:91-5
This new technique of using prefabricated thigh flap has significantly reduced the donor site morbidity both aesthetically and functionally without the use of skin grafting in whole procedure. The use of prefabricated flap has shown good aesthetic result but at the cost of multiple surgeries.

Phalloplasty in Female-to-Male Transsexuals by Gottlieb and Levine's Free Radial Forearm Flap Technique-A Long-Term Single-Center Experience Over More than Two Decades.
Wirthmann AE, et. al. J Reconstr Microsurg. 2017 Nov 15.
From January 1993 until December 2015, 402 phalloplasties were performed in our clinic. Among the 247 free radial forearm flap phalloplasties, 232 free radial forearm flap phalloplasties were performed after Gottlieb and Levine in 229 patients. The rate of total flap failure was 3%; 46% of the patients were heavy smokers. Urinary fistulae and strictures are common. The revision rate for urinary fistulae and/or strictures was 1.3 per patient. The number of postoperative complications, such as bleeding (14.2%), thrombosis of the flap requiring revision (11.2%), or delayed wound healing (16.8%) was considering the high rate of nicotine abuse (45.9%) reasonable. The operative results are satisfactory for both patients and surgeons even in the presence of relevant comorbidities and heavy smoking.

MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery.
Watfa W, di Summa PG, Meuli J, Raffoul W, Bauquis O. J Sex Med. 2017 Aug 23.
This study compares two methods of donor site closure for functional and cosmetic long-term results: full-thickness skin grafting vs split-thickness skin grafting with MatriDerm. Pressure perception values showed better sensory return in the MatriDerm group. Split-thickness skin grafting with MatriDerm achieved superior results in skin sensibility, superficial radial nerve recovery, and cosmetic aspect. Our experience showed that the combination of a split-thickness skin graft with MatriDerm substantially decreases postoperative complications at the donor site defect on the forearm of transgender patients.

fMRI after Phalloplasty with Nerve Anastomosis in a Trans-Man Patient [FULL TEXT]
Doria-Medina R, Carlsson Å, Jönsson EH, et al. Plastic and Reconstructive Surgery Global Open. 2017;5(6):e1353.
This is the first case showing genital cortex representation on fMRI after RFF phalloplasty with nerve anastomosis on a trans-man patient, similar to previous reports on imaging related to genital sensitivity. It contradicts the classic Penfield and Rasmussen homunculus, that is, the activations were bilateral with a left-sided dominance in the lateral parts of the medial postcentral gyrus (overlapping the groin region), and no activations were observed in the mesial parts of the postcentral gyrus.

Minimising the donor area morbidity of radial forearm phalloplasty using prefabricated thigh flap: A new technique [FULL TEXT]
Aggarwal A, Singh H, Mahendru S, et al.  Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India. 2017;50(1):91-95.
This new technique of using prefabricated thigh flap has significantly reduced the donor site morbidity both aesthetically and functionally without the use of skin grafting in whole procedure. The use of prefabricated flap has shown good aesthetic result but at the cost of multiple surgeries.

An Update on the Surgical Treatment for Transgender Patients.
Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. Sex Med Rev. 2016 Sep 10.
A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery. The gold standard for a phalloplasty remains the free radial forearm flap.

Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula.
Salgado CJ, Nugent AG, Moody AM, Chim H, Paz AM, Chen HC. J Plast Reconstr Aesthet Surg. 2016 Jun 2. This paper was in part presented at the American Society of Reconstructive Microsurgery in Scottsdale Arizona on January 18, 2016.
Radial forearm phalloplasty is accompanied by high rates of fistula formation. In our patient series, inclusion of a pedicled myofascial gracilis flap at the time of radial forearm phalloplasty with urethroplasty was associated with an absence of fistula formation. Therefore, we have since made inclusion of this flap a standard practice for all transmales undergoing phalloplasty with urethroplasty.

The Free Microvascular Groin Flap - Optimizing the Donor Site after Free Radial Forearm Flap Phalloplasty - a Comparative Study.
Rieger UM, Majenka P, Wirthmann A, Sohn M, Bozkurt A, Djedovic G. Urology. 2016 Sep;95:192-6. Epub 2016 Apr 22.
To improve the donor-site-morbidity of the radial forearm flap through coverage with a free vascularized groin flap and comparing this flap coverage to the current standard, a full thickness skin graft (FTSG). We suggest that the free microvascular groin flap should be considered for immediate defect closure after phalloplasty with a radial forearm flap due to its beneficial functional and aesthetic results and the low rate of complications.

Long-Term Evaluation of Donor-Site Morbidity after Radial Forearm Flap Phalloplasty for Transsexual Men
Van Caenegem, E., Verhaeghe, E., Taes, Y., Wierckx, K., Toye, K., Goemaere, S., Zmierczak, H.-G., Hoebeke, P., Monstrey, S. and T'Sjoen, G. (2013), Journal of Sexual Medicine, 10: 1644–1651. doi: 10.1111/jsm.12121.

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube-in-tube phalloplasty with radial forearm flap: A report of two cases
Tchang, L. A.H., Largo, R. D., Babst, D., Wettstein, R., Haug, M. D., Kalbermatten, D. F. and Schaefer, D. J. (2013) Microsurgery. doi: 10.1002/micr.22168

The Etiology and Treatment of the Softened Phallus after the Radial Forearm Osteocutaneous Free Flap Phalloplasty. [Full Text PDF]
The use of a rib bone with cartilaginous tip graft could be an option for improvement of the softened phallus. Silicon rod insertion is also worth considering for rigidity of the softened phallus. Decreased rigidity due to soft tissue atrophy could be alleviated with repeated fat injection and artificial dermis grafting.
Kim SK, Kim TH, Yang JI, Kim MH, Kim MS, Lee KC. Arch Plast Surg. 2012 Jul;39(4):390-396.

Radial Forearm Flap Phalloplasty
Monstrey, Stan, Philippe Houtmeyers, Nicolaas Lumen, and Piet Hoebeke. 2012. In Penile Reconstructive Surgery, ed. Miroslav Djordjevic and Richard Santucci, 254–275. Saarbrücken, Germany: Lambert Academic Publishing.

Penile Reconstruction with the Radial Forearm Flap: An Update.
M Doornaert, P Hoebeke, P Ceulemans, G T'sjoen, G Heylens, S Monstrey
Department of Plastic Surgery, Gent University Hospital, Gent, Belgium. (Handchir Mikrochir Plast Chir. 2011 Aug ;43 (4):208-214 21837613)

Phalloplasty in female-to-male transsexuals: experience from 259 cases
Baumeister S, Sohn M, Domke C, Exner K. Handchir Mikrochir Plast Chir. 2011 Aug;43(4):215-21. doi: 10.1055/s-0030-1267965. Epub 2011 Aug 11. [Article in German]
The radial forearm flap can be performed in various designs. If the patient wishes a glans plasty the Gottlieb design is favoured. In obese patients with a short forearm the Chang design is recommended as it provides a sufficient pedicle length for anastomosis without a venous interpositional graft.

Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals.
We have been able to construct a good phallus with radial forearm osteocutaneous free flaps that is aesthetically and functionally acceptable. In addition, complications have been minimal.
Kim SK, Lee KC, Kwon YS, Cha BH. J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):309-17. doi: 10.1016/j.bjps.2007.11.011. Epub 2008 Mar 4.

Total Phallic Construction in Female to Male Transsexuals [FULL TEXT]
Giulio Garaffa, Nim A. Christopher, David J. Ralph (Current Urology, Vol. 3, No. 3, 2009)

Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique? -
Monstrey, Stan; Hoebeke, Piet; Selvaggi, Gennaro; al etc. (Journal of Plastic and Reconstructive Surgery, Volume 124 Issue 2, August 2009)

Use of forearm free-flap phalloplasty in bladder exstrophy adults
Marc-Olivier Timsit, Pierre Mouriquand, Alain Ruffion, Alain Bouillot, Diala Dembelé, Arnaud Mejean, Fanny Lalloue, Albert Leriche and Nicolas Morel-Journel (BJU International, Volume 103 Issue 10, Dec 2008)

Reconstructive Surgery for Severe Penile Inadequacy: Phalloplasty with a Free Radial Forearm Flap or a Pedicled Anterolateral Thigh Flap
N. Lumen, S. Monstrey, P. Ceulemans, E. van Laecke, and P. Hoebeke. Adv Urol. 2008; 2008: 704343.
Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Sensitivity in the RFF was superior compared to the ALTF.

Free Radial Forearm Flap for Phalloplasty [Full Text PDF]
Abdel-Hamid Abdel-Khalek, M.D.; Abdel Mohsen Allam, M.D.; Amged Hendy, M.D. and Helmy Shalaby, M.D. Egypt, J. Plast. Reconstr. Surg., Vol. 32, No. 2, July: 169-173, 2008.

Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism
Albert Leriche, Marc-Olivier Timsit, Nicolas Morel-Journel, André Bouillot, Diala Dembele and Alain Ruffion (BJU International, Volume 101 Issue 10, Jan 2008)

Closure of radial forearm free flap donor site defect with a local meshed full-thickness skin graft: a retrospective study of an original technique.
Karimi A, Mahy P, Reychler H. J Craniomaxillofac Surg. 2007 Dec;35(8):369-73. Epub 2007 Nov 26.

One-Stage Sex Reassignment Surgery from Female to Male
Kruegera M., Yekania S.A.H., Hundta G., Daverio P. International Journal of Transgenderism, Volume 10, Issue 1, 2007.
A detailed description of the one-step sex reassignment surgery performed by Dr. Daverio and Dr. Krueger successfully more than 350 times. The surgery itself consists of several steps: the removal of the mammae, the uterus, the adnexes, the ovaries and the vagina, the prolongation of the urethra, the creation of a sensate neo-phallus containing a neo-urethra from a radial free forearm flap and the transplantation of the same.

Donor-Site Morbidity of the Radial Forearm Free Flap after 125 Phalloplasties in Gender Identity Disorder - [longer article preview]
Selvaggi, G., Monstrey, S., Hoebeke, P. | Plast Reconstr Surg | vol. 118, 1171 - 1177, 2006
This was the largest series to date of donor-site morbidity after harvest of a very large radial forearm free flap with the specific indication of constructing a phallus in the female-to-male transsexual.

Phalloplasty for female transsexuals with sensate free forearm flap
Rong-Hwang Fang, Jin-Teh Lin, Shiuh Ma (Microsurgery, Volume 15 Issue 5, Oct 2005)

Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique
J. Joris Hage, Floris H. De Graaf. Microsurgery, Volume 14 Issue 9, Oct 2005.

A New Surgical Procedure for Phallic Reconstruction: Istanbul Flap
Mutaf, Mehmet. Journal of Plastic and Reconstructive Surgery, Volume 105 Issue 4, April 2000.

Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases
R.H. Fang, Y.S. Kao, S. Ma, J.T. Lin, British Journal of Plastic Surgery, Volume 52, Issue 3, April 1999, Pages 217-222, ISSN 0007-1226.

Closure of radial forearm free flap donor site with local full-thickness skin graft.
van der Lei B, Spronk CA, de Visscher JG. Br J Oral Maxillofac Surg. 1999 Apr;37(2):119-22.

ALT Phalloplasty and Related

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty
Richard A Santucci, Emma R Linder, Galen S Wachtman, Curtis N Crane. Plast Reconstr Surg Glob Open, 2021 Jun 22;9(6):e3654.
Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience.
D'Arpa S, Claes K, Lumen N, Oieni S, Hoebeke P, Monstrey S. Plast Reconstr Surg. 2019 Feb;143(2):382e-392e.
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. 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.

The Pedicled Anterolateral Thigh Phalloplasty.
Xu KY, Watt AJ. Clin Plast Surg. 2018 Jul;45(3):399-406.
The anterolateral thigh (ALT) flap is a viable and reliable option for phalloplasty. The primary advantages of the ALT flap remain an inconspicuous donor site and flexibility in phallus length. The disadvantages of the ALT flap are a higher incidence of both flap and urethral complications compared with a radial forearm phalloplasty. Although the ALT phalloplasty can achieve the primary goals of standing micturition, penetrative intercourse, and an aesthetic phallus, multiple stages and revisions are often necessary. Careful patient selection is paramount in attaining acceptable results with the ALT phalloplasty technique.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males. [FULL TEXT]
Terrell M, Roberts W, Price CW, Slater M, Loukas M, Schober J. Clin Anat. 2018 Mar;31(2):160-168. doi: 10.1002/ca.23017. Epub 2017 Dec 27.
Surgical text descriptions enhanced by new anatomic illustrations.

Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. [FULL TEXT]
van der Sluis WB, et. al. Microsurgery. 2017 Nov;37(8):917-923.
Between January 2008 and December 2015, nineteen transgender men (median age 37, range 21-57) underwent pedicled ALT phalloplasty combined with RFFF urethral reconstruction in one stage. The size of the ALT flaps ranged from 12 × 12 to 15 × 13 cm, the size of the RFFFs from 14 × 3 to 17 × 3 cm. Total RFFF failure occurred in two patients, total ALT flap failure in one patient, and partial necrosis of the ALT flap in one patient. Long-term urinary complications occurred in 10 (53%) patients, of which 9 concerned urethral strictures.

Outcomes of Single-Staged Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender-Confirming Surgery [FULL TEXT]
Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. J Urol. 2017 Jul 29.
This study examines outcomes between transmales who had phalloplasty with vaginectomy and full-length urethroplasty utilizing the anterolateral thigh pedicled flap (pALT) or radial forearm free flap (RFFF). There were 213 patients included: 149 RFFF and 64 pALT phalloplasties. RFFF patients had a significantly higher body mass index (BMI) than pALT patients. The overall urethral complication rate for RFFF phalloplasty was 31.5%; the overall pALT rate was 32.8%. The rate of partial or total neophallus loss was 7.8% for pALT and 3.4% for RFFF. Patients in the pALT cohort experienced significantly greater odds of urethral fistula (OR=2.50, p=0.024), non-urethral complications (OR=2.38, p=0.027), and phallus wound dehiscence (OR=5.03, p=0.026). pALT phalloplasty was associated with overall greater odds of urethral and other complications at six months follow-up.

Pre-Expanded Anterolateral Thigh Perforator Flap for Phalloplasty [View Article Summary]
Salvatore D'Arpa, Britt Colebunders, Filip Stillaert, Stan Monstrey. October 2 2016.
The anterolateral thigh (ALT) perforator flap for phalloplasty is gaining popularity because it avoids the well-known scars of the radial forearm flap. However, scars are not eliminated, just moved to a different location, the thigh, that can for some patients be of great sexual value. Preexpansion of the ALT flap allows primary donor site closure, thus avoiding not only the unsightly appearance of a skin grafted ALT donor site, but also the skin graft donor site scar. Preoperative perforator location by means of computed tomography angiography allows safe expander placement through 2 small remote incisions.

[The pedicled anterolateral thigh flap for penile reconstruction].
Zhe Y, Yangqun L, Yong T, Muxin Z, Wen C, Ning M, Weixin W. Zhonghua Zheng Xing Wai Ke Za Zhi. 2015 Nov;31(6):406-10. [Article in Chinese]
From May 2011 to May 2015, 12 male patients presented with absence of the penis or congenital malformation received phalloplasty with the pedicled ALT flap. An acceptable reconstructed phallus was achieved in 10 patients. These flaps were primarily healed with satisfactory functional and cosmetic results. The reconstructed penis was completely necrosis because of the flap failure in one case. The distal half of the phallus was lost due to infection in one case. Both of them were treated with pedicled ALT flap from the other side. Reliable results were achieved. At a median follow-up of 1.5 year (range 1 to 4 years), 9 patients (90%) were fully satisfied with phallic cosmesis and size, and 4 patients who was married had successful sexual intercourse. 8 patients had normal urinate function. Fistula was developed in 2 patients (20%) which was treated with delayed repair at 6-12 months with local scrotal flaps.

The pedicled ALT flap can be simply used to reconstruct an entire penis as well as a urethra. It has several advantages including a less conspicuous donor site, greater bulk, better color match and no necessary for microsurgery.

Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty: The Mushroom Flap.
Morrison SD, Son J, Song J, Berger A, Kirby J, Ahdoot M, Lee GK. Ann Plast Surg. 2014 May;72 Suppl 1:S22-6.
The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the "mushroom flap"), we feel that we have been able to achieve a more natural-appearing neoglans. (Note: Not FTM-specific.)

Phalloplasty with an Innervated Island Pedicled Anterolateral Thigh Flap in a Female-to-Male Transsexual [Full PDF]
Hasegawa K, Namba Y, Kimata Y. Acta Med Okayama. 2013 Oct;67(5):325-31.
As compared to a forearm flap, use of an innervated island-pedicled flap may have the following advantages in phalloplasty:1) no need for a microsurgical technique; 2) no scars at noticeable sites; 3) small functional loss in the flap donor area; 4) no sacrifice of major blood vessels.

Preoperative planning of a pedicled anterolateral thigh (ALT) flap for penile reconstruction with the multidetector CT scan.
Preoperative evaluation of ALT perforators and the subcutaneous fat tissue layer is feasible with an MDCT scan and provides precise data to make an adequate patient and perforator selection and determine the exact flap size.
Sinove Y, Kyriopoulos E, Ceulemans P, Houtmeyers P, Hoebeke P, Monstrey S. Handchir Mikrochir Plast Chir. 2013 Aug;45(4):217-22. doi: 10.1055/s-0032-1333271. Epub 2013 Mar 6.

A systematic review of anterolateral thigh flap donor site morbidity
The anterolateral thigh (ALT) flap is widely used in reconstruction. Its advantage over other flaps is its purported minimal donor site morbidity. The present systematic review summarizes the types of complications and their incidence with this flap. A secondary objective is to delineate factors that influence these complications and make recommendations to avoid them.
Jessica Collins, Olubimpe Ayeni, and Achilleas Thoma.
Can J Plast Surg. 2012 Spring; 20(1): 17–23.

Phalloplasty with pedicled anterolateral thigh flap ("ALT-Flap")
T. Holzbach, R. E. Giunta, H.-G. Machens, D. Müller. Handchir Mikrochir plast Chir 2011; 43(4): 227-231
DOI: 10.1055/s-0030-1269908.
Phalloplasty by means of a pedicled anterolateral-thigh-flap ("ALT-flap") in a patient who underwent unsuccessful groin-flap-phalloplasty. Innervation was via coaptation to a branch of the pudendal nerve. The operative time was a reasonable 360 min. The benefit of a pedicled transposition vs. a free transplantation becomes obvious. The shortened operating time and the lack of possible complications of microvascular anastomoses bear advantages.

A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled Anterolateral Thigh Flap -
Lee, Gordon K.; Lim, Angeline F.; Bird, Erin (Journal of Plastic and Reconstructive Surgery, Volume 124 Issue 1, July 2009)

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals
Rubino, C.; Figus, A.; Dessy, L.A.; Alei, G.; Mazzocchi, M.; Trignano, E.; Scuderi, N. Journal of Plastic, Reconstructive & Aesthetic Surgery vol. 62 issue 3 March, 2009. p. e45-e49

Reconstructive Surgery for Severe Penile Inadequacy: Phalloplasty with a Free Radial Forearm Flap or a Pedicled Anterolateral Thigh Flap
N. Lumen, S. Monstrey, P. Ceulemans, E. van Laecke, and P. Hoebeke. Adv Urol. 2008; 2008: 704343.
Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Sensitivity in the RFF was superior compared to the ALTF.

Neophalloplasty in Female-to-Male Transsexuals with the Island Tensor Fasciae Latae Flap
Santanelli, Fabio M.D., Ph.D.; Scuderi, Nicolò (Journal of Plastic and Reconstructive Surgery, Volume 105 Issue 6, May 2000)

Abdominal Phalloplasty

The anatomy of abdominal flap phalloplasty for transgender surgery.
Kim, S., Dennis, M., Holland, J., Terrell, M., Loukas, M., & Schober, J. (2017). Clinical Anatomy, 31(2), 181–186.
Surgical text descriptions enhanced by new anatomic illustrations. Note: Surgical description is based on Pryor's Technique.

Surgical Outcomes and Patients' Satisfaction with Suprapubic Phalloplasty
Terrier, J.-É., Courtois, F., Ruffion, A. and Morel-Journel, N. (2014), Journal of Sexual Medicine, 11: 288–298. doi: 10.1111/jsm.12297
The aim of this study was to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty. Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

"Bird-Wing" abdominal phalloplasty: A novel surgical technique for penile reconstruction.
Bajpai M. J Indian Assoc Pediatr Surg 2013;18:49-52

Pedicled pubic phalloplasty in females with gender dysphoria.
Bettocchi C, Ralph DJ, Pryor JP. BJU Int. 2005 Jan;95(1):120-4.
Between 1989 and 2000, 85 female-to-male transsexual patients had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, and which incorporated the neourethra made from a pedicled tube of labial skin.

MLD Phalloplasty and Related

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery.
Djordjevic ML, Bencic M, Kojovic V, Stojanovic B, Bizic M, Kojic S, Krstic Z, Korac G. World J Urol. 2019 Jan 23.
Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively.

Total Phalloplasty With Latissimus Dorsi Musculocutaneous Flap in Female-to-male Transgender Surgery. Jun MS, Pušica S, Kojovic V, Bizic M, Stojanovic B, Krstic Z, Korac G, Djordjevic ML. Urology. 2018 Oct;120:269-270. doi: 10.1016/j.urology.2018.06.032.
Total MLD flap phalloplasty with urethral lengthening is a challenging and complex surgical procedure. This technique presents good variant for female transgenders with acceptable cosmetic outcome and enables good volume of neophallus, sexual arousal, and voiding while standing.

The anatomy of the musculocutaneous latissimus dorsi flap for neophalloplasty. [FULL TEXT]
Dennis M, Granger A, Ortiz A, Terrell M, Loukos M, Schober J. Clin Anat. 2018 Mar;31(2):152-159. doi: 10.1002/ca.23016. Epub 2017 Dec 28.
Surgical text descriptions enhanced by new anatomic illustrations.

Surgical Therapy: Total Phalloplasty Using Latissimus Dorsi Flap
Rados P. Djinovic. Management of Gender Dysphoria pp 271-279. First online January 2, 2015.
Developed in 1996, Musculocutaneous latissimus dorsi flap phalloplasty is a staged procedure with flap transfer in the first stage, urethroplasty in the second, and implantation of penile implants in the third. Implantation of testicular implants and glansplasty are done in the second or third stage. The majority patients get a satisfactory functional and esthetic outcome.

Total Phalloplasty Combined with Metoidioplasty As a One-Stage Procedure in Female[-to-Male] Transsexuals: Is It Possible?
M. Djordjevic, D. Stanojevic, V. Kojovic, M. Bizic and M. Majstorovic. Belgrade Gender Dysphoria Team, School of Medicine, University of Belgrade, Serbia. Poster (PDF) presented at the 13th Congress of the European Society for Sexual Medicine.

Total phalloplasty in female transsexuals: technique and outcomes.
Djordjevic M., Kojic S., Stanojevic D., Jocic D., Bizic M. Eur Urol Suppl 2011;10(9):579.
Total phalloplasty is feasible and safe surgical procedure. The main advantage is complete reconstruction of neophallus that avoids multi-staged gender reassignment surgery in female transsexuals. Our results confrmed successful outcome.

Total phalloplasty combined with metoidioplasty as a single stage procedure in female to male gender reassignment surgery: preliminary report.
Djordevic M, Stanojevic D, Kojovic V, Bizic M, Majstorovic M, Pandey S, XXI Biennial Symposium WPATH, Oslo, Norway, 2009; p40.

Combined total phalloplasty and metoidioplasty as a single stage procedure in female to male gender reassignment surgery.
Kojovic V, Bizic M, Majstorovic M, Kojic S, Stanojevic D, Korac G, Djordjevic M. EurUrolSuppl, 2009;8(8):648
Combined total phalloplasty and metoidioplasty is feasible and safe surgical procedure. The main advantage is complete reconstruction of neophallus that avoids multi-staged gender reassignment procedures in female to male transsexuals. Our results confirmed successful outcome.

Neophalloplasty With a Reinnervared Latissimus Dorsi Free Flap: A Functional Study Of a Novel Technique
Ranno R., Veselý J., Hýža P., Stupka I., Justan I., Dvorák Z., Monni N., Novák P., Ranno S., Scripta Medica (BRNO) – 81 (1): 1#–22, April 2008

An Objective Evaluation of the Contraction Power of a Neophallus Reconstructed with Free Reinnervated LD in Female-to-Male Transsexuals Ranno R., Hýža P., Veselý J., Dessy L.A., Kadanka Z., Scripta Medica (BRNO) – 81 (1): 1#–22, April 2008

Total Phalloplasty Using a Musculocutaneous Latissimus Dorsi Flap
Sava V. Perovic, Rados Djinovic (British Journal of Urology, Reconstructive Urology, Volume 100 Issue 4, Sep 2007)

Penile Reconstruction by the Free Scapular Flap and Malleable Penis Prosthesis
Yang, Mingyong; Zhao, Muxin; Li, Senkai; Li, Yangqun (Journal of Plastic and Reconstructive Surgery, Volume 59 Issue 1, July 2007)

New Technique of Total Phalloplasty With Reinnervated Latissimus Dorsi Myocutaneous Free Flap in Female-to-Male Transsexuals
Vesely, Jiri; Hyza, Petr; Ranno, Raul; Cigna, Emanuele; Monni, Nicola; al etc. (Annals of Plastic Surgery, Volume 58 Issue 5, May 2007)

Musculocutaneouslatissimusdorsi free transfer flap for total phalloplasty.
Djordjevic M, Perovic S, Djinovic R. Urology, 2006; 68(suppl.5):168 (abs.MP17.22)

Complications of microsurgical phalloplasty in transsexuals.
R.T. Adamyan, N.O. MIlanov, T.V. Kazaryan. 2000. National Research Centre of Surgery, Russian Academy of Medical Sciences, Moscow, Russia.
A thoracodorsal flap cut from the broadest muscle of the back appears to be the most promising material among free microsurgical autografts employed in phalloplasty. Its feeding pedicle contains the motor thoracodorsal nerve (apart from an artery and a vein) which is indispensable for the reinnervation of the muscular portion of the flap and thus the restoration of its motor function.

Simultaneous Penis and Perineum Reconstruction Using a Combined Latissimus Dorsi-Scapular Free Flap with Intraoperative Penile Skin Expansion
Rohrich, Rod J.; Allen, Terry; Lester, Fred; Young, Jonathan P.; Katz, Scott L. (Journal of Plastic and Reconstructive Surgery, Volume 99 Issue 4, April 1997)

Fibula Flap Phalloplasty

The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender
surgery. [FULL TEXT]
Zaheer U, Granger A, Ortiz A, Terrell M, Loukas M, Schober J. Clin Anat. 2018 Mar;31(2):169-174. doi: 10.1002/ca.23018. Epub 2018 Jan 23.
Surgical text descriptions enhanced by new anatomic illustrations.

Phalloplasty in Complete Aphallia and Ambiguous Genitalia
Rachel Bluebond-Langner, M.D. and Richard J. Redett, M.D. Semin Plast Surg. 2011 August; 25(3): 196–205.

A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients.
Schaff J, Papadopulos NA. Microsurgery. 2009;29(5):413-9.

13 Years Experience with Free Fibula Flap Phalloplasty [link not found]
Sengezer M, Ozturk S, Deveci M, and Zor F. Department of Plastic and Reconstructive Surgery, Gülhane Military Medical Academy, GATA Plastik Cerrahi AD, Etlik, Ankara, Turkey, 2008.

Free Fibula Donor-Site Morbidity: Clinical and Biomechanical Analysis
Farhadi, Jian MD; Valderrabano, Victor MD, PhD; Kunz, Christoph MD, DDS; Kern, Reinhard MD; Hinterman, Beat MD; Pierer, Gerhard MD. Annals of Plastic Surgery: April 2007 - Volume 58 - Issue 4 - pp 405-410
The aim of this study was the quantitative assessment of donor-site morbidity after fibula harvest. The overall donor-side morbidity was low, but an eversion torque deficit could initiate or support a progressive functional ankle instability and in long-term cause or accelerate a ligamentous secondary ankle osteoarthritis. (Editor's Note: This study is not specific to FFF phalloplasty.)

Enlarged Range of Free Flaps for Phalloplasty in Transsexual Reassignment Surgery
Description of our concept for complete phalloplasty, applied in 66 female-to-male transsexuals using free prelaminated osteofasciocutaneous fibula or fasciocutaneous forearm flaps.
Schaff J., International Journal of Transgenderism, Volume 10, Issue 1, 2007. Published online: 15 Oct 2008

Phalloplasty With Free (Septocutaneous) Fibular Flap Sine Fibula
Dabernig J, Chan LKW, Schaff J, J Urol. 2006:176 (5):2085-88

Long-Term Follow-Up of Total Penile Reconstruction with Sensate Osteocutaneous Free Fibula Flap in 18 Biological Male Patients
Sengezer, Mustafa; Öztürk, Serdar; Deveci, Mustafa; Odabasi, Zeki (Journal of Plastic and Reconstructive Surgery, Volume 114 Issue 2, August 2004)

Long-Term Fate of the Bony Component in Neophallus Construction with Free Osteofasciocutaneous Forearm or Fibula Flap in 18 Female-to-Male Transsexuals
Papadopulos, Nikolaos A.; Schaff, Juergen; Biemer, Edgar (Journal of Plastic and Reconstructive Surgery, Volume 109 Issue 3, March 2002)

Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction.
Papadopulos NA, Schaff J, Biemer E. J Reconstr Microsurg. 2001 Aug;17(6):407-12.
Patients with fibula flaps had better sexual intercourse, although their neophallus sensibility was minor, when compared to the forearm flap patients.

Phalloplasty with free osteocutaneous fibular flap in a transsexual case.
Yavuzer, Reha. Plastic & Reconstructive Surgery: September 1999 - Volume 104 - Issue 3 - p 890

Fibula free flap phalloplasty: modifications and recommendations. [Full PDF]
Hage JJ, Winters HA, Van Lieshout J. Microsurgery. 1996;17(7):358-65.

One-stage total penile reconstruction with a free fibula osteocutaneous flap.
Sadove RC, Sengezer M, McRoberts JW, Wells MD. Plastic and Reconstructive Surgery 92:1314–1323, 1993.

Total phallic reconstruction with the free fibula osteocutaneous flap.
Sadove RC, McRoberts JW. Plastic and Reconstructive Surgery 89: 1001, 1992.

Pedicled Groin / Hip

Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps.
Koshima I, Nanba Y, Nagai A, Nakatsuka M, Sato T, Kuroda S. J Reconstr Microsurg. 2006 Apr;22(3):137-42.
The advantages of this method are minimal donor-site morbidity with a concealed donor scar, and possible one-stage reconstruction for a longer urethra of 22 cm in length without insufficiency, even for GID female-to-male patients. A disadvantage is poor sensory recovery.

Phalloplasty in a female-to-male transsexual using a double-pedicle composite groin flap.
Tayfun Aköz, Eksal Kargi. Annals of Plastic Surgery (impact factor: 1.32). 05/2002; 48(4):423-7; discussion 427.

Phalloplasty using a lateral groin flap in female-to-male transsexuals.
Zielinski T. Acta Chir Plast. 1999;41(1):15-9.
The paper presents a one-stage procedure for neophallus construction using a lateral groin flap. 127 female-to-male transsexuals underwent surgery in the Department of Plastic Surgery of the Medical University of Lódz (Poland) using this method.

One-Stage Reconstruction of the Penis with Composite Iliac Crest and Lateral Groin Skin Flap
Sun, Guang-ci M.D.; Huang, Jin-jing. Annals of Plastic Surgery, Volume 15 Issue 6, December 1985.

Construction of Male Genitalia in the Transsexual, Using a Tubed Groin Flap for the Penis and a Hydraulic Inflation Device
Puckett, Charles L., Montie, Joseph E. Plastic and Reconstructive Surgery, April 1978.

Vaginectomy

Outcomes of Transperineal Gender-Affirming Vaginectomy and Colpocleisis.
Hougen HY, Dugi DD 3rd, Berli JU, Sajadi KP. Female Pelvic Med Reconstr Surg. 2020 Mar 19.
This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low: 2 blood transfusions, 1 pelvic hematoma, and 1 C. diff. infection of the colon. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.

Vaginal Colpectomy in Transgender Men: A Retrospective Cohort Study on Surgical Procedure and Outcomes.
Nikkels C, van Trotsenburg M, Huirne J, Bouman MB, de Leeuw R, van Mello N, Ronkes B, Groenman F. J Sex Med. 2019 Jun;16(6):924-933.
Colpectomy, removal of the vaginal epithelium, may be performed in transgender men because of a disturbed male self-image, to reduce vaginal discharge, or to reduce the risk of fistula formation at the urethral-neourethral junction in future phalloplasty or metaidoioplasty. This single-center retrospective cohort study included 143 transgender men who underwent vaginal colpectomy between January 2006 and April 2018. Vaginal colpectomy is a procedure with a high complication rate, but its advantages seem to outweigh its disadvantages. In all but 1 case, no long-term sequelae were reported. However, the high complication rate and reintervention rate should be discussed with patients who are considering undergoing this procedure.

Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation after Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery.
Al-Tamimi, M., Pigot, G. L., van der Sluis, W. B., van de Grift, T. C., Mullender, M. G., Groenman, F., & Bouman, M.-B. The Journal of Urology, December 2018, olume 200, Issue 6, Pages 1315–1322.
A total of 294 transgender men underwent gender affirming surgery with urethral lengthening. A urethral fistula developed in 111 of the 232 patients (48%) without colpectomy and in 13 of the 62 (21%) who underwent primary colpectomy (p <0.01). Secondary colpectomy resulted in 100% fistula closure when performed in 17 patients with recurrent urethral fistula at the proximal urethral anastomosis and the fixed part of the neourethra.

Gender-Affirming Vaginectomy And Colpocleisis
Helen Hougen, Kamran Sajadi. The Journal of Urology, April 2018, Volume 199, Issue 4, Supplement, Page e1073.
Vaginectomy decreases the likelihood of retained mucocele and may be safer than blind fulguration of the vagina, which is another common practice. The companion video demonstrates the key steps in this procedure as well as differences from a prolapse colpocleisis.

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men.
Medina CA, Fein LA, Salgado CJ. Int Urogynecol J. 2017 Nov 29. [Epub ahead of print]
Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. There were no intraoperative complications. One patient had a urologic complication (urethral stricture) in the neobulbar urethra. Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

Phalloplasty with Urethral Lengthening: Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications.
Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Plast Reconstr Surg. 2017 Oct;140(4):551e-558e.
This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on phalloplasty complication rates. Of 224 total phalloplasty patients, 215 underwent vaginectomy and nine underwent vaginal preservation. Urethral complications occurred in 27 percent of patients with vaginectomy and in 67 percent of patients with vaginal preservation (OR, 0.18; p = 0.02). Vaginectomy was associated with decreased urethral stricture (OR, 0.25; p = 0.047) and urethral fistula formation (OR, 0.13; p = 0.004). Non-urethra-related complications occurred in 15 percent of vaginectomy patients but were not statistically significant (OR, 3.37; p = 0.41). Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because vaginectomy affords additional horizontal urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue.

Robot-assisted laparoscopic colpectomy in female-to-male transgender patients; technique and outcomes of a prospective cohort study [Full text]
Freek Groenman, Charlotte Nikkels, Judith Huirne, Mick van Trotsenburg, Hans Trum
Surgical Endoscopy, August 2017, Volume 31, Issue 8, pp 3363–3369.
Study results show that [robot-assisted laparoscopic Vaginectomy] combined with [robot-assisted laparoscopic Hysterectomy] is feasible as a single-step surgical procedure in FtM transgender surgery.

Laparoscopic Vaginal-Assisted Hysterectomy With Complete Vaginectomy for Female-To-Male Genital Reassignment Surgery.
Gomes da Costa, Valentim-Lourenço, Santos-Ribeiro, Carvalho Afonso, Henriques, Ribeirinho, Décio Ferreira. J Minim Invasive Gynecol. 2016 Mar-Apr;23(3):404-9.
This study suggests the feasibility of laparoscopic vaginectomy in genital reassignment surgery. The procedure can be executed as a continuation of the hysterectomy with the potential advantage of the laparoscopy providing better exposure of the anatomic structures with low blood losses (less than 500 mL) and few complications. Furthermore, using this approach, adequate-sized vaginal mucosa flaps were obtained for the urethral reconstruction.

Outcome and Risk Factors for Vaginectomy in Female to Male Transsexuals
M. Spilotros, DJ Ralph, N Christopher, Institute of Urology London, presented at the World Meeting on Sexual Medicine. 2013.
This presentation includes reasons, treatment and results for vaginectomy. Complications are few and easy to manage. The severity of bleeding is directly related to vaginal length. Patients report high satisfaction rates.

Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-a and -ß expression of young women.
Baldassarre M, Giannone FA, Foschini MP, Battaglia C, Busacchi P, Venturoli S, Meriggiola MC. Int J Impot Res. 2013 Sep;25(5):172-7.

Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals.
Perrone AM, Cerpolini S, Maria Salfi NC, Ceccarelli C, De Giorgi LB, Formelli G, Casadio P, Ghi T, Pelusi G, Pelusi C, Meriggiola MC. J Sex Med. 2009 Nov;6(11):3193-200.

The role of colpocleisis with urethral lengthening in transsexual phalloplasty.
Chesson RR, Gilbert DA, Jordan GH, Schlossberg SM, Ramsey GT, Gilbert DM. Am J Obstet Gynecol. 1996 Dec;175(6):1443-9; discussion 1449-50.
Extending the urethra during colpocleisis allows for better healing and significantly decreased fistula formation. Proper blood supply for microvascular surgery and adequate tissue for the anastomosis site contribute to better results.

Urethroplasty

Staged Urethroplasty for Repairs of Long Complex Pendulous Strictures of a Neophallic Urethra
Jessica Schardein, Matthew Beamer, Michelle A Kittleman, Dmitriy Nikolavsky. Urology, Jan 28 2022.
A staged urethroplasty is a feasible option for transgender men with long complex penile strictures of the neophallus. This technique demonstrates promising early functional outcomes and high patient satisfaction.

One or Two Stage Buccal Augmented Urethroplasty has a High Success Rate in Treating Post Phalloplasty Anastomotic Urethral Stricture
Matthew R Beamer, Jessica Schardein, Nabeel Shakir, Min Suk Jun, Rachel Bluebond-Langner, Lee C Zhao, Dmitriy Nikolavsky. Urology. 2021 Jun 10;S0090-4295(21)00471-4.
Single-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

Single-stage Double-face Buccal Mucosal Graft Urethroplasty for Neophallus Anastomotic Strictures.
Schardein J, Beamer M, Hughes M, Nikolavsky D. Urology. 2020 Sep;143:257.
After gender-affirming phalloplasty the anastomosis between the perineal urethra (pars fixa) and the penile urethra is the most common site of stricture. Excisional urethroplasty after phalloplasty is known to have high failure rates due to poor vascularization of neourethra. Our objective is to demonstrate the feasibility of a single-stage repair of neophallus anastomotic strictures using a "double-face" urethroplasty technique.

Urethral lithiasis after phalloplasty.
Pereira-Lourenço MJ, Eliseu M, Temido P, Figueiredo A. BMJ Case Rep. 2019 Jul 12;12(7). pii: e229825. doi: 10.1136/bcr-2019-229825.
Female-to-male transsexual patient, 22 years old, with neophallus from radial forearm free flap (phalloplasty in March 2014), history of urethral fistula and urethral stricture 1 year later treated with surgical correction (fistulectomy) and suprapubic urinary diversion. Subsequently, he developed a new urethral stenosis located in the urethral anastomosis. Immediately proximal to the stenosis, there was a urethral dilatation (pseudodiverticulum) with a fibrous septum and several retracted stones. The stones were fragmented, the fibrous septum destroyed and the urethral stricture corrected, all with holmium laser. After 40 months of follow-up the patient shows satisfactory urinary flow with no signs of residual lithiasis or stricture.

Urethral stricture after phalloplasty. [FULL TEXT]
Jun MS, Santucci RA. Transl Androl Urol. 2019 Jun;8(3):266-272.
The most common complications after Phalloplasty surgery are urinary, mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures. Improvements in surgical technique have driven down complication rates over the past few decades. Despite these innovations, complication rates remain high, and transgender surgeons must be well versed in their diagnosis and treatment. Over the same time period, gender affirming surgery has seen unprecedented growth in the United States. Phalloplasty surgeons are few, and their patients often travel great distances for their index surgery. As such, locally available reconstructive urologists will be called upon to treat these complications with greater frequency and must be proficient in diagnosis and treatment to help these patients achieve a good outcome.

Presenting Complications to a Reconstructive Urologist After Masculinizing Genital Reconstructive Surgery.
Dy GW, Granieri MA, Fu BC, Vanni AJ, Voelzke B, Rourke KF, Elliott SP, Nikolavsky D, Zhao LC. Urology. 2019 Jun 20. pii: S0090-4295(19)30540-0. doi: 10.1016/j.urology.2019.04.051.
Fifty-five patients who had reconstructive surgery for complications from masculinizing GRS from September 2004 to September 2017 were identified. The median age at surgical correction was 33 years. Fifteen (27%) patients had prior metoidioplasty and 40 (73%) had prior phalloplasty. The median time from date of GRS to presentation to a reconstructive urologist was 4 months. Urethral strictures (n = 47, 86%) were the most common indication for subsequent surgery, followed by urethrocutaneous fistulae (n = 31, 56%) and vaginal remnant (n = 26, 47%). The majority of patients presented with 2 or more simultaneous complications (n = 40, 73%). There are several common presenting urologic complications after masculinizing GRS. Patients may present to reconstructive urologists early after GRS performed elsewhere. The long-term outcomes of GRS deserve further study.

Urethral stricture after phalloplasty.
Jun MS, Santucci RA. Transl Androl Urol. 2019 Jun;8(3):266-272. doi: 10.21037/tau.2019.05.08.
The most common complications after Phalloplasty surgery are urinary, mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures. Improvements in surgical technique have driven down complication rates over the past few decades. Despite these innovations, complication rates remain high, and transgender surgeons must be well versed in their diagnosis and treatment. Over the same time period, gender affirming surgery has seen unprecedented growth in the United States. Phalloplasty surgeons are few, and their patients often travel great distances for their index surgery. As such, locally available reconstructive urologists will be called upon to treat these complications with greater frequency and must be proficient in diagnosis and treatment to help these patients achieve a good outcome.

Robotic transanal minimally invasive rectal mucosa harvest.
Howard KN, Zhao LC, Weinberg AC, Granieri M, Bernstein MA, Grucela AL. Surg Endosc. 2019 Jun 11.
Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. The feasibility and safety of a novel technique of Robotic Transanal minimally invasive surgery (TAMIS) is described. All reconstructions had excellent graft take. Patients reported minimal postoperative pain and all regained bowel function on postoperative day one. There have been no long-term complications at a median follow-up of 17 months.

Review: Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence [FULL TEXT]
Richard A. Santucci, Clinical Anatomy, 2018 March, 31:187–190
Radial forearm free flap phalloplasty (RFFP) is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required.

Urologic Complications After Phalloplasty or Metoidioplasty.
Nikolavsky D, Hughes M, Zhao LC. Clin Plast Surg. 2018 Jul;45(3):425-435.
In the past decade, issues facing transgender individuals have come to the forefront of popular culture, political discourse, and medical study. The evaluating physician should have knowledge of the reconstructed anatomy, as well as potential postoperative complications. This knowledge will aid in providing appropriate care and recognizing issues that may require specialized urologic care. Transgender anatomic definitions and a synopsis of common urologic complications specific to transmen, including urethrocutaneous fistulae, neourethral strictures, and persistent vaginal cavities are discussed.

Outcomes After Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication? [FULL TEXT]
Remington AC, Morrison SD, Massie JP, Crowe CS, Shakir A, Wilson SC, Vyas KS, Lee GK, Friedrich JB. Plast Reconstr Surg. 2017 Oct 10.
Cismale patients undergoing phalloplasty had lower urethral and flap complication rates when compared to transmale patients. Staged urethroplasty had more flap complications, as well as worse outcomes and patient satisfaction compared to primary urethroplasty.

Urologic Sequelae Following Phalloplasty in Transgendered Patients.
Nikolavsky D, Yamaguchi Y, Levine JP, Zhao LC. Urol Clin North Am. 2017 Feb;44(1):113-125.
Transgender patients at various stages of their transformation will present to urologic clinics requiring general or specialized urologic care. Knowledge of specifics of reconstructed anatomy and potential unique complications of the reconstruction will become important in providing urologic care to these patients. In this article, we have concentrated on describing diagnosis and treatment of the more common urologic complications after female-to-male reconstructions: urethrocutaneous fistulae, neourethral strictures, and symptomatic persistent vaginal cavities.

Fasciocutaneous Flap Reinforcement Of Ventral Onlay Buccal Mucosa Grafts Enables Neophallus Revision Urethroplasty [FULL TEXT]
Zhao, Lee C, Khurana, Kiranpreet, KWilson, Stelios C et al. The Journal of Urology, Volume 195, Issue 4, e790 - e791.
Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty.

Men's health and transgender surgery: a urologist's perspective. [full text]
Garcia MM. Translational Andrology and Urology. 2016;5(2):225-227.
Because the principal long-term complications associated with GCS are decidedly urologic—sexual function, genital prosthetics, and urinary function—transgender patients will often follow-up with their urologist for years to come. It is especially important for the urologist to inform and help guide patients' expectations regarding their reconstruction—as this helps optimize long-term outcome quality and patient satisfaction.
(Includes: Neophallus length and surgical options, Pitfalls related to genital dimensions; Surgical strategies to optimize erogenous sensation.)

Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient [Full article]
Christopher J. Salgado, Lydia A. Fein, Jimmy Chim, Carlos A. Medina, Stephanie Demaso, Christopher Gomez. Case Reports in Urology, Volume 2016.
The aim of this case report is to describe the successful use of uterine mucosa for prelamination of the penile urethra within a radial forearm osteocutaneous free flap for phalloplasty in the FtM transgender patient.

Fasciocutaneous Flap Reinforcement of Ventral Onlay Buccal Mucosa Grafts Enables Neophallus Revision Urethroplasty [FULL TEXT]
Lee C Zhao, Kiranpreet K Khurana, Stelios C Wilson, John T Stranix, Jamie P Levine. The Journal of Urology, Volume 195 , Issue 4 , e790 - e791 (April 2016)
Urethral strictures or fistulas are common complications after neophallus surgery. These urethral defects are difficult to reconstruct using standard urological techniques because there is insufficient ventral tissue to support a graft. We report our experience with local fasciocutaneous flaps for support of ventrally placed buccal mucosal grafts (BMG) in neophallus reconstruction.

Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals?
Zhang YF, Liu CY, Qu CY, Lu LX, Liu AT, Zhu L, Wang H, Lin ZH, Zhao YZ, Zhu XH, Hua-Jiang.
World J Urol. 2015 Apr 26.
With prefabrication of vaginal mucosal graft, we reconstruct a competent phallic neourethra in these FTM transsexuals. According to its histological similarities and source character, the vaginal mucosa is the excellent substitute material for promising urethral reconstruction in FTM transsexuals.

Postoperative Imaging of Phalloplasties and Their Complications [FULL TEXT]
Eric Blaschke, Gregory T. Bales and Stephen Thomas. American Journal of Roentgenology. 2014;203: 323-328.
Summary of the common phalloplasty indications, surgical techniques, and relevant anatomy, plus imaging techniques used in postoperative evaluation of the neophallus and illustrate the postoperative appearance and urinary complications associated with phalloplasty.

Preconstruction of the Pars Pendulans Urethrae for Phalloplasty with Digestive Mucosa Using a Prefabricated Anterolateral Thigh Flap in a One-arm Patient [FULL TEXT]
Cai-Yue Liu, MD, PhD, Zi-Ran Wei, MD, Hua Jiang, MD, Yao-Zhong Zhao, MD, and Ying-Fan Zhang, MD, PhD. Plast Reconstr Surg Glob Open. 2013 Oct; 1(7): e53. Published online 2013 Nov 7.
We believed that in fabrication of a neourethra, the digestive mucosa has unique merits as follows: (1) it is abundant and easily stretchable; (2) it is a wet epithelium, making its characteristics more histologically similar to the characteristics of urethral mucosa than skin; (3) it is smooth, hairless, and pliable; and (4) it has a dense subdermal plexus, rendering it more prone to obtain a blood supply from the graft site and thus to healing. Apart from the substitute materials, we believe that the operative idea of urethral prefabrication also plays a significant role in the construction of a neourethra.

[Variety of the radial forearm phalloplasty with respect to urethral construction - a review].
[Article in German]
Scholten MM, Grundentaler R, Bull S, Küntscher MV. Handchir Mikrochir Plast Chir. 2013 Aug;45(4):211-6. Epub 2013 Jul 11.
The radial forearm flap is an established procedure for phalloplasty. 3 different methods concerning flap design and urethral construction are reported in the literature. The results show a higher rate of urological complications for the technique with urethra prefabrication so far. However, this technique presents with a lower incidence of partial flap loss and smaller donor sites compared to the Chang design phalloplasty. No conclusions can be drawn for the Gottlieb design penile construction because only few and incomplete data are available in the literature.

A Case of Urethral Reconstruction Using a Superficial Circumflex Iliac Artery. [full text]
Yoo, K.-W., Shin, H.-W., & Lee, H. K. (2012). Archives of Plastic Surgery, 39(3), 253–256.
For the reconstruction of the penis, a SCIP flap and anterolateral thigh free flap was performed [in a cis gender man.] SCIP flap is appropriate for urethral reconstruction. Because of its proximity to the recipient sites, it makes surgical preparation easier and the primary closure at the donor site available. It is also advantageous in that its location is almost unnoticeable.

Buccal mucosa urethroplasty for adult urethral strictures
W. Britt Zimmerman and Richard A. Santucci
Indian J Urol. 2011 Jul-Sep; 27(3): 364–370.
Buccal repair of bulbar urethral strictures have gained popularity and has replaced the anastomotic urethroplasty in our hands, even for short strictures. With its ease of technical performance, reliability, and overall high success rate, it is our procedure of choice in management of most bulbar urethral strictures. (Note: Study was done with cis gender subjects.)

Urethroplasty for Strictures After Phallic Reconstruction: A Single-Institution Experience [FULL TEXT]
Nicolaas Lumen, Stan Monstrey, An-Sofie Goessaert, Willem Oosterlinck, Piet Hoebeke. European Urology, Volume 60, issue 1, pages e1-e8, July 2011.
The main stricture location after phalloplasty is the anastomosisbetween the phallic and the ?xed part. Urethroplasty for strictures after phallo-plasty is associated with a relatively high recurrence rate.

Long anterior urethral reconstruction using a jejunal free flap
Tourbach SA1, Hunter-Smith D, Morrison WA. J Plast Surg Hand Surg. 2011 Feb;45(1):54-6.
The case of a transgender patient requiring correction of chronic strictures of his neophalloplasty.

A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery.
Kim SK, Moon JB, Heo J, Kwon YS, Lee KC. Ann Plast Surg. 2010 Jun;64(6):759-64.
For construction of the urethra, an anteriorly based vaginal wall flap and labium minoral flaps were used in this technique. Urethrocutaneous fistulas at the level of the female external urethral orifice can be successfully reduced using this new method.
Also see: Kim FTM Phalloplasty

Total urethral construction with the radial artery-based forearm free flap in the transsexual [FULL TEXT]
Giulio Garaffa, David J. Ralph and Nim Christopher. St Peter's Andrology Centre and the Institute of Urology, London, UK. Accepted for publication 27 November 2009.
To report our experience of using a radial artery-based forearm free flap urethroplasty (RAFFFU) inside a pre-fashioned pedicled pubic phalloplasty for female-to-male gender reassignment. The RAFFFU is the best technique of total urethral construction in female-to-male transsexuals who opt not to undergo a
RAFFF phalloplasty.

Urethral reconstruction using the radial forearm free flap: experience in oncologic cases and gender reassignment.
Dabernig J, Shelley OP, Cuccia G, Schaff J. Eur Urol. 2007 Aug;52(2):547-53. Epub
Many reconstructive techniques currently in use recreate the urethra but are prone to recurrent stricture formation and fail to achieve micturition with a good stream when standing. The authors propose using the radial forearm fasciocutaneous free flap as a single-stage technique of male urethral reconstruction.

Treatment of urethral stricture in a female-to-male transsexual with a tubulized flap from the labia minora.
Cavadas PC, Landin L. J Reconstr Microsurg. 2005 Apr;21(3):153-6.
After one unsuccessful attempt at direct repair and a failed grafting procedure, a tubulized island flap from the remnants of the labia minora was successfully used to reconstruct the urethral stenosis. Current options for treatment of urethral stenoses in female-to-male transsexuals are discussed.

Impact of sex reassignment surgery on lower urinary tract function.
Hoebeke P, Selvaggi G, Ceulemans P, De Cuypere G, T'Sjoen G, Weyers S, Decaestecker K, Monstrey S. Eur Urol. 2005 Mar;47(3):398-402. Epub 2004 Dec 2.
Post-void dribbling was reported by 79% of the FTM transsexuals who had phalloplasty. SRS can cause minor changes in urinary habits. Even if they do not result in patients seeking medical help, transsexuals should be warned about these eventual discomforts pre-operatively.

Urethroplasty in female-to-male transsexuals.
Rohrmann D, Jakse G. Eur Urol. 2003 Nov;44(5):611-4.
One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.

Urethral Complications During Phalloplasty
David J. Ralph. Polare 33, Article 5, October 1999.
Great advances have now been made with the urethral formation in patients having a phalloplasty procedure. The urethra should be harvested from vascular areas of the body to have a uniform structure to prevent stone formation and spraying at micturition.

Review of the literature on construction of a neourethra in female-to-male transsexuals.
Hage JJ, Bloem JJ. Ann Plast Surg. 1993 Mar;30(3):278-86.
A review of the literature on the construction of a pars pendulans and a pars fixa urethrae in phalloplasty is given. The use of local tissue for lengthening of the fixed part of the urethra can be successful in case a vaginal flap is incorporated.

Scrotoplasty

Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases
Travis J Miller, Walter C Lin, Bauback Safa, Andrew J Watt, Mang L Chen. Ann Plast Surg. Sept 1 2021; 87(3):324-330.
We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications.

Scrotal Reconstruction in Transgender Men Undergoing Genital Gender Affirming Surgery Without Urethral Lenghtening: A Stepwise Approach
Pigot GL, Al-Tamimi M, van der Sluis WB, Ronkes B, Mullender MG, Bouman MB.
A 29-year-old transgender men underwent scrotal reconstruction and phalloplasty without urethral lengthening. For this purpose, the traditional scrotal reconstruction technique in patients that undergo urethral lengthening was modified. Scrotal reconstruction using a horseshoe-shaped pedicled pubic flap, labia majora fat pads, and 2 cranially pedicled U-shaped labia majora flaps results in a neo-scrotum that resembles the biological scrotum closely in terms of bulkiness, size, shape, tactile sensation, and anatomical position.

Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty.
Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, De Cuypere G, Monstrey S
Plast Reconstr Surg. 2009 Jun;123(6):1710-8.

Testicular Prostheses: Development and Modern Usage
D Bodiwala, DJ Summerton, and TR Terry. Ann R Coll Surg Engl. 2007 May; 89(4): 349–353.
Testicular prostheses produced from various materials have been in use since 1941. The most common substance used around the world in the manufacture of these implants is silicone; however, in the US, this material is currently banned because of theoretical health risks. This has led to the development of saline-filled prostheses as an alternative. The long-term fears associated with silicone implants, namely connective tissue or autoimmune diseases and carcinogenesis, have not been substantiated. Longer-term quality-of-life results are still pending.

Glansplasty

The Comparison of A New Durable Coronaplasty Technique with Norfolk Method for Glans Reconstruction after Phalloplasty [FULL TEXT]
Mohammad Reza Akhoondinasab, Mahdy Saboury, Yousef Shafaeei, Siamak Forghani, and Mohammad Javad Fatemi. World J Plast Surg. 2020 Jan; 9(1): 39–43.
In this study, the results of a new surgical technique were presented for glans sculpturing, in which delivered more permanent results using a medium thickness skin graft and dorsal aspect coverage of distally raised flap with mattress sutures. This new technique showed remarkably better results relative to the usual technique for glans sculpting in transsexual patients. Moreover, it has the ability to be easily applied along with ALT/RFFF flaps in both immediate and delayed situations.

Commentary: Cultural Considerations Regarding Glansplasty [FULL TEXT]
Nolan I, Crowe CS, Massenburg BB, Massie JP, Santucci RA, Morrison SD. Plast Reconstr Surg. 2018 Sep;142(3):427e.
A variety of flaps have been pioneered to meet the goals of Phalloplasty and many of them allow for glansplasty to approximate a corona. However, not all transmale patients may desire the appearance of a circumcised phallus after glansplasty. Although construction of foreskin is not currently an option, foregoing glansplasty is certainly possible and can more closely resemble an uncircumcised penis.

A New Technique for Coronaplasty in Penile Reconstruction.
Sommeling CE, Wolf EJ, Salim A, Monstrey S, Opsomer D, Claes K, D'Arpa S.
J Sex Med. 2018 Feb 28. [Epub ahead of print]
This article describes a new coronaplasty technique that exploits opposing contracting forces of two different skin grafts to hold the shape of a thick, distally based skin flap, resulting in a natural looking neo-phallus. The harvested distal flap is progressively thicker and not folded, resulting in a more naturally looking ridge. The donor site is deeper than other techniques, creating a well-defined sulcus. By using two skin grafts the opposing force vectors increase the projection of the ridge and the deepness of the sulcus. This procedure can be applied to all different kind of flaps used for phalloplasty, both in an immediate or delayed fashion. As grafts are used, partial or complete graft lost can appear. Furthermore, attention must be paid not to incise the distal flap too deep so vascularity to the distal part of the flap will not be impaired. The new technique shows a more distinct coronal sulcus and coronal ridge, long-lasting results, and a more aesthetically pleasing and natural-appearing glans penis.

Sculpturing the glans in phalloplasty.
Hage JJ, de Graaf FH, Bouman FG, Bloem JJ. Plast Reconstr Surg. 1993 Jul;92(1):157-61; discussion 162.
One of the goals of phalloplasty is the construction of an aesthetically appealing neophallus with a urethral meatus at its tip. Aesthetic considerations imply the creation of a glanslike structured tip. A review of the scarce literature on sculpturing of a glans is given. The Norfolk technique of coronal ridge and sulcus construction has best results. We consider Munawar's technique to be obsolete, since it tends to lead to flattening of the coronal ridge.

Glans sculpting in phalloplasty — experiences in female-to-male transsexuals - Rong-Hwang Fang, Yi-Sheng Kaoa, Shiuh Ma, Jin-Teh Lin (Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 51, Issue 5, July 1998)

Penile Implants

NEW: Safety outcomes of the first Rigi10™ malleable penile prostheses implanted worldwide. [FULL TEXT]
Wilson, S.K., Wen, L., Carrion, R. et al. Int J Impot Res (2023).
The new malleable prosthesis, Rigi10® showed remarkable early safety from the necessity of reoperation in a multi-center study of the initial patients receiving the implant. Followed up to 3 years with a mean of 21.6 months, the Rigicon Rigi10® had no mechanical breakage and only required revision/removal surgery in less than 1% of 605 patients.

NEW: Is there still a place for malleable penile implants in the United States?
There are still certain situations and conditions where the simplicity of a rod may be preferred over an inflatable prosthesis. A pair of semirigid rods has been shown to have less risk of malfunction and need for revision surgery. In addition, patients with poor manual dexterity may be better served with a rod.
Khera, M., Mulcahy, J., Wen, L. et al. Int J Impot Res 35, 82–89 (2023).

Surgical Outcomes at a Single Institution of Infrapubic Insertion of Malleable Penile Prosthesis in Transmen
Helen H. Sun, Ilaha Isali, Kirtishri Mishra, Michael Callegari, Nicholas C. Sellke, Kimberly S. Tay, Shubham Gupta, Mang L. Chen. Urology, Volume 173, March 2023.
Description of the surgical technique for the infrapubic approach for malleable penile prosthesis (MPP) insertion after phalloplasty in transgender men, and a review of surgical outcomes.

Penile Prosthesis in Transgender Men after Phalloplasty [FULL TEXT]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9398527/
Rajveer S. Purohit, Marissa Kent, and Miroslav L. Djordjevic. Indian J Plast Surg. 2022 Apr; 55(2): 168–173.
A penile prosthesis can be successfully implanted after phalloplasty in transgender men to permit sexual intercourse. There are a variety of techniques and devices available and the choice depends both on the surgeon and patient preferences as well as the type of phalloplasty that was utilized initially. While successful implantation can improve patients’ quality of life, surgeons should counsel patients about the relatively high risk of the need for revision surgery.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications
Brenna L Briles, Ravyn Y Middleton, Kenan E Celtik, Curtis N Crane, Michael Safir, Richard A Santucci. J Sex Med. 2022 Mar 1;S1743-6095(22)00552-5.
We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. Our data suggest that surgical experience may further decrease complications over time.

Infrapubic Insertion of Penile Implants in Transmen After Phalloplasty
Mang L Chen, Darshan P Patel, Rachel A Moses, Isak A Goodwin, Bauback Safa, Andrew J Watt, James M Hotaling. Urology. Jun 2021; 152:79-83.
Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

The Frontier of Penile Implants in Phalloplasty: Is the ZSI 475 FTM what we have been waiting for? [FULL TEXT]
Preto, M., Blecher, G., Timpano, M. et al. Int J Impot Res, January 2021.
Unfortunately, the perfect prosthesis, particularly in phalloplasty, eludes us. Ideally it would be completely inert and remain free from infection. It would also provide perfect rigidity and stability when erect and be easily incorporated into the pelvis. It would remain permanently free from mechanical damage and would never find its way eroding through local tissues. So what is the reality for trans-males undergoing PP implantation in a phalloplasty? The incidence of postoperative complications are dramatically higher in phalloplasty, compared to a native phallus. While the phalloplasty surgical community has long awaited dedicated technologies and implants, the ZSI-475 FTM appears to claim some benefits. However, little can be solidly concluded at this early stage as we eagerly await further objective, well planned trials to assess both surgical complications, implant survival, and patient reported outcomes.

Infrapubic Insertion of Penile Implants in Transmen after Phalloplasty
Mang L. Chen, Darshan P. Patel, Rachel A. Moses, Isak A. Goodwin, Bauback Safa, Andrew J. Watt, James M. Hotaling. Urology, 2021-01-26.
Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of post-operative complications.

Implantation of the Zephyr ZSI 475 FTM erectile device in cis- and transmen after phalloplasty: initial experience and prospective analysis of surgical outcome
Wesley Verla, MD, Dept. of Urology, Ghent University Hospital, AUA Virtual Conference presentation, May 15, 2020.
46 patients with a median (IQR) age of 35 (27-43) years were included for analysis, comprising 7 cismen and 39 transmen. Median (IQR) follow-up was 12 (8-18) months. Postoperative complications comprised infection of the prosthesis in 5 patients (11%), prosthesis malpositioning in 2 patients (4.3%), mechanical failure in 2 patients (4.3%) and distal cilinder protrusion in 1 patient (2.2%). All complications required revisional surgery. Implantation of the Zephyr ZSI 475 FTM erectile device in patients after phalloplasty is feasible and safe. Early surgical outcome is promising, though future analyses with longer follow-up are required to confirm these findings.

Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty.
Pigot GL, Sigurjónsson H, Ronkes B, Al-Tamimi M, van der Sluis WB. The Journal of Sexual Medicine, 2020 Jan;17(1):152-158.
This is the first study on the ZSI Malleable Penile Implant prostheses. 25 patients were retrospectively identified, with a mean age of 36 ± 9 years at implantation. With a mean follow-up of 6.3 months, prosthesis explantation because of complications was performed in 8 patients (32%), because of infection (n = 3), protrusion (n = 4), or pubic pain (n = 1). In an additional 3 patients, the prosthesis was explanted due to difficulty living with the malleable prosthesis. Of those with the prosthesis in place, 13 of 14 patients (93%) were able to engage in penetrative sexual intercourse.

Prosthetic Placement After Phalloplasty.
Blecher GA, Christopher N, Ralph DJ. Urol Clin North Am. 2019 Nov;46(4):591-603.
Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle. Increased complications compared with nonphalloplasty cohorts remain one of the biggest challenges, including rates of infection, erosion, mechanical malfunction, and malposition. Nonetheless, the placement of penile prosthesis within a phalloplasty enables trans men to achieve a once near-impossible goal of penetrative sexual intercourse without an external device.

Supersonic Transporter Deformity in Transgender Men following Phalloplasty
Christopher J Salgado, Lydia A Fein , Eva A Williams, Rachita Sood. Plast Reconstr Surg. 2019 Jul;144(1):225-227.
Phalloplasty is often the final stage of gender-affirmation surgery for transgender men. Obtaining penile rigidity is important for sexual function, but may also bring complications, including supersonic transporter deformity, in which the glans becomes ventrally displaced and flaccid. Two cases of supersonic transporter deformity are presented here, one with a hydraulic penile implant and one with an autologous bone transplant. Attempt at surgical correction was performed in both. Careful attention must be paid to the unique anatomy of the neophallus and type of penile prosthesis to prevent or correct supersonic transporter deformity in transgender men.

Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male.
Kang A, Aizen JM, Cohen AJ, Bales GT, Pariser JJ. Transl Androl Urol. 2019 Jun;8(3):273-282. doi: 10.21037/tau.2019.06.02.
For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty
Wouter B. van der Sluis, Garry L.S. Pigot, Muhammed Al-Tamimi, Jan Maerten Smit, Marlon E. Buncamper, Mark-Bram Bouman. Reconstructive Urology, Volume 132, P195-201. Published: June 20, 2019. DOI:https://doi.org/10.1016/j.urology.2019.06.010
Review study that assesses surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty.

The Rise of the Neophallus: A Systematic Review of Penile Prosthetic Outcomes and Complications in Gender-Affirming Surgery.
Rooker SA, Vyas KS, DiFilippo EC, Nolan IT, Morrison SD, Santucci RA. J Sex Med. 2019;16(5):661-672. doi:10.1016/j.jsxm.2019.03.009
This is the first study to aggregate all reported penile prosthesis characteristics and outcomes in trans masculine patients. Prosthesis implantation in gender-affirming operations poses significant risk of complication, but it is still a reasonable and useful method to achieve rigidity necessary for sexual intercourse. There is a great need for a prosthesis designed to meet the specific needs of the trans masculine patient after phalloplasty.

First Outcomes of the ZSI 475 FtM, a Specific Prosthesis Designed for Phalloplasty
Paul Neuville, Nicolas Morel-Journel, MD, Delphine Cabelguenne, PhD, Alain Ruffion, MD, PhD, Philippe Paparel, MD, PhD, Jean-Etienne Terrier, MD. The Journal of Sexual Medicine, January 2019
Volume 16, Issue 1.
This is the first study to report data on the ZSI 475 FtM, a new prosthesis that has recently been specifically designed for FTM Phalloplasty patients. It has several advantages: a large base for pubic bone fixation, realistically shaped hard glans, and a pump shaped like a testicle. Complications after 21 implantations included 2 (9.5%) infections that were medically treated (Clavien II), 1 (4.7%) infection treated by explantation (Clavien IIIb), 2 (9.5%) mechanical failures (Clavien IIIb), and 1 (4.7%) malpositioning (Clavien IIIb). 13 of 14 patients (92.8%) who answered a satisfaction questionnaire were satisfied or very satisfied with the prosthesis. Preliminary results for the ZSI 475 FtM are encouraging. Safety seems to be satisfactory, and patient satisfaction is high. Long-term studies are needed.

Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery [FULL TEXT]
Marco Falcone, Giulio Garaffa, Arianna Gillo, Dino Dente, Andrew N. Christopher, David J. Ralph
BJU International, Volume121, Issue1, January 2018, Pages 139-144.
Between January 2001 and October 2015, 247 female to male transsexuals underwent implantation of an inflatable PP into a phalloplasty as the last stage of sex reassignment surgery.

• The patients ranged in age from 21 to 69 years at the time of their surgery, with an average age of 38 years. No significant comorbidities were reported.
  
• After a median follow up of 20 months, 140 of the patients (56.6%) still had their original devices.
  
• The remaining 107 patients (43.3%) required revision surgery due to infection of the device (21 patients or 8.5%), mechanical failure (38 patients or 15.4%), or patient dissatisfaction (48 patients or 19.4%).
  
• Twelve patients needed more than one revision surgery.
  
• The overall 5-year survival rate of the implants was 78%. There was no statistical significance in survival between the different types of prostheses.
  
• One hundred four patients completed the patient and partner satisfaction questionnaire. Of these, 83% had satisfactory phallic sensation. All patients could cycle their device, 77% were having penetrative intercourse, 61% had achieved orgasm, and 88% were fully satisfied with the cosmetic and functional outcomes. Sixty percent of partners were satisfied.
  
• The authors noted that while 88% of patients were satisfied, only 77% were having penetrative intercourse. The latter result could be explained by lack of partners.
• Only two and three piece hydraulic PPs should be implanted into the phallus because the risk of erosion is much lower than with the semirigid devices.
  

In conclusion, even though inflatable PP implantation represents the only solution to guarantee the rigidity necessary to engage in penetrative sexual intercourse in gender dysphoric patients, it represents a highly complex procedure with high complication rates.

Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus.
Cohen AJ, Bhanvadia RR, Pariser JJ, Hatcher DM, Gottlieb LJ, Bales GT. Urology. 2017 Jul;105:2-5.
Describes outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures. Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to the pubic bone is one strategy to achieve proximal stabilization.

Sexual Function and Quality of Life before and after Penile Prosthesis Implantation Following Radial Forearm Flap Phalloplasty.
Young EE, Friedlander D, Lue K, Anele UA, Khurgin JL, Bivalacqua TJ, Burnett AL, Redett RJ, Gearhart JP. Urology. 2017 Feb 2. pii: S0090-4295(17)30112-7. doi: 10.1016/j.urology.2017.01.031. (Not FTM-specific.)
Among patients who have undergone flap phalloplasty, the subsequent placement of penile prosthesis appears to effectively allow for both intercourse and masturbation, resulting in measurable improvements in orgasmic function, intercourse satisfaction and overall sexual satisfaction. Despite these important benefits, prosthesis placement does not appear to result in improvements in penile perception scores, or general or sexual quality of life.

Midline Infrapubic Penile Implant Insertion in Transmen after Phalloplasty may Decrease Complication Rates and Operative Times
Vollstedt, A.J. et al., The Journal of Sexual Medicine, Volume 14, Issue 2, e25 (Feb 2017)
The complication rate for penile implant insertion in transmen after phalloplasty is high overall. We have observed shorter operative times and lower complication rates using a lower midline infrapubic approach for penile implant insertion when compared to prior studies.

Surgical Outcomes of Erectile Implants After Phalloplasty: Retrospective Analysis of 95 Procedures.
Neuville P, Morel-Journel N, Maucourt-Boulch D, Ruffion A, Paparel P, Terrier JE. J Sex Med. 2016 Sep 29.
The aim of the study was to report the outcome of patients with phalloplasty after implantation of erectile implants using standardized surgical techniques and the use of recent prosthesis types with or without a vascular graft. Almost 90% of the subjects were transsexual men. The erectile prostheses used were the two-piece AMS Ambicor, the Ambicor with a vascular graft, and the AMS 700CXR, AMS 700CX, or AMS600-650. Early-onset complications were always related to infection. Late-onset complications were erosion, infection, dysfunction, and malpositioning.

Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction.
Zuckerman JM, Smentkowski K, Gilbert D, Storme O, Jordan G, Virasoro R, Tonkin J, McCammon K. J Sex Med. 2015 Dec;12(12):2485-91. doi: 10.1111/jsm.13067. Epub 2015 Dec 8.
The aim of this study was to evaluate outcomes following neophallus penile prosthesis placement [in cis male patients.]

Titanium-bone-anchored penile epithesis: Preoperative planning and immediate postoperative results
Selvaggi G, Branemark R, Elander A, Liden M, Stalfors J. J Plast Surg Hand Surg. 2014 Jun 16;:1-5

Erectile Implants in Female-to-Male Transsexuals: Our Experience in 129 Patients
Piet B. Hoebeke, Karel Decaestecker, Matthias Beysens, Yasmin Opdenakker, Nicolaas Lumen and Stan M. Monstrey. European Urology, February 2010

Novel technique for proximal anchoring of penile prostheses in female-to-male transsexual.
Large MC, Gottlieb LJ, Wille MA, DeWolfe M, Bales GT. Urology. 2009 Aug;74(2):419-21.

Penile Prosthesis Implantation: Past, Present and Future
M. Simmons, D.K. Montague. Int J Impot Res. 2008;20(5):437-444.
This review examines the past, present and future of penile prosthesis implantation. Advances in prosthetic design and implantation techniques have resulted today in devices that produce nearly normal flaccid and erect states, and have remarkable freedom from mechanical failure.

Use of Erectile Prostheses in Patients with Free Forearm Flap Phalloplasty
Kruegera M., Yekania S.A.H., Hundta G., Daverio P. International Journal of Transgenderism, Volume 10, Issue 1, 2007.
Our experiences with more than 100 patients that we provided with erectile prostheses show that the complication rate in transsexual patients is not significantly higher than in biological males. We therefore recommend the use of erectile prostheses in transsexual patients as a safe, reliable and successful way of obtaining the ability to have sexual intercourse.

Use of penile implants in the constructed neophallus.
Mulcahy JJ. Int J Impot Res. 2003 Oct;15 Suppl 5:S129-31.
The hydraulic nondistally expanding penile implants provide the best support with less chance of distal erosion. Covering the device with cadaver pericardium or porcine small intestinal submucosa has been helpful in creating a neocorpus cavernosum.

Obtaining rigidity in total phalloplasty: experience with 35 patients.
Hoebeke P, de Cuypere G, Ceulemans P, Monstrey S. J Urol. 2003 Jan;169(1):221-3.
Good results were observed after implantation of the Dynaflex prosthesis in patients who underwent total phalloplasty. This model is no longer available today. For the more complex 3-piece CX and CXM prostheses implantation results are comparable to those of the 1-piece model.

Penile prosthesis implantation in a transsexual neophallus.
Tan HM. Asian J Androl. 2000 Dec;2(4):304-6.
Successful insertion of an inflatable prosthesis is described. The AMS CX prosthesis is used in a 45 year old transsexual, who had a large bulky neophallus constructed from the anterior abdominal subcutaneous fat 9 years previous.

Dynaflex prosthesis in total phalloplasty.
Hage JJ. Plast Reconstr Surg. 1997 Feb;99(2):479-85.
Promising results have been obtained with self-contained Dynaflex hydraulic penile implants. The results and complications observed in five cases are reported.

Osseous fixation of a penile prosthesis after transsexual phalloplasty: a case report.
Fisch M, Wammack R, Ahlers J, Sennerich T, Müller SC, Hohenfellner R. J Urol. 1993 Jan;149(1):122-5.
Report on a patient who had undergone female-to-male transsexual surgery and subsequent phalloplasty by means of a free latissimus dorsi muscle graft with pudendal nerve coaptation elsewhere 10 years ago. The surgical strategy for implantation and osseous fixation of a penile prosthesis is described.

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Last updated: 10/06/23