Ventral phalloplasty

Aim： To present a simple technique during penile prosthesis implantation that promotes the perception of increased phallic length. Methods： The penoscrotal web is defined. A ＂check mark＂ incision is made with excision of scrotal tissue. Excellent exposure is provided for implantation of the cylinders, pump and reservoir. Wound closure is performed longitudinally. Results： This technique is a modified extension of surgeries described in the pediatric literature for webbed penis. Loss of penile length following penile implantation surgery is worrisome for patients suffering from erectile dysfunction （ED）. This technique helps with patient satisfaction, cosmetic results, and improves perception of penile length. Conclusion： Ventral phalloplasty is a safe, technically simple procedure that may be performed in concert with penile prosthesis implantation or as a stand alone procedure under＇certain circumstances.

Phalloplasty following penectomy for penile cancer

Objective:Penile reconstruction or phalloplasty following penectomy can be offered where the functional penile length is inadequate for a man to void while standing or to have sexual intercourse.Phalloplasty is usually staged due to the complex surgical techniques required.This narrative review describes the technical concepts and summarises the contemporary outcomes following phalloplasty in this challenging cohort.Methods:A retrospective review of the English literature was performed between January 1946 till November 2021.The data were synthesised and complemented by the expert opinion of the authors with 20 years of experience in this field.The flaps are ideally designed with an integrated urethra or alternatively,a further free flap urethroplasty can be offered.Phallo-plasty is further complicated following penectomy by scarring from the previous surgery and the potential loss of structures that would normally be present at the recipient site.Results:There are limited published data with a total of 19 men recorded in the literature.Only the radial artery forearm free flap and anterolateral thigh flap have been described in this cohort of patients.Functional outcomes including standing micturition,sensation in the neo-phallus,and the ability to orgasm are good.Overall quality of life and satisfaction was also good despite the high risk for long-term complications of the neophallus and donor site.Conclusion:Phalloplasty following penectomy requires microsurgical transfer of a free flap or a pedicled flap to reconstruct a neophallus.An erectile device is inserted at a later stage to facilitate sexual intercourse,if desired.Surgical scarring from penectomy and the potential loss of vasculature that would normally be present at the recipient site may further complicate reconstruction.Surgical and functional outcomes are acceptable based on the limited published experience to date.

Pre-fabricated radial forearm phalloplasty with cadaveric bone graft

Phalloplasty is a complex set of procedures used in efforts to improve the anatomical,physiological,and aesthetic deficiencies caused by loss or absence of the penis.Methods have evolved significantly,and the use of free tissue transfer has become common amongst reconstructive surgeons.The inclusion of bone autograft,usually radius or fibula,within the neophallus has caused significant morbidity,and efforts continue to find the optimal solution.We present a novel approach using a pre-fabricated,radial forearm fasciocutaneous free flap containing cadaveric bone graft for phalloplasty following traumatic penis amputation.

Prefabricated Anterolateral Thigh Flaps for Phalloplasty in Female-to-Male Transsexuals

Background Phalloplasty is still a challenging operation because of the high urethral complication rate.Several options regarding different flaps can be chosen,but there is still no perfect solution for phalloplasty in female-to-male(FTM)transgender patients.Our group tried to use prefabricated anterolateral thigh(ALT)flaps for phalloplasty to overcome the urethral complications.Methods A total of 21 transgender patients were included from 2010 to 2019.A twostage operation was performed to reconstruct the phallus.The vaginal mucosa was prefabricated as neourethra at the first stage,and the shaft of the phallus was reconstructed at the second stage.Results All reconstructed phallus survived completely in our study,and the satisfaction rate was 76.2%.The total complication rate was 57.1%.The occurrence of fistula and strictures after the operation was 52.4%and 5.8%,respectively Conclusion Prefabricated ALT flaps with vaginal mucosa have a lower stricture rate.This technique provides a simple,effective surgical option in FTM transsexuals.

Postphalloplasty urinary function test:an observational study of novel outcome instrument to capture urinary dysfunction and quality of life after phalloplasty

Due to growing social acceptance,there has been an increasing number of gender-affirmation surgeries performed in North America.Most research in this patient population focuses on surgical outcomes and advancing techniques.However,little work has been done to study functional outcomes.To better evaluate urinary dysfunction in the postphalloplasty trans men patient population,our group developed a novel patient-reported outcome instrument-the postphalloplasty urinary function test(PP UFT)and protocol to measure postvoid urethral volume(PVUR),and we present our preliminary results.We conducted a cross-sectional pilot study in a cohort of 15 adult trans men who had undergone phalloplasty with urethral lengthening surgery between 2018 and 2021.Patients had stable urinary function via the neophallus at the time of survey.Patients filled out the PP UFT and were asked to record their PVUR as per our protocol.The average PP UFT score was 8.9 out of 40 and the average quality-of-life(QOL)score was 2.6.Postvoid dribbling constituted the major complaint and on average comprised 63.2%of the reported PP UFT score.The average PVUR was 2.2 ml(range:0.5-5.6 ml).There was a positive correlation between higher PP UFT and worse-reported quality of life(P<0.01;R?=0.4).Current questionnaires accepted in cis-male urology have limitations for accurately capturing urinary dysfunction in this specific patient group.The combination of PP UFT and PVUR measurement offers potential for quantifying urinary function and quality of life in patients who undergo phalloplasty.Future studies will validate these instruments.

Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery

An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria.Phalloplasty is the most complex of these surgeries,and this complexity creates a wide range of potential complications.Some of the most common complications and therefore,targets for improvement in outcomes,concern neourethral fistula/stricture,efficacy of reinnervation of the phalloplasty flap,postoperative flap monitoring,and donor site morbidity.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.

Is V-Y plasty necessary for penile lengthening？ Girth enhancement and increased length solely through circumcision： description of a novel technique

Our objective is to describe a novel ligamentolysis approach using a subcoronal incision technique and to determine its safety and efficacy. During the last 7 years, 82 consecutive patients had penile augmentation surgery. Ligamentolysis, through a lower abdominal incision （V-Y plasty） in the first 35 males, was performed （Group A）, followed by circumcision ligamentolysis in the next 47 males （Group B）. The operation time, complications, and the preoperative and postoperative values of penile length and girth along with the self-esteem and relations questionnaire score as well as satisfaction score was calculated before and after the surgery, and a comparison was conducted between the groups. The mean age at presentation was 32 years （range： 18-56 years）. Seventy-nine patients suffered from penile dysmorphophobia, and three patients had micropenises （length 〈7.5 cm）. The mean surgical times were 150.7 and 125.2 rain for Groups A and B, respectively （P=0.005）. Postoperatively, four Group A patients and three Group B patients （11% versus 6%, respectively） experienced penile retraction （P=0.453）. Hypertrophic scars were observed in 18 men （51%） in the former group. In the circumcision group, no major wound complications were recorded. The length and girth improvements between the groups were similar. In terms of satisfaction and SEAR improvement, the resulting difference for both variables favored the circumcision group （P=0.007 and 〈0.001, respectively）. With strict selection criteria, the circumcision ligamentolysis procedure compared to the V-Y plasty demonstrated improved results in terms of safety, operation time, retraction rate and cosmetic appearance without any compromise in the gained penile size.

Penile reconstruction

During the most recent years, a variety of new techniques of penile reconstruction have been described in the literature. This paper focuses on the most recent advances in male genital reconstruction after trauma, excision of benign and malignant disease, in gender reassignment surgery and aphallia with emphasis on surgical technique, cosmetic and functional outcome.

Robotics in genital gender-affirming surgery

Gender-affirming genital surgery includes a constellation of pelvic procedures that can help feminize or masculinize the genitalia.Technological advances in robotic surgery can aid surgical access to and visualization of the pelvis,thereby facilitating certain procedures.In this scoping review,we will discuss the developing role of the robot in genital affirming genital surgery.Indications,techniques,and outcomes using the robot in both feminizing and masculinizing genital procedures will be reviewed.

Weight stigma mitigating approaches to gender-affirming genital surgery

The use of body mass index(BMI)to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested.While BMI thresholds are often meant to be protective,restricting patients from access to surgery can also cause harm.There is a rationale for the continued use of BMI,but the inherent problems with it must also be recognized,including how weight stigma impacts patients’access to gender-affirming surgery and influences clinical care.This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries,as well as analogous procedures,existing de facto BMI thresholds,and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss.BMI factors into surgical decision-making based on the existing literature,which demonstrates that high BMI is associated with increased surgical risk,including higher incidences of surgical site infections and poor wound healing,as well as the possibility of free flap complications,which are a component of certain genital procedures.This patient population is at higher risk for eating disorders,and it is prudent to find alternatives to requiring patient self-monitored weight management.The impacts of weight stigma should be considered when treating gender-affirming surgery patients,and further data and research are needed to augment shared decision-making and lead to practice change.

Management of urethral strictures after masculinizing genital surgery in transgender men

Transgender men undergoing phalloplasty and metoidioplasty have a high rate of urethral stricture.Evaluation of stricture includes evaluation of symptoms and uroflow,cystoscopy,and retrograde urethrogram.Important anatomic differences between the phallus of cis-gender and transgender men increase the likelihood and complexity of treating urethral strictures in transgender men after surgery.Urethral strictures after masculinizing procedures are more likely to require open surgical treatment and recur after treatment.There is a paucity of data,but less invasive options such as dilation and urethrotomy have had minimal success.Open surgical options with a variety of techniques,including one-stage and two-stage techniques,have higher success rates in treating strictures,but there is minimal comparative data on outcomes.We present a review on management options for urethral reconstruction in transgender men and our data on urethroplasty for these patients.