Pubic phalloplasty in female-to-male transsexuals
C Bettochi, DJ Ralph, JP Pryor
Institute of Urology, The Middlesex Hospital, U.C.H. London, UK
[Abstract] Full Text [PDF]
A considerable variety of phalloplasty techniques has been described using either pedicled or free flaps. We report our experience at The Middlesex Hospital-London during the period 1989-96 in phallic construction for female-to-male transsexuals using a pubic pedicled flap.
Patients and method
Sixty five patients were referred to our department after a psychiatric assessment. All of them had a male hormonal replacement therapy. Usually they have undergone a mastectomy previously and they had a hysterectomy and oophorectomy at the same time as the phalloplasty. The patients were fully informed about the operation, objectives to achieve and risk of complications. Operative technique: with the patient in a supine position, the phallus was formed by anterior abdominal wall skin, and the flap fashioned 10cm wide and 10cm length from the clitoris, mobilized and tubed after insertion of the neourethra. The skin cover was performed by a complete mobilization of the anterior abdominal wall skin and umbilicus up to the costal margin. The neourethra was fashioned in one stage at the same time as the phalloplasty up to 1993 and subsequently in 2 stages. The first stage occurred at the time of the phallus formation and this was fashioned using a major labial flap, tubed over a 18 Fr silicone catheter, and turned through a skin tunnel into the neophallus. The second stage involved the isolation of the opposite major labia and this was tubed in a similar fashion and anastomosed to the native urethra.
Thirty seven patients had a one-stage phalloplasty (Group A) and 28 had a two-stage operation (Group B). Group A: one patient experienced the total loss of the phallus due to gangrene. Five patients did not want the neourethra because of the high risk of complications. Neourethral problems were frequent, being present in all but one patient; strictures (94%) and fistula (97%) required numerous re-operations (average three per patient) such as dilation, meatotomy/plasty and urethrotomy/plasty. The stenoses were usually in the distal part of the phallus and in the meatus (75%), while the fistula were always in the perineal area. Three patients reported to be able to penetrate just with the neophallus stiffness itself, while five others required a penile prosthesis: unfortunately in 3 of them it was removed due to perforation. Five patients have an implant of testicular prostheses bilaterally. The cosmetic outcome was considered good in 59% of patients. Group B: two patients had to have the amputation of the neophallus due to infection and necrosis. The incidence of neourethra complications was lower (86%), being present as either strictures (71%) and/or fistulas (36%). At the present time, 15 (60%) patients have completed the second stage of the urethroplasty and the flow was found to be satisfactory in 80% of them. Two patients were able to penetrate without prosthesis implant and four are on the waiting list for this procedure. The cosmetic outcome was considered good in 73% of patients.
The ideal technique for phalloplasty still has to come and this explains the presence of such a variety of techniques. We think that pubic phalloplasty is a simple and relatively quick procedure, with minimal scarring or disfigurements in the donor area, esthetically acceptable to the patient and his partner, as for all the other techniques, and the use of new forms of urethroplasty may help to sort this problem out.
Citation: XV Harry Benjamin International Gender Dysphoria Association Symposium , an article published on the Internet by The International Journal of Transgenderism, 1997 <http://www.symposion.com/ijt/>