BACKGROUND: The anterolateral thigh (ALT) flap is becoming increasingly popular for phalloplasty as an alternative to the radial forearm flap (RFF) or other techniques. However, the ALT is often too thick to reconstruct the urethra with the tube-in-tube technique. Based on a 93 cases series, the largest reported so far, we aim at describing different options for urethral reconstruction in ALT phalloplasties and comparing their urinary outcomes.
METHODS: Ninety-three ALT phalloplasties were performed between 2004 and 2016. In 7 cases the urethra was not reconstructed due to the presence of a urinary derivation. In the remaining 86 case the urethra was reconstructed with the tube-in-tube technique (n=5), with prelamination with a skin graft (n=8), with a free radial forearm flap (RFF) (n=39), with a pedicled superficial circumflex iliac artery perforator (SCIAP) flap (n=38), with a skin flap from a previous phalloplasty (n=6).
Indications were gender confirming surgery (n=79), severe penile insufficiency due to congenital malformation (n=11), amputation for cancer (n=1), multiple penile implant failures (n=1) or trauma (1).
RESULTS: Fistulas rates were:: tube-in-tube ALT: 20%; pre-laminated ALT: 0%; free RFF: 27.6%; SCIAP: 23.7%; skin flap from previous phalloplasty: 16.7%.
Stricture rates were: tube-in-tube ALT: 20%; pre-laminated ALT: 87.5%; free RFF: 10.3%; SCIAP: 2.6%; skin flap from previous phalloplasty: 0%.
Voiding while standing was achieved in 91.86% of patients. The remaining patients have a temporary perineostomy and are waiting completion of urethral reconstruction.
CONCLUSION: A skin flap lined urethra is, in our experience, the best option for urethral reconstruction in ALT phalloplasty. When this cannot be accomplished with the same ALT flap with the tube-in-tube technique due to excess flap thickness our first choices are the SCIAP or the RFF flaps. Due to the high stricture rates, flap prelamination has been abandoned. When there is existing penile skin, like in cases of an unsatisfactory previous phalloplasty, the penile skin could be tubed in to reconstruct the urethra.