Genital gender-affirming surgery can be part of the transition process in transgender patients. The 2 standard options for transmasculine patients are phalloplasty and metoidioplasty. These complex procedures brings along the risk of complications such as fistulas or urethral strictures at the level of the neo-urethra.
Urethral strictures pose a specific challenge to the reconstructive urologist, and studies that focus on the management of urethral strictures are scarce. This systematic review gives an overview of the known literature about strictures in transmasculine patients, the different treatments and the outcome .
Author and Year | Mean/Median Age at Urethral Procedure (Months) | Stricture Time to Onset (Months) |
Stricture Localization | Previous Endoscopic Procedures |
Previous Meatotomy/Meatoplasty | Previous Urethroplasty | Urethrotomy (Otis/DVIU/Meatotomy/HM Stricturoplasty) | Augmented Urethroplasty with Graft |
Augmented Urethroplasty with Local Flap |
Primary Anastomotic Repair | Staged Urethroplasty with or without Augmentation | Definitive Preineal/Scrotal Urethrostomy | Perioperative Complications (Clavien Dindo) | Stricture Recurrence | Postoperative Complications |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Lumen et al. 2020 [6] | 30 (IQR:24–40) | 9 (IQR: 12–17) | 1/12 (8.3%) Anastomosis Native–Pars fixa, 4/12 (33.3%) Anastomosis Pars fixa–Pars pendulans, 4/12 (33.3%) Pars pendulans, 3/12 (24.9%) Meatal, 1/12 (8.3%) Panurethral | None | None | None | 2/12 (17%) Meatotomy, 3/12 (25%) HM | None | 1/12 (8.3%) Labium Minus flap (pan-urethral stricture) | None | 6/12 (50%) | None | No CD ≥3, Lower grades not reported | 1/3 (33.3%) after HM, 1/2 (50%) after meatotomy, 2/6 (33.3%) after staged repair, 0/1 (0%) after local flap repair | No Clavien Dindo complications ≥ 3, Lower NR |
Verla et al. 2020 [9] | 31 (IQR: 23–40) | 10 (IQR: 6–22) | 44/44 (100%) Anastomosis Pars fixa–Pars pendulans | 11/44 (25%) | None | 17/44 (39%) | None | None | None | 44/44 (100%) EPA | None | None | 11% CD 1, 14% CD2, 2.3% CD3 (Placement of suprapubic catheter) | 19/44 (43%) After EPA repair | 11% of patients CD I, 14% of patients CD II, 2.3% of patients CD III (placement of SPC) (3/44 (6.8%) UTI, 3/44 (6.8%) Wound infection, 2/44 (4.5%) Hematoma, 4/44 (9.1%) Retention, 5/44 (11%) Fistula) |
Schardein et al. 2020 [13] | 37 (range: 28–59) | NR | 9/9 (100%) Anastomosis Pars fixa–Pars pendulans | NR | NR | NR | None | 9/9 (100%) Double faced BMG | None | None | None | None | NR | 2/8 (25%) after BMG repair, 1 case no information on follow-up | NR |
Wilson 2016 [10] | 32 Yo, 47 Yo | NR | 2/4 (50%) Anastomosis Pars fixa–Pars pendulans, 1/4 (25%) Pars pendulans, 1/4 (25%) Meatal | NR | None | None | 1/4 (25%) HM, 1/4 (25%) intervention not reported | 2/4 (50%) BMG, both reinforced with fasciocuteaneous flap | None | None | None | None | NR | 0/2 (0%) after BMG with flap, 0/1 (0%) after HM, 1 case no information on intervention or outcome | NR |
Pariser 2015 [11] | 39 (range: 26–56) Including cis gender patiënt | NR | 9/9 (100%) Anastomosis Native–Pars fixa | 9/9 100% | None | 2/9 (22.2%) | None | 1/9 (11.1%) Excision with dorsal anastomosis with ventral onlay BMG; 8/9 (88.9%) Incision with ventral onlay BMG | None | None | None | None | 1/9 of patients CD1 (11.1%) | 4/9 (44.4%) after BMG | 1/9 of patients CD1 (11.1%) Mild rhabdomyolysis |
Lumen 2011 [8] | 37.6 (range: 19–65) Including cis gender patients | Overall median 23.5 (range: 13.5-31.2) 24.4 (meatal), 35.3 (pars pendulans), 13.5 (anastomosis pars pendulans - pars fixa), 28.1 (pars fixa) | 18/118 (15.3%) Meatal, 28/118 (23.7%) Pars pendulans, 48/118 (40.7%) Anastomosis Pars fixa–Pars pendulans, 15/118 (12.7%) Pars fixa, 9/118 (7.6%) Multifocal | NR | NR | NR | 8/118 (6.8%) Meatotomy, 19/118 (16.1%) HM | 2/118 (1.7%) Free graft (type not reported) | 10/118 (8.5%) Pedicled flap urethroplasty (3/10 were neo-scrotal pedicled flaps, 7/10 were neophallic skin flaps) | 14/118 (11.9%) EPA | 33/118 (28.0%) Johanson staged urethroplasty, 21/118 (17.8%) Perineostomy followed by urethral reconstruction, 10/118 (8.5%) Still at first stage of stage urethroplasty or perineal urethrostomy and awaiting further treatment | 1/118 (0.8%) | NR | 2/8 (25%) after meatotomy, 8/19 (42.1%) after HM, 6/14 (42.9%) after EPA, 1/2 (50%) after free graft, 4/10 (40%) after pedicled flap, 10/33 (30.3%) after staged repair, 13/21 (61.9%) after perineostomy with urethral reconstruction | NR |
Lumen 2009 [7] | 33 (range: 20–52) Including cis gender patients | 20 (range: 1–90) | 19/22 (86.4%) Anastomosis pars pendulans–Pars fixa 3/22 (13.6%) Pars pendulans | None | None | 8/22 (36.4%) | 32/32 (100%) DVIU (total of 32 procedures), (15/22 had 1 incision, 6/22 had 2 incisions, 1/22 had repetitive incisions) including cisgender patient | None | None | None | None | None | NR | 12/22 (56.2%) after 1 DVIU | NR |
Dabernig 2006 [12] | 35.1 (range: 22–55) Including cis gender patients | NR | 6/6 (100%) Pan-urethral | Yes, but percentage not reported | NR | Yes, but percentages not reported | None | None | 6/6 (100%) Complete urethral reconstruction using RFFF | None | None | None | None | 2/6 (33.3%) after complete free flap reconstruction | None |