Microsurgical Phalloplasty in Nontranssexual Patients - Considerations After a Retrospective Single-center Analysis of 23 Cases

Abdominal wall complications: An unknown aspect of morbidity in phalloplasty. A comprehensive analysis and clinical implications

BACKGROUND

Phalloplasty is a complex reconstructive procedure with complications broadly categorized as urinary, vascular, or donor-site related. This study investigates abdominal wall complications, such as bulging and lateral hernias, associated with the use of the inferior epigastric artery as the recipient vessel in microsurgical phalloplasty-a rare and underreported complication.

METHODS

A retrospective review was conducted on 37 patients who underwent microsurgical phalloplasty at a university hospital from January 2016 to February 2020. The most commonly employed technique was forearm flap phalloplasty, followed by the MSLD flap technique. The inferior epigastric artery was accessed via a 7cm oblique incision. Data collected included demographic details, BMI, smoking status, surgical technique, recipient vessel used, and postoperative complications. Follow-up evaluations were performed at 15 days, 3 months, 6 months, and 1 year postoperatively.

RESULTS

Of the 37 patients, the mean age was 33 years, with 84% undergoing phalloplasty for gender affirmation. Abdominal wall complications occurred in 11% of patients (n=4). Three patients developed parietal complications (hernia or bulging), all requiring surgical revision. All three were smokers, one had a BMI>28, and none had prior abdominal surgeries. Contributing factors included musculoaponeurotic disruption, relative denervation from vessel exposure, and smoking-related wound healing impairment.

CONCLUSIONS

The use of the inferior epigastric artery in microsurgical phalloplasty may increase the risk of abdominal wall complications, particularly in smokers and patients with elevated BMI. Optimizing preoperative risk factors, including smoking cessation and careful vessel selection, is essential for reducing these complications. To reduce the occurrence of these complications, the choice of the recipient vessel should be considered alongside the surgical technique during operative planning. Further studies should explore technical refinements to minimize abdominal wall morbidity.

Urethra Reconstruction and Revision Urethroplasty in Pedicled Anterolateral Thigh Flap Penile Reconstruction

OBJECTIVE

Neophallic urethroplasty remains a significant challenge in penile reconstruction. Currently, there is no ideal recognized method. Through this article, we aimed to share our experiences of urethral reconstruction in the pedicled anterolateral thigh flap penile reconstruction using modified techniques and alternative flaps.

METHODS

In this single-center study from 2010 to 2020, 49 patients underwent penile reconstruction with a pedicled anterolateral thigh flap; 17 patients had a micropenis, 3 had iatrogenic defects, and 29 had penile defects after trauma. Different urethroplasty methods, complications, and revision methods were separately described. The tube-in-tube technique was used in 6 cases; the superficial iliac circumflex artery perforator (SCIAP) flap and pudendal-thigh flap were used in 26 and 11 cases, respectively, and the pedicled scrotal flap was used in 6 cases. Revision urethroplasty due to postoperative necrosis (n = 3), stricture (n = 8), and fistula (n = 2) were performed in 13 cases.

RESULTS

The urethral complications (flap necrosis, urinary fistula, and stricture) were as follows: tube-in-tube, 66.7%; SCIAP flap, 46.2%; pudendal-thigh flap, 38.5%; and scrotal septum flap, 50%. After revision procedures, all patients could urinate while standing.

CONCLUSIONS

The characteristics and requirements of patients should be considered before designing a surgical plan. The tube-in-tube technique is the first choice for reconstructing the penis and urethra in a single stage for thinner patients. For other patients, a different flap can be used as a substitute for urethral reconstruction. The SCIAP, pudendal-thigh, and pedicled scrotal flaps can be used to reconstruct the urethra. The tubed SCIAP flap and pudendal-thigh flap are reliable, simple, and suitable for revision urethroplasty.