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Phalloplasty Risks and Complications

Educating patients about Phalloplasty risks and complications is essential. While all surgeries carry risks, FTM Phalloplasty is a high-risk, high-reward procedure. Techniques have improved drastically since the surgery was first performed in 1946, reducing complication rates overall, but Phalloplasty remains technically complex. Despite this, a review of 29 academic studies found remarkably high patient satisfaction rates and showed that about 95% of transsexual men are able to stand-to-urinate after Phalloplasty with Urethroplasty.

Keep In Mind:

  • Different Phalloplasty techniques vary in complexity and risk.
  • Complication rates differ between surgeons.
  • Some complication rates come from self-reported data by surgeons, which may be less reliable than complication rates published in peer-reviewed studies.

Dr. Gabriel Del Corral - Phalloplasty Baltimore"I tell all my patients that the complication rate for Phalloplasty can be 100%. There's something that's going to happen. The question is how do we as surgeons really try to navigate minimizing all the potential issues." — Dr. Gabriel Del Corral

General Surgical Risks

  • Infection
  • Bleeding
  • Damage to surrounding tissues
  • Pain

Common Phalloplasty Complications

  • Urethral complications (fistulas, strictures)
  • Wound breakdown
  • Pelvic bleeding or pain
  • Bladder or rectal injury
  • Lack of sensation
  • Prolonged need for drainage
  • Partial necrosis or flap loss
  • Dissatisfaction with penis size or shape
  • Need for additional surgeries

Donor Site Risks

  • Decreased sensation: Some degree of decreased sensation is expected, especially in procedures where the donor site flap includes nerves, as nerve harvest or disruption can lead to partial or prolonged numbness in the donor area.
  • Wound breakdown
  • Decreased mobility
  • Hematoma
  • Pain
  • Excessive scarring
  • Hypergranulation, slowing wound healing and increasing infection risk
  • Adhesions (bands of scar tissue binding tissues together)

Early-Onset Complications

Urethral Complications: Urinary fistulas (openings causing urine leakage) are common, especially when urethral lengthening is performed. Fistula risk varies by procedure1:

  • Suprapubic abdominal flaps: ~55%
  • Radial Forearm Phalloplasty: 22–68%
  • Prelaminated Osteocutaneous Fibula Flap: 15–22%
  • Pedicled flaps (ALT, extended groin): <10% (in cis male studies)

A 2017 study comparing Radial Forearm (RFF) and Anterolateral Thigh (ALT) Flaps found2:

  • Urethral complications: RFF 31.5%, ALT 32.8%
  • Partial or total neophallus loss: ALT 7.8%, RFF 3.4%
  • ALT had significantly higher odds of urethral fistula, non-urethral complications, and phallus wound dehiscence.

Other early urinary complications can include:

  • Partial or total necrosis of urethral tissue
  • Clogged catheter
  • Bladder spasms
  • Urinary tract infections (UTIs)

Wound Complications:

  • Infections (cellulitis or fungal) typically treated with antibiotics/antifungals.
  • Breakdown often occurs where multiple incisions meet (e.g., base of penis); usually treated with local wound care, but severe cases may need surgery.
  • Hematomas may require drains or surgical evacuation.

Bladder and Rectal Injury: Rare but serious; may occur during Vaginectomy. Early detection allows immediate repair, but missed injuries can cause sepsis or require multiple surgeries over months.

Partial Necrosis/Flap Loss: Occurs in up to 18% of cases3, usually within 72 hours post-op. Early treatment is critical.

Long-Term Complications

  • Urethral Stricture: Narrowing of the urethra due to scar tissue or hair growth, usually 6–12 months post-op. Symptoms include weak stream, difficulty or inability to urinate. Without surgery, repeated dilations are often required.
  • Postvoid Incontinence/Dribbling: Affects ~79% of patients4.
  • Wound Contracture: Can distort tissues or create contour issues.
  • Scarring: Hypertrophic (raised), keloids (overgrown), or stretched scars.

Risks with Penile and Testicular Implants

  • Infection: The most common complication; typically requires implant removal, with replacement possible around 6 months later.
  • Erosion: Occurs when the implant breaks through the skin; requires surgical removal.
  • Implant Loss/Displacement: Occurs in 2–30% of cases5, can increase urethral complications.

There's a lack of data on penile prosthesis use in transsexual men, with existing studies limited to small or moderate-sized series. The largest published series (Falcone et al) included 247 patients who received an inflatable penile prosthesis after radial forearm or abdominal phalloplasty. A Dacron envelope was used to stabilize the implant, anchoring it to the pubic bone. They reported a 43% overall complication rate, including:

  • 8.5% infections
  • 15.4% mechanical failures (cylinder rupture, aneurysm, connecting tube rupture)
  • 19.4% patient dissatisfaction with the prosthesis

The overall 5-year implant survival rate was 78%, with no significant difference in survival between different prosthesis types6.

The second-largest series reported on 129 patients (185 prostheses) and similarly found a high need for removal or revision (41.1%). Complications included:

  • 11.9% infections
  • 8.1% prosthesis protrusion
  • 9.2% prosthesis leaks
  • 14.6% migration of the prosthesis

Other smaller series have confirmed a consistently high need for revisions and replacements7.

Though Phalloplasty carries significant risks, several studies show high satisfaction rates among transsexual men who undergo the procedure. Most complications can be treated by the original surgeon or an experienced Reconstructive Urologist or Plastic Surgeon.

 

References:

  1. Rashid M, Tamimy MS. Phalloplasty: The dream and the reality. Indian J Plast Surg. 2013;46:283-93.
  2. Ascha M et al. Outcomes of Single-Staged Phalloplasty. J Urol. 2017 Jul 29.
  3. Carroll L, Mizock L. Clinical Issues and Affirmative Treatment with Transgender Clients. Elsevier. 2017.
  4. Hoebeke P et al. Impact of sex reassignment surgery on urinary tract function. Eur Urol. 2005;47(3):398-402.
  5. Selvaggi G et al. Scrotal reconstruction in female-to-male transsexuals. Plast Reconstr Surg. 2009;123(6):1710-8.
  6. Falcone M, Garaffa G, Gillo A, Dente D, Christopher AN, Ralph DJ. Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery. BJU Int. 2018 Jan;121(1):139-144.
  7. van der Sluis W B, Pigot G LS, Al-Tamimi M. A retrospective cohort study on surgical outcomes of penile prosthesis implantation surgery in transgender men after phalloplasty. Urology. 2019;132:195–201.

 

Last updated: 06/29/25



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