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.




Related articles

1. Djordjevic ML. Primary and secondary reconstruction of the neophallus urethra. In: Brandes SB and Morey AF, Eds. Advanced male urethral and genital reconstructive surgery, 2nd Edition. New York: Humana Press; 2014. p. 493-505.

2. Djordjevic ML, Salgado CJ, Bizic M, Kuehhas FE. Gender dysphoria: the role of sex reassignment surgery. ScientificWorldJournal. 2014;2014:645109.

3. Djordjevic M., Kojic S., Stanojevic D., Jocic D., Bizic M. Total phalloplasty in female transsexuals: technique and outcomes. Eur Urol Suppl 2011;10(9):579.

4. Djordjevic ML, Bizic M, Stanojevic D, Bumbasirevic M, Kojovic V, Majstorovic M, Acimovic M, Pandey S, Perovic SV. Urethral lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap. Urology 2009; 74:349-353

5. Djordevic M, Stanojevic D, Kojovic V, Bizic M, Majstorovic M, Pandey S, Total phalloplasty combined with metoidioplasty as a single stage procedure in female to male gender reassignment surgery: preliminary report. XXI Biennial Symposium WPATH, Oslo, Norway, 2009; p40.

6. Kojovic V, Bizic M, Majstorovic M, Kojic S, Stanojevic D, Korac G, Djordjevic M. Combined total phalloplasty and metoidioplasty as a single stage procedure in female to male gender reassignment surgery. EurUrolSuppl, 2009;8(8):648

7. Djordjevic ML, Bumbasirevic MZ, Vukovic PM, Sansalone S, Perovic SV. Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Ped Urol 2006; 2:333-339

8. Djordjevic M, Perovic S, Djinovic R. Musculocutaneouslatissimusdorsi free transfer flap for total phalloplasty. Urology, 2006; 68(suppl.5):168 (abs.MP17.22)


 

CASE 1

Total phalloplasty in FTM patient

Preoperative appearance


Very long urethra is created using urethral plate, both labia minora and clitoral hairless skin

 

Scrotoplasty is finished. Perineum is created as in male. New urethra is created

 

MLD phalloplasty is performed. Neophallus with long neurovascular pedicle is created

 

Result after surgery

 

New urethral opening is placed in distal part of the neophallus

 

Second stage included implantation of malleable penile prosthesis

 

Distal urethra is created using buccal mucosa graft


 

CASE 2

Total phalloplasty in FTM transgender

Preoperative appearance of female genitalia

 

Appearance of donor site after harvesting the MLD flap

 

Appearance of the male genitalia. Scrotum with two testicles is formed. Neophallus lies just above the scrotum. Clitoral glans is placed just under the base of the neophallus

 

Ventral view. Urethra is lengthened and new opening is located in first part of the neophallus


 

CASE 3

Total phalloplasty with scrotoplasty, urethral lengthening, hysterectomy and vaginectomy

Preoperative appearance of the female external genitalia. Vaginal approach will be used for hysterectomy, oophorectomy and vaginectomy

 

Closure of the MLD donor site in one line

 

Appearance after surgery

 

Outcome nine days later. Suprapubic catheter is placed for urine drainage in first three weeks

 

Outcome nine days later. Suprapubic catheter is placed for urine drainage in first three weeks


 

CASE 4

Total phalloplasty and chest reconstruction

Closure of the donor site

 

Appearance after total phalloplasty

 

Reconstruction of failed nipples

 

Appearance of the genitalia, donor site and chest, three weeks later

 

Appearance of the genitalia, donor site and chest, three weeks later

 

Appearance of the genitalia, donor site and chest, three weeks later

 

Appearance after chest reconstruction, five months later

Appearance of the nipples and chest, five months later

 

Appearance of donor site and chest reconstruction, five months later

Appearance of the chest and donor site, five months later

 

Appearance of the genitalia, five months later

Appearance of the genitalia, five months later

 

Appearance of the genitalia, five months later

Appearance of the genitalia, five months later


 

CASE 5

MLD phalloplasty after metoidioplasty

Dissection of the blood vessels. Marked lines show the place for the neophallus

 

Appearance after surgery. Good sized and shaped phallus is created

 

Outcome three months later

 

Appearance of the donor site


 

CASE 6

Phalloplasty after metoidioplasty

Outcome after metoidioplasty performed two years ago

 

A 15cm long neophallus is created and placed at proper position

 

Appearance of the neophallus. Good shape and dimensions are achieved


 

CASE 7

Phalloplasty after metoidioplasty

Result after complete one-stage metoidioplasty

 

Design of the MLD flap

 

Result after surgery

 

Appearance three weeks later

 

Appearance three weeks later


 

CASE 8

FTM reversal surgery

Appearance of the female genitalia after MTF surgery

 

Design of the MLD flap with dimensions according to patient's wishes

 

Tubularization of the flap

 

Outcome of the phalloplasty after microvascular anastomosis


 

CASE 9

Second stage with penile prosthesis implantation

AMS three-component inflatable prosthesis is inserted into the neophallus

 

Urethra is reconstructed using buccal mucosa graft and surrounding skin

 

Appearance at the end of surgery. Neophallus is in erection

 

Appearance in flaccid state. Glansplasty is also done


 

CASE 10

Third stage - neophallic urethroplasty

Aspect of the ventral side. Clitoral head is placed above the neophallus. In left hemiscrotum, penile prosthesis pump is visible over the testicle implant

 

Urethral lengthening is performed using buccal mucosa graft

 

Closure of the neophallus

 

Appearance after complete urethral lengthening and glans reconstruction


 

CASE 11

Third stage - neophallic urethroplasty

Appearance of the neophalus

 

Appearance of the neophalus

 

Urethral lengthening using buccal mucosa graft

 

Urethral tubularisation


 

CASE 12

Total phalloplasty after metoidioplasty

Phalloplasty after previous metoidioplasty

 

Meto incorporation, urethral lengthening with clitoral skin flaps and buccal mucosa graft


 

 

CASE 13

FTM reversal surgery

Preoperative appearance

 

Scrotoplasty and urethral lengthening

 

Flap design

 

Phalloplasty outcome

 

Glanuloplasty

 

Final appearance


 

 

CASE 14

FTM surgery

Preoperative appearance

 

Urethral lengthening and scrotoplasty

 

Donor area closure

 

Final appearance

 

Outcome two weeks later

 

Donor site, two weeks later


 

CASE 15

Total phalloplasty outcome in FTM patient

 

 


 

CASE 16

Second stage phalloplasty in FTM transgenderism

Appearance of the neophallus after MLD phalloplasty

 

Result after reconstruction of the glans and implantation of penile prosthesis

 

Result after reconstruction of the glans and implantation of penile prosthesis


 

CASE 17

Total phalloplasty outcome in FTM patient

Appearance of the donor site and neophallus

 

Appearance of the neophallus, donor site and nipples

 

Neophallus appearance


 

CASE 18

Follow-up two years after total phalloplasty

Appearance in flaccid state.

 

Appearance in erection.


 

CASE 19

Revision after abdominal phalloplasty

Appearance after metoidioplasty, abdominal phalloplasty and insertion of scrotal tissue expanders. Neophallus is positioned with a base at the left inguinal area. Scrotums are completely deformed. Right testicular implant lies close to the anus.

 

Tissue expanders are removed.

 

Reconstruction of the scrotum with implantation of testicular implants. Transposition of the neophallus in proper midline position. Incorporation of the clitoris into the new phallus.

 

Reconstruction of the scrotum with implantation of testicular implants. Transposition of the neophallus in proper midline position. Incorporation of the clitoris into the new phallus.

 

Reconstruction of the scrotum with implantation of testicular implants. Transposition of the neophallus in proper midline position. Incorporation of the clitoris into the new phallus.


 


 

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