Phalloplasty

Neophalloplasty is one of the most difficult surgical procedures in genital reconstructive surgery. It is indicated in men when the penis is missing due to either congenital or acquired reasons, as well as in women with gender dysphoria. Many different tissues have been applied such as local vascularized flaps or microvascular free transfer grafts. The main goal of the neophalloplasty is to construct the functional and cosmetically acceptable penis. Urethral reconstruction in neophalloplasty presents a great challenge for surgeons who manage genital reconstruction. Different flaps (penile skin, scrotal skin, abdominal skin, labial skin, vaginal flaps, etc.) or grafts (skin, bladder, buccal mucosa) have been suggested for urethral lengthening. Although serious complications were reported in the past, new techniques and modifications for primary and secondary neophallus urethroplasty seem to be safe in experienced hands.

Several surgical techniques for neophallic reconstruction have been reported using either available local vascularized tissue or microvascular tissue transfer. However, none of them satisfy all the goals of modern penile construction, i.e. reproducibility, tactile and erogenous sensation, a competent neourethra with a meatus at the top of the neophallus, large size that enables safe insertion of penile implants, satisfactory cosmetic appearance with hairless and normally colored skin. Normal penis has some unique characteristics and restoring its psychosexual function in both the flaccid and erectile state, and the possibility of sexual intercourse with full erogenous sensations, is almost impossible. Surgical indications are expanded to many other disorders such as penile agenesis, micropenis, disorder of sexual development (intersex conditions), failed epispadias or hypospadias repair, penile cancer, as well as female transsexuals.

The most widely used flap for total neophalloplasty is the radial forearm flap. However, it has many drawbacks, e.g. an unsightly donor site scar, very frequent urethral complications, and small sized penis that does not allow the safe insertion of penile prosthesis in majority of cases. This was the main reason for us to develop a new technique using the musculocutaneous latissimus dorsi free transfer flap, which mostly satisfies the requirements noted above. Due to its workable size, ease to identification, long neurovascular pedicle and minimal functional loss after removal, the latissimus dorsi flap has been used for a variety of reconstructions. It has a reliable and suitable anatomy to meet the esthetic and functional needs for phallic reconstruction. It can also be used successfully in children. Phallic retraction with muscle based grafts seems less likely to occur than with use of fasciocutaneous forearm flap, since denervated well-vascularized muscle is less prone than connective tissue to contract.

Operative technique

We perform phalloplasty in female transsexuals in two or three stages and it includes several procedures:

FIRST STAGE (7-9 hours, three surgical teams)

1. Removal of internal (uterus, Fallopian tubes, ovaries) and external female genitalia (vagina, vulva).

2. Lengthening of the urethra using all available vascularized hairless genital skin. 

3. Scrotoplasty with insertion of testicular implants.

4. Musculocutaneous latissimus dorsi free transfer phalloplasty.

SECOND STAGE (6 months later, 2.5 - 3.5 hours)

1. Reconstruction of the neophallic urethra using buccal mucosa graft. 

2. Glans reconstruction.

3. Implantation of the semirigid or inflatible penile prosthesis. 

THIRD STAGE (if necessary, 2 hours)

1. Urethral tubularisation. 

2. Additional correction of all esthetic deformities.

Musculocutaneous latissimus dorsi phalloplasty

A latissimus dorsi musculocutaneous flap of the non-dominant side is designed and harvested with thoracodorsal artery, vein and nerve. The surface of the flap is templated in two parts: (1) a rectangular part for neophallic shaft to be approxiamtely 15-17 x 12-14 cm and (2) additional, circular or semilunar component for glans reconstruction. The flap is tubularized in the midline and the neoglans formed by folding over and approximating to the penile shaft. The new constructed phallus is detached from the axilla after clamping dividing neurovascular pedicle with aim to achieve maximal pedicle length. The donor site defect is closed by direct skin approximation. If it is impossible, remaining donor site defect is grafted with split-thickness skin graft. Incision is made in the pubic area and a wide tunnel toward the femoral region is created to place the flap pedicle. The neophallus is transferred to the recipient area and microsurgical anastomoses are created between thoracodorsal and femoral artery, thoracodorsal and saphenous vein and thoracodorsal and ilioinguinal nerve. Specially constructed dressing is used to keep the neophallus in an elevated position for approximately two weeks.

Second stage includes implantation of penile prosthesis either maleable or inflatible, further urethral lengthening and glans reconstruction. Cylinders are covered with vascular PTFE or Dacron graft that imitate tunica albuginea and additionally fixed to the periostium of the inferior pubic rami. Glans is reconstructed using Norfolk technique.

Urethral reconstruction

Urethral reconstruction presents the main problem in this type of sex reassignment surgery and includes creation of a very long neourethra, since the native urethral meatus in females is positioned too far from the tip of the glans. Lengthening of the native urethra presents a great challenge, especially the first part that should be the bridge between native meatus and neophallic urethra. Neophallic urethral reconstruction is followed in the second stage and includes complete urethral lengthening (if possible) or placement of the buccal mucosa graft on the ventral side of the neophallus, and later tubularisation (third stage).

Reconstruction of the neourethra starts with reconstruction of its bulbar part. A vaginal flap is harvested from the anterior vaginal wall with the base close to the female urethral meatus. This flap is joined with the remaining part of the divided urethral plate forming the bulbar part of the neourethra. Additional urethral lengthening is performed using all available vascularized hairless tissue to lengthen the neourethra, maximally preventing the postoperative complications. For this reason, both labia minora and available clitoral skin are used for urethral tubularization. This way, the new urethral opening is placed in first half of neophallus, minimizing the requests for longer neophallus urethroplasty. It is always done in the first stage of total phalloplasty.

The most promising technique for the further lengthening of the neophallus urethra is based on two-staged procedure. The first stage includes creation of the new "urethral plate" using buccal mucosa graft.  The use of buccal mucosa graft that was first described seven decades ago, has been the gold standard for urethral reconstruction. It is tough, elastic, simple to harvest, easy to handle and leaves no noticeable scar at the donor site. Buccal mucosa grafts (either pairs or single, depending on the width and length of neourethra needed) are placed on the ventral side of the penis. When the healed grafts are ready for final stage tubularization and closure, it is important to incise the underlying tissue that will support the neourethra and avoid ischemia at the neourethral suture line. It is recommended to create second layer from surrounding tissue to cover and support the new created urethra. The key for successful repair is waiting long enough until the skin is supple. The classic mistake is to perform second stage too early.

Second stage should be performed when the "urethral plate" has matured enough to be supple and thus more easily mobilized for a tubularization. If it is necessary, additional buccal mucosa grafts can be used for urethral plate augmentation and easier tubularization.

Complications and secondary repair

Most of the urethral problems can be corrected with secondary procedures. Our experience so far has showed that more than half of urethral fistulas and strictures are solved conservatively, while less than half complications need an additional surgical procedure. At least, there is still no ideal technique for phalloplasty resulting in excellent esthetic and functional outcomes. There are still problems with the neourethral reconstruction, but the incidence of complications has been reduced with new refinements of one stage repair or by using a staged procedure.