Abstract
Introduction
Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes.
Materials and methods
All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student’s T-test, Chi-squared test, Fisher’s exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction.
Results
Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively.
Conclusions
We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results.
Keywords: Free tissue flaps, gender confirmation surgery, postoperative complications, transgender persons, urologic surgical procedures
Introduction
Urethral lengthening in the transmasculine population
Phalloplasty is the surgical construction of a phallus that may be offered to transmasculine patients as part of a vast spectrum of gender affirmation surgeries. In the literature, the procedure is notably performed in gender affirmation cases for patients who want to accomplish both standing voiding and penetrative sexual functions. Furthermore, there are other indications for which different patient populations undergo phalloplasty such as congenital disorders (absence, malformation, hypoplasia), trauma, ambiguous genitalia, and oncologic reconstruction (Rashid & Tamimy, 2013).
The ideal phalloplasty is a reproducible technique, creating a neophallus which incorporates a neourethra to facilitate voiding while standing, has tactile and erogenous sensation, maintains rigidity for penetrative coitus and gives satisfactory esthetic results (Khavanin & Redett, 2020). Furthermore, the phallic reconstruction should create minimal donor site morbidity in terms of function and post-operative scarring (Rashid & Tamimy, 2013).
For this patient population, the ability to void from a standing position is a high priority. In order to allow for this, phalloplasty necessitates urethral lengthening to connect the native urethra to the urethra within the neophallus, which is named the pars pendulans. This intermediate portion is known as the pars fixa (Figure 1). The native urethra is anastomosed with the pars fixa at the perineal scrotal junction and is considered as the proximal urethral anastomosis. The connection between the fixed and pendulous urethra is regarded as the distal urethral anastomosis and it is located at the scrotal phallic junction.
Figure 1.
Sagittal representation of the native urethra, pars fixa and pars pendulans.
Historically, there have been multiple initiatives to create a urethra and try to minimize the occurrence of complications (Golpanian et al., 2016). Urethral reconstruction for phalloplasty was first attempted in 1941 by Humby and Higgins using bladder and buccal mucosa graft for the formation of the pars fixa. Other tissues that have been utilized included bladder, buccal and vaginal mucosa, as well as the labia minora and clitoral hood tissues (Al-Tamimi et al., 2020; Djordjevic et al., 2009; Massie et al., 2017; Nikolavsky et al., 2017; Rashid & Tamimy, 2013). The creation of the pars pendulans can be made with multiple surgical options including prelamination, prefabrication, tube-in-tube techniques and pedicled flaps (Lumen et al., 2011; Rashid & Tamimy, 2013; Veerman et al., 2020). The distal end of the phallic urethra is named meatus.
Recently, Berli et al. published a review of different techniques and staging of neourethral formation and phalloplasty, organizing techniques into single-stage phalloplasty, two-stage phalloplasty with metoidioplasty-first approach, and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach (Berli et al., 2021). In this article, we focus specifically on three types of urethral lengthening techniques, independent from type of phalloplasty. These three techniques can be used at any stage of phalloplasty where the urethra must be separated from the clitoris, making it useful independent from the donor site of phalloplasty and which staging technique is used. We present these three surgical techniques of urethral lengthening in phalloplasty in detail and report on the clinical outcomes.
Materials and methods
A single-center retrospective study of transmasculine patients undergoing phalloplasty with urethral lengthening between November 2016 and February 2019 was conducted to allow for adequate follow-up. All operations were performed by three surgeons from our center (MB, EB, PB). Measured outcomes included patient demographics (age, number of years on testosterone therapy and smoking status), type of surgery performed (type 1, 2 or 3) and urological complications (stenosis, fistula, or both). This study was conducted in compliance with the principles of the Declaration of Helsinki.
Surgical techniques
In all three types of urethral lengthening, the patients are placed in lithotomy position. We perform three types of urethral lengthening depending on patient anatomy—the goal of the urethral lengthening is to fill in the gap between the native urethra and the base of the neophallus without tension. The decision as to which type is performed is based on patients’ labia minora length and clitoral hood length, elasticity, and quality.
Type 1 lengthening, in which the urethra is formed from the labia minora only, is selected when the labia minora are long enough to reach the base of the neophallus (minimum 4 to 5 cm), and of adequate quality. In type 1 urethral lengthening, incisions are made from the native meatus to the inner part of the labia minora. Complete thickness flaps of the labia are dissected, which are then wrapped around a foley urethral catheter with monocryl 3-0 mattress sutures (Figure 2a–d). The average length in centimeters for this type of lengthening is 5 cm.
Figure 2.
(a) In type 1 urethral lengthening, incisions are made through the anterior walls of the labia minora and full thickness flaps are dissected, wrapped, and sutured around a urinary catheter. (b) In type 1 urethral lengthening, incisions are made through the anterior walls of the labia minora and full thickness flaps are dissected, wrapped, and sutured around a urinary catheter. (c) In type 1 urethral lengthening, incisions are made through the anterior walls of the labia minora and full thickness flaps are dissected, wrapped, and sutured around a urinary catheter. (d) In type 1 urethral lengthening, incisions are made through the anterior walls of the labia minora and full thickness flaps are dissected, wrapped, and sutured around a urinary catheter.
When the labia minora are of too small caliber to create adequate urethral coverage, we proceed with type 2 lengthening in which the clitoral hood is used in conjunction with the hypoplasic labia minora and vestibular flaps. Type 2 urethral lengthening consists of a circumferential incision at the base of the clitoral glans, which is then degloved and buried temporarily. We then proceed with vestibular v-patterned incisions, creating lateral labia minora vestibular flaps. The incision begins at the native meatus, crosses the hypoplasic labia minora and ends at the edge of the labia minora including a small portion of the vestibule, followed by a minimal lateral elevation of the vestibular skin. The whole is then wrapped around a urethral catheter and sutured in a similar fashion as type 1 (Figure 3a–d). When necessary, the labia minora may be trimmed in order to avoid too much bulk in the neourethra tube. On average, this type of lengthening produces a 7 cm urethra.
Figure 3.
(a) In type 2 urethral lengthening, circumferential incisions are made at the base of the clitoris, which is then separated and buried under the skin. This incision is sutured. Next, incisions are made in the lateral vestibulum, and full thickness flaps are raised. These are then wrapped around a foley catheter and sutured. (b) In type 2 urethral lengthening, circumferential incisions are made at the base of the clitoris, which is then separated and buried under the skin. This incision is sutured. Next, incisions are made in the lateral vestibulum, and full thickness flaps are raised. These are then wrapped around a foley catheter and sutured. (c) In type 2 urethral lengthening, circumferential incisions are made at the base of the clitoris, which is then separated and buried under the skin. This incision is sutured. Next, incisions are made in the lateral vestibulum, and full thickness flaps are raised. These are then wrapped around a foley catheter and sutured. (d) In type 2 urethral lengthening, circumferential incisions are made at the base of the clitoris, which is then separated and buried under the skin. This incision is sutured. Next, incisions are made in the lateral vestibulum, and full thickness flaps are raised. These are then wrapped around a foley catheter and sutured.
Type 3 lengthening, which utilizes a labia minora V-Y flap and a part of the vestibule while keeping the clitoral hood intact, is more often used in metoidioplasty and is rarely performed with a phalloplasty unless the patient has undergone a previous metoidioplasty. In type 3 urethral lengthening, incisions are first made in a V-pattern at the introitus including the anterior face of the inner labia. Circumferential incisions are then made around the native urethra. The two V-Y flaps are then advanced and sutured together with monocryl 3-0. The entirety is then wrapped around the urethral catheter and sutured (Figure 4a–d), resulting in an average length of 5 cm. Contrary to type 1 and 2, type 3 creates a circumferential incision at the proximal urethral junction.
Figure 4.
(a) In type 3 urethral lengthening, V-shaped incisions are done through the anterior labia minora from the vaginal opening laterally. Next, two V to Y advancement flaps are performed and sutured in the midline. These flaps are then wrapped around a catheter and sutured. (b) In type 3 urethral lengthening, V-shaped incisions are done through the anterior labia minora from the vaginal opening laterally. Next, two V to Y advancement flaps are performed and sutured in the midline. These flaps are then wrapped around a catheter and sutured. (c) In type 3 urethral lengthening, V-shaped incisions are done through the anterior labia minora from the vaginal opening laterally. Next, two V to Y advancement flaps are performed and sutured in the midline. These flaps are then wrapped around a catheter and sutured. (d) In type 3 urethral lengthening, V-shaped incisions are done through the anterior labia minora from the vaginal opening laterally. Next, two V to Y advancement flaps are performed and sutured in the midline. These flaps are then wrapped around a catheter and sutured.
Patients remain hospitalized nine days post-operatively. We remove the urethral catheter at POD 21. Follow-up appointments are scheduled 4 weeks and 4 months post-operatively.
In most cases, the newly created pars fixa urethra is anastomosed to the pars pendulans urethra within the neophallus during a second surgery (two-step anastomosis), performed at minimum six months later.
Statistical analysis
All statistical analyses were performed using GraphPad Prism 9. One-way ANOVA and student t test were used for continuous variables, while chi-squared or Fischer’s Exact test for categorical variables. Patient characteristics were compared between the three surgical groups, as well as the incidence of urethral complications. Statistical significance was established at p < 0.05.
Results
Patients and demographics
Since November 2016, 84 transmasculine patients underwent phalloplasty with urethral lengthening at our center. The mean follow-up time was 3.6 years (range 2–5 years). All patients who underwent phalloplasty in our institution had a urethral lengthening procedure. Baseline demographics are presented in Table 1. Average patient age was 33.7 ± 11.2 years. Patients had been on testosterone for an average of 5.9 years (range 2–25) before surgery. Current smokers were counseled to stop smoking three months prior to surgery. Twelve patients (14.3%) were current smokers, 10 patients had a past medical history of smoking (11.9%) and 62 patients (73.8%) were lifetime nonsmokers. Patients undergoing type 1, 2, and 3 urethral lengthening as well as those who had primary versus secondary anastomosis were similar in age, testosterone use, smoking status.
Table 1.
Patient demographics.
| Type 1 |
Type 2 |
Type 3 |
||||
|---|---|---|---|---|---|---|
| Average (years) | Range (years) | Average (years) | Range (years) | Average (years) | Range (years) | |
| Patient age | 32.1 | 18–55 | 33.7 | 21–61 | 40.7 | 19–56 |
| Years on testosterone therapy pre-operatively | 5.8 | 2–25 | 5.6 | 2–20 | 7 | 4–15 |
| Smoking status | Number of patients | Percentage (%) | Number of patients | Percentage (%) | Number of patients | Percentage (%) |
| Yes (quit within 3 months) | 8 | 17.8 | 4 | 14.3 | 0 | 0 |
| History | 5 | 11.1 | 4 | 14.3 | 1 | 9.1 |
| No | 32 | 71.1 | 20 | 83.3 | 10 | 90.9 |
Urethral lengthening
Of the 84 patients, 45 had type 1, 28 had type 2, and the remaining 11 patients had type 3 urethral lengthening. Eighteen patients underwent a single surgery with immediate anastomosis of the pars fixa to the pars pendulans. Of the remaining 66 patients, 33 had secondary anastomosis at least six months later. The other 33 patients elected to not have any additional surgeries to date.
Urethral complications
Post-operative urethral complications were statistically significantly higher (p < 0.0001) for patients undergoing single-stage anastomosis versus two-staged anastomosis (Tables 2 and 3).
Table 2.
Urological complications presented by anastomosis stage.
| Number | Percentage % | P value | |
|---|---|---|---|
| Total cases, single-stage anastomosis | 18 | ||
| Fistula | 10 | 55.6% | |
| Stenosis | 2 | 11.1% | |
| Fistula and stenosis | 2 | 11.1% | |
| Total urological complications | 14 | 77.8% | |
| Total cases, secondary staged anastomosis | 33 | <0.0001* | |
| Fistula | 2 | 6.1% | |
| Stenosis | 4 | 12.1% | |
| Fistula and stenosis | 0 | 0% | |
| Total urological complications | 6 | 18.2% | |
| Total cases, no anastomosis | 33 | ||
| Total urological complications | 0 | 0% |
Statistically significant (p < 0.05).
Table 3.
Urological complications presented by type of lengthening.
| Number | Percentage % | P value | |
|---|---|---|---|
| Total cases, urethral lengthening, type 1 | 45 | 0.37 | |
| Fistula | 3 | 6.6% | |
| Stenosis | 3 | 6.6% | |
| Fistula and stenosis | 1 | 2.2% | |
| Total urological complications | 7 | 15.6% | |
| Total cases, urethral lengthening, type 2 | 28 | 0.13 | |
| Fistula | 5 | 17% | |
| Stenosis | 1 | 3.6% | |
| Fistula and stenosis | 1 | 3.6% | |
| Total urological complications | 7 | 25% | |
| Total cases, urethral lengthening, type 3 | 11 | 0.013* | |
| Fistula | 4 | 36.4% | |
| Stenosis | 2 | 18% | |
| Fistula and stenosis | 0 | 0% | |
| Total urological complications | 6 | 54% |
Statistically significant (p < 0.05).
Complications were reported in 77.8% (14/18) of patients undergoing a single surgery (10 fistulas, 1 urethral stenosis and 1 had both complications.) Eighteen percent (6/33) of the patients who underwent two-stage surgery had urethral complications—6.1% developed fistula (2) and 12.1% (4) developed urethral stenosis (Table 3). Five patients (15.1%) developed a stenosis of the non-utilized neophallus urethra before secondary surgery—they were all dilated and anastomosed after two to six months with no additional complications. There were no reported urethral complications in patients who had urethral lengthening but who did not undergo the second stage urethral anastomosis, thus urinating through a scrotal urethrostomy.
Patients who underwent type 3 urethral lengthening had significantly more complications (54%, p = 0.013) than those who had type 1 (15.6%), although it is not for type 2 (25%) (Table 3). There was no statistically significant difference in terms of complications between type 1 and type 2.
Discussion
The creation of a pars fixa urethra is an integral component of phalloplasty, allowing for a connection to be made between the native urethra and the pars pendulans. Some techniques have been described in the literature for urethral lengthening. These include labia minora, labial ring, anterior vaginal and urethral plate flaps, as well as buccal, vaginal, bladder and uterine mucosa (Table 4).
Table 4.
Reconstruction of pars fixa for phalloplasty and metoidioplasty in transgender patients.
| Author | Year | |
|---|---|---|
| Pedicled labia minora + buccal mucosa | Lin-Brande(15) | 2020 |
| Kocjancic(16) | 2020 | |
| Djordjevic(17) | 2019 | |
| Djinovic(18) | 2018 | |
| Djordjevic(19) | 2013 | |
| Labia minora + clitoral hood | Felici(20) | 2006 |
| Labia minora + clitoral hood +/− buccal mucosa if needed | Al-Tamimi(5) | 2020 |
| Labia minora | Veerman(8) | 2020 |
| Djordjevic(17) | 2018 | |
| Ascha(13) | 2017 | |
| van de Sluis(12) | 2017 | |
| Massie(7) | 2017 | |
| Cohanzad(21) | 2016 | |
| Djordjevic(19) | 2013 | |
| Monstrey(22) | 2011 | |
| Labial ring flap | Takamatsu(23) | 2009 |
| Labia minora + anterior vaginal flap | Chen(24) | 2019 |
| Medina(25) | 2018 | |
| Djordjevic(26) | 2018 | |
| Garaffa(27) | 2010 | |
| Kim(28) | 2010 | |
| Rohrmann(29) | 2003 | |
| Hage(14) | 1993 | |
| Pedicled anterior vaginal flap | Zhang(30) | 2015 |
| Labia minora + Urethral plate | Rohrmann(29) | 2003 |
| Bladder and buccal mucosa grafts | Levine (31) | 1998 |
| Urethral plate + anterior vaginal flap | Perovic(32) | 2003 |
We describe a first classification system for urethral lengthening based on techniques that are currently utilized in our center and reported in the literature. We believe this classification to be a useful method to aid in standardizing and communicating about urethral lengthening. The three types of surgery allow us to offer a personalized approach by tailoring the type of lengthening to each patient’s specific anatomy. This is determined in the operating room after examination of the labia length and quality.
Despite advances in microsurgical techniques since the first penile reconstruction, formation of the neourethra presents an important challenge in this type of gender affirmation surgery, resulting in a significant complication rate. Urethral fistulas and strictures are the most frequent complications, with reported incidence varying from 10% to 75% and 14% to 58%, respectively (Ascha et al., 2018; Massie et al., 2017; Morrison et al., 2017; Nikolavsky et al., 2017; van der Sluis et al., 2017). Meatal stenosis can also occur (Ascha et al., 2018). Overall, urethral complications occur on average in 33% of patients undergoing phalloplasty with urethral lengthening. Hence, patients may be prevented from a standing micturition and require further operations.
It is a commonly-held hypothesis that the distal urethral anastomosis is subject to more complications as the distal pars fixa and the proximal penile flap are the most poorly vascularized components of the urethra. Additionally, we surmise that another contributing factor is the mechanical stress on the fixed urethra that spans horizontally between the pars pendulans urethra and the native urethra. The connections at which the urine stream is forced at an orthogonal turn are especially subject to complications because of the pressure induced on the urethral junctions. Weak spots on the curvatures are subjected to fistula development. Thus, the construction of the bridging pars fixa is crucial to minimize potential complications (Hage et al., 1993; Massie et al., 2017).
Our results demonstrate statistically significant lower rates of these urethral complications (18.2%) when the distal urethral anastomosis between the pars fixa and the pars pendulans is completed during a second surgery at least 6 months later as opposed to a single stage surgery with primary anastomosis (77.8%, p < 0.0001). In light of the results, we rarely complete a single-stage surgery, and only do so if conditions are absolutely ideal—that is, when the patient is reliable and local, tissue swelling is minimal and there is no tension on the anastomosis. We found this trend as well in our review of literature—on average, surgeons who performed single stage versus two-staged anastomosis of the pars fixa to the pars pendulans reported complications 34% and 23% of patients, respectively. Recently, other centers have also moved toward a staged approach. One hypothesis states that staging may decrease complication severity by separating microsurgical from urethral complications (Berli et al., 2021).
Additionally, we found higher rates of complications when we performed type 3 urethral lengthening compared to the other two techniques (p = 0.013). This can perhaps be explained by the fact that we most often perform type 3 urethral lengthening in patients who have already undergone a metoidioplasty and desire a conversion to phalloplasty. Therefore, our procedure is often a second or even third surgery, and the soft tissues are scarred and of lesser quality. Additionally, type three urethral lengthening also implies a circumferential incision and suture line at the proximal urethral junction, possibly contributing to the higher rates of stenosis and fistulae observed in these patients.
This study is not without limitations—notably the retrospective nature of the study, the small sample size (partly due to the nature of the procedure), and it being a single center experience. However, our findings, highlighting the significant differences in urethral complication rates between single- and secondary-stage anastomosis as well as type 1 and type 3 surgical techniques, establish a strong foundation for further research on this topic.
Conclusion
There exists very little organization of the techniques used to lengthen urethra for phalloplasty in the literature. We have developed the Montréal classification, which organizes urethral lengthening into type 1, type 2 and type 3. We present these three surgical techniques of urethral lengthening for phalloplasty in detail. In type 1 lengthening, the urethra is formed from the labia minora only, type 2 lengthening utilizes both the clitoral hood and labia minora, and type 3 lengthening consists of a labia minora V-Y and vestibular flap. We report excellent results and few urethral complications with a two-staged approach where the pars fixa is anastomosed to the pars pendulans at least 6 months after the initial surgery. Overall, our classification of urethral lengthening has allowed us to standardize care depending on patient characteristics, leading to excellent results and reproducible data.
Disclosure statement
The authors declare that they have no conflict of interest.
Ethical approval statement
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (approval 4t November 2020) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Funding
The author(s) reported there is no funding associated with the work featured in this article.
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