2.4. PROMs and Satisfaction
Schardein et al.
[13] stated that 7/8 (88%) patients (only those with available data included) were able to void while standing, and reported a mean postoperative International Prostate Symptom Score (IPSS) of 3.1 (range 0–11) and an IPSS-QoL of 0.9 (range 0–3). However, they did not provide any preoperative data. On a global response assessment question (GRA), 6/8 (75%) patients reported a marked improvement, 1/8 (13%) a moderate improvement and 1/8 (13%) a slight improvement. Dabernig et al.
[12] stated that all patients (six cases) reported an improvement in their mental well-being, and stated that they would undergo the procedure again if they would have to. However, these parameters were not assessed preoperatively.
3. Summary
Transmasculine patients are more likely to choose a phalloplasty rather than a metoidioplasty, resulting in a higher absolute number of documented phalloplasty related stricture cases. Another reason might be the fact that urethral complications (strictures/fistulas) are less likely after a metoidioplasty than after a phalloplasty, given the less elaborated reconstruction and the less invasive type of tissue transfer. However, Waterschoot et al. reported urethral complications after metoidioplasty in 19%, whereas after phalloplasty this is in the same range
[14].
For meatal stenosis repair after phalloplasty, Lumen et al.
[8] treated eight meatal strictures with a meatotomy yielding a patency rate of 75%. The other 10 were treated with a pedicled flap repair (five cases) or a staged repair (five cases), but separate outcomes were not reported. Due to these small patient numbers, no conclusions can be drawn on the preferred technique in this type of patient. However, different local factors can influence the choice of the technique that is performed. For example, if the patient is satisfied with a hypospade meatus, a meatotomy can be a straightforward and relatively simple solution. Otherwise, more complex options, such as a local flap urethroplasty or a staged repair might be necessary.
When considering strictures at the pendulous urethra after metoidioplasty, three different surgical techniques were reported. Lumen et al.
[6] performed a HMS, staged urethroplasty and labium minus flap urethroplasty in respectively one, one and two patients with a 100% patency rate
[6]. So, it appears that strictures at the pendulous urethra after metoidioplasty are treatable, although larger studies are needed to confirm these results and to better understand the outcomes of each type of surgery. Here, again, multiple techniques for stricture treatment are possible depending on several patient and stricture characteristics.
Regarding pendulous strictures after phalloplasty, DVIU (11) has been attempted in only three cases with recurrence in two patients. In cisgender men, DVIU is not recommended for penile strictures, and based on the very limited experience, DVIU seems to have a limited role in the treatment of pendulous strictures in transmasculine individuals
[15].
Lumen et al.
[8] reported 28 strictures at the pendulous urethra. These were most commonly treated with a staged urethroplasty or a temporary perineal urethrostomy. However, separate outcome data per stricture location could not be obtained from this study. Another option is an RFFF as a complete urethral substitute, as described by Dabernig (REF invoegen). As this is an extensive and complex procedure with (additional) visible scarring at the forearm, this technique should be reserved in case (almost) the entire pendulous urethra is strictured and scarred. However, given the low patient numbers and high risk of bias, no definitive recommendations can be made on the ideal treatment of strictures at the pendulous urethra.
Strictures at the anastomosis between the fixed and pendulous urethra were most frequently reported (125/224 strictures) (
Table 1). The commonly used techniques in this anatomic region were AR, GAU with BMG, DVIU and HMS in respectively 44, 10, 19 and 16 strictures
[7][8][13][10][9][6]. A patency rate of 75% (6/8 cases) and 100% (2/2 cases) was seen after GAU with BMG
[13][10]. The success rates after DVIU, AR and GAU are respectively 37% (7/19) and 57% (25/44) at this location
[7][9]. In cisgender males, DVIU is a potential first-line treatment for short and primary bulbar strictures, with a patency rate ranging between 26% and 77% being found after a single session
[16]. Furthermore, Lumen et al.
[7] showed that the shorter the time interval between phalloplasty and DVIU, the higher the risk of urethral stricture recurrence. Therefore, DVIU could be a potential first-line option as well for short (<3 cm) and primary anastomotic strictures that occur in the long run after phalloplasty
[7].
Table 2. Intervention and outcomes of included studies. DVIU (Direct Vision Internal Urethrotomy), HM (Heineke Miculicz), BMG (Buccal Mucosal Graft). CD (Clavien-Dindo), EPA (Exision and Primary Anastomosis) FtM (Female to Male), NA (Not Applicable), NR (Not Reported), IQR (Inter Quartile Range).
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 |
Although AR is often associated with an excellent patency rate in cisgender men (93–97%), these favorable outcomes were not reached in transmasculine patients. These differences in success rates between cisgender and transgender patients could be explained by different facts. In general, vascularization is compromised at the proximal and distal end of the reconstructed skin urethra, due to the anatomy of free and pedicled skin flaps
[17]. The new connection is one between the mucosal tissue and skin, which could explain the formation of more scar tissue after healing. Furthermore, safely mobilizing the neo-urethra without further compromising its vascularization is hardly possible, which makes it very difficult to create a tension free anastomosis. This is in contrast to cisgender men, in which a pure mucosal anastomosis is feasible, and mobilization of the urethra is much easier without compromising the vascularization, due to the natural curve it contains. Thus, as suggested by Verla et al.
[9], probably only very short anastomotic strictures (<2 cm) with a peri-operatively assessed and good vascularization might be treated successfully with this technique, provided that a tension free anastomosis can be made. Based on the data of Lumen et al.
[6] and Schardein et al.
[13], a BMG or two stage urethroplasty might be a valuable alternative when there is any doubt on the quality of the tissue or tension of the anastomosis, but comparative studies are needed to confirm these results. Despite the lack of native supportive tissue (corpus spongiosum) for fixating a local flap or graft, Schardein et al.
[13] showed a 78% (7/9) success rate after double-face BMG urethroplasty, with a median follow-up of 31 months. We hypothesized that the interposition of well-vascularized fatty tissue, analogous to the martius flap to support the ventral graft in the double-face BMG urethroplasty, could be the reason for this good surgical outcome. Finally, a patency rate of 100% in two patients was seen after staged augmented urethroplasty, as a result of the increased healing time after the first stage and therefore the possibility of tubularization on a well-vascularized graft bed in the second stage, at least 3 months later
[6]. However, the long-term survival rates of grafts in this population still need to be studied, especially given the observation in cisgender men where grafts tend to result in lower success rates after long-term follow-up
[18].
For strictures at the anastomosis between the fixed and native urethra, we only have data from two studies with small sample sizes. A 100% (1/1) recurrence was seen after HMS
[6] and 44% (4/9) had a stricture relapse after ventral onlay BMG urethroplasty
[11]. In this last study, no supportive tissue was used to optimize the vascularization of the BMG, which could have had an impact on graft survival rates.
Lumen et al. reported a 25% recurrence rate after meatotomy (8 cases), 42% after HMS (19 cases). About half of the cases remain patent after both a free graft or pedicled flap urethroplasty. However, a patency rate of 70% was reported after a staged urethroplasty repair. Unfortunately, we cannot draw any conclusions based on these results, as the indication for each technique remains unclear.
[8].
In cisgender patients, the dartos layer and the bulbospongious muscle are more developed compared to transgender men who thus lack this extra protective layer that could potentially provide bulk and vascular support to stricture repairs, in the region of the anastomosis between the fixed and pendulous urethra. In addition, the vascularization, as already mentioned above, is compromised and a very thin layer to cover these strictures gives a potentially higher risk of developing fistulas. Verla et al.
[19] reported a similar rise in fistulization rate after stricture repair in failed hypospadias cases. Due to the ill developed dartos layer and often numerous previous procedures, only a thin layered coverage can be performed after stricture repair in these cases.