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Neophallus construction (NPC) and penile prosthesis implantation (PPI) techniques are critical components of masculinizing genital gender affirming surgery (gGAS). We aim to summarize the recent techniques and complications from the literature on NPC and PPI over the last 3 years. Phalloplasty techniques include suprapubic pedicled phalloplasty, musculocutaneous latissimus dorsi flap (MLDF), single stage radial forearm free flap (RFFF), groin flap phalloplasty, and anterolateral thigh flap (ALT). Various implants and implantation techniques are described, two of which are novel devices designed specifically for transgender surgery: ZSI 100 FtM Malleable penile implant and ZSI 475 FtM implant (Zephyr Surgical Implants, Geneva, Switzerland). NPR and PPI are associated with higher complication rates compared to routine prosthetic surgery. Urethral fistulas remain the most prevalent complication; however, recent technical advancements and the exclusion of urethral lengthening procedures have reduced the rates of fistula formation. There are exciting PPI technology innovations in transgender-specific care, but, at this juncture, the lack of comparison studies makes it difficult to access outcomes.

Objective To determine the prevalence of patients who require vaginal cavity remnant excision and obliteration during neourethral stricture repair and to characterize the histological composition of the excised tissue. Methods A retrospective review was performed of all transgender men who underwent neourethral stricture repair. Preoperative imaging and operative reports were reviewed to determine the presence of a vaginal cavity remnant that was excised and obliterated during neourethral reconstruction. Pathology slides were reviewed by 2 pathologists to determine if there was presence of stratified squamous epithelium consistent with vaginal tissue within the vaginal cavity remnant. Results A total of 47 consecutive transgender men underwent neourethral stricture repair between January 2014 and December 2020. Of these, 18 patients (38%) with a mean age of 37 years (23-59) underwent excision and obliteration of a vaginal cavity remnant. Seventy eight percent (14/18) had a prior phalloplasty and 22% (4/18) had a prior metoidioplasty. Primary vaginectomy type was not associated with whether or not a patient had a vaginal cavity remnant (P = .12). Histological evaluation demonstrated the presence of vaginal epithelium in all vaginal cavity remnant specimens. Conclusion A high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either incompletely excised or regenerated. While the implications of this residual vaginal epithelium require further investigation, total removal of vaginal tissue primarily or during reconstruction is important given the risk of associated symptoms.

Objective To describe the outcomes of single-stage and staged repairs in properly selected patients with phalloplasty anastomotic strictures. Methods A bi-institutional retrospective review was performed of all patients who underwent anastomotic stricture repairs between 7/2014-8/2020. Those who had prior augmented urethroplasties or poorly vascularized tissue underwent two-stage repairs (Group-2), all others underwent single-stage repair with a double-face (dorsal inlay and ventral onlay) buccal mucosal graft urethroplasty (Group-1). Postoperatively, urethral patency and patient reported outcome measures (PROMs) were assessed. Results Twenty-three patients with anastomotic strictures were identified. Fourteen patients met inclusion criteria and had 1-year follow-up (9 in Group-1; 5 in Group-2). Nine patients (64%) had prior failed interventions (56% Group-1; 80% Group-2). At a mean follow-up of 33.9 (Group-1) and 35.2 months (Group-2) there were two stricture recurrences in Group-1 (22%) and none in Group-2. PROMs were completed by 12 patients. All patients reported the ability to void standing. Post-void dribbling was present in the majority of patients (7/7 Group-1; 2/4 in Group-2). Mean IPSS was 3.9 (0-14) for Group-1 and 1 (0-3) for Group-2. All reported at least a moderate improvement in their condition on GRA (Group-1 +3 71%, +2 29%; Group-2 +3 100%). Conclusion Single-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

Introduction Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated. Objectives To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy. Methods A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries). Results The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or “watershed” procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes. Conclusion There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605–618.

Introduction. Penile agenesis (aphallia) is an extremely rare congenital defect characterized by the complete absence of the penis in a child with a male karyotype 46XY.Material. The analysis of the literature on keywords in the Pubmed and Medline databases was carried out.Results. The incidence of aphallia is estimated 1 out of 10-40 million newborn boys. Aphallia, in spite of its rarity, is a congenital defect which is thoroughly described in the medical literature. The combination of agenesis of the penis with other congenital anomalies often leads to death in such children. Currently, it is believed that these patients should be left with their genetic male sex, therefore, there is a difficult dilemma of choosing the optimal method and age for creating the neophallus and neourethra.Conclusions. The rarity of the aphallia determines the lack of publications covering the long-term results of phalloplasty in both children and adults.

Summary Introduction Phalloplasty is a complex surgical task and remains a significant challenge in plastic surgery. To date, there are various techniques; however, complication rates are still not satisfactory. Here, we present our surgical approach of a modified tube-in-tube concept combining a radial forearm free flap and an anterolateral thigh flap and assess its outcome in a series of female-to-male transsexuals. Patients and Methods In this report, 21 female-to-male transsexual patients were included. The first surgical step includes colpectomy and elongation of the fixed part of the urethra with a full-thickness skin graft. Subsequently, a radial forearm free flap was adapted to build the inner tube which represents the neourethra. For the last step, a free anterolateral thigh flap is utilized as the outer tube of the neophallus. All patients were evaluated regarding aesthetic and functional outcomes as well as postoperative complications and revision surgeries. Results Our results showed a 100% flap survival rate with a mean follow-up of 4.4 years (range, 2.7–6). Three radial forearm free flaps and one free anterolateral thigh flap presented with partial flap necrosis. Generally, complications occurred in 11 patients (52.4%). The most common complications were related to urethral reconstruction including fistula formation (n = 8) and stenosis (n = 5). All except one patient obtained the ability to void while standing. Conclusion Despite the complexity, the initial results are very promising for a single-stage phalloplasty with complete functional creation of a neophallus. Further improvements have to be implemented for reduction of postoperative complications particularly regarding urethral reconstruction. Level of Evidence IV (Therapeutic)

For many transgender individuals, pursuing gender-affirming surgery (GAS) to minimize gender incongruence—commonly referred to as gender dysphoria—is a medically necessary element of comprehensive ...

Background Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. Methods This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Results Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. Conclusion PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

PURPOSE OF REVIEW Although immediate surgical outcomes of genitourinary reconstruction used to be the main focus in hypospadias and exstrophy-epispadias complex (EEC), recent research demonstrates rising concerns about long-term functional and psychosexual outcomes. Recent results about long-term outcomes of complex genitourinary reconstruction in those children transitioning into adulthood are summarized and discussed in this comprehensive review. RECENT FINDINGS Long-term outcomes in hypospadias focus on psychosexual satisfaction and decisional regret. Interestingly, uncomplicated hypospadias repair results in equal satisfaction rates to those found in controls. Most adult patients are happy with their parents' decision to have them undergo surgery during childhood. No decisional regret was found in parents. Reinterventions were associated with a decline in satisfaction, as was a decrease in perceived penile length. Long-term, males with EEC are more dissatisfied with penile length than with continence problems. In cases of severe penile insufficiency, phalloplasty shows promising psychosexual outcomes at the price of a high complication rate. Female EEC patients show higher rates of pregnancy complications, portending a higher risk of miscarriage. SUMMARY Psychosexual satisfaction of patients with repaired hypospadias transitioning into adulthood demonstrates equal satisfaction rates to those found in controls, without decisional regret associated with surgery during childhood. In EEC, more complications are seen when transitioning into a sexually active adult life.

Introduction There have been major advancements in the field of urologic reconstruction and gender-affirming surgeries over the past 10 years. These operations have become increasingly complex involving multiple revisions, with limited healthy native tissue availability. Grafts are frequently needed when a patient's own tissue is expected to have poor wound-healing properties. To reduce the morbidity associated with autologous grafts and complications associated with synthetic grafts, acellular dermal matrices (ADMs) can be used as substitutes in genitourinary surgery as they demonstrate decreased immunogenicity and retaine structural integrity. Objectives The purpose of this review is to describe the importance and potential uses of ADMs by reviewing the literature and highlighting key examples of our institution's expanded application of ADM grafts in genitourinary reconstruction. Methods We performed a literature review for the use of ADMs in genitourinary surgery including the search terms acellular dermal matrix, alloderm, extracellular matrix, penis, penile reconstruction, intrapenile prosthesis, phalloplasty, neophallus, urethroplasty, artificial urinary sphincters, Peyronie's disease, and urology. We highlight 5 representative genitourinary reconstructive cases performed at this institution where ADMs contributed to surgical success. Genitourinary reconstructive surgeries that have used ADMs in the literature included neophallus construction for gender affirmation, phalloplasty for trauma, penile augmentation, and plaque excision and grafting for Peyronie's disease. Results Biomechanical studies across different graft types are limited in genitourinary applications. Initial studies using ADMs indicate benefits of limited inflammatory response, finite elasticity, and substantial tensile strength, acceptably mimicking properties of the native tissue. Conclusion Our experience and the current literature suggest that human ADM is a valuable option for tunica albuginea replacement, but its use to support free grafts should be cautioned secondary to graft take. Haney NM, Huang MM, Liu JL, et al. Acellular Dermal Matrix Tissues in Genitourinary Reconstructive Surgery: A Review of the Literature and Case Discussions. Sex Med Rev 2020;XX;XXX–XXX.

Background Various phalloplasty methods have been reported; however, a consensus has not been reached. Therefore, we suggest an alternative algorithm for an ideal phalloplasty considering the factors that affect flap selection. Methods We retrospectively examined 32 phalloplasty cases of female-to-male transgender. Flaps used for phalloplasty were classified into three groups as follows: (1) radial forearm (RF) group, (2) anterolateral thigh (ALT) group, and (3) flap combination (FC) group. Statistical analyses were performed to determine the significance of age and body mass index (BMI) as well as differences in the rates of postoperative complication, reoperation, esthetic acceptability, tactile or erogenous sensibility, and the ability to urinate while standing. Results Ten cases were included in the RF group and 7 and 15 cases in the ALT and FC groups, respectively. With respect to BMI, the RF group (mean [standard deviation (SD)] = 25.9 [3.3]) showed significantly higher BMI than the ALT (21.7 [0.9]) or FC group (22.2 [4.5]). The RF (mean [SD] = 3.7 [0.4]) and ALT groups (3.5 [0.9]) had significantly higher esthetic acceptability evaluation scores (from 1 to 4) than the FC group (2.5 [1.2]). Moreover, the RF and ALT groups were superior than the FC group in terms of tactile or erogenous sensibility rates. Conclusion BMI effected flap choices for phalloplasty because of the correlation between BMI and skin thickness. FC becomes an option between ALT flap and RF flap in terms of flap choice based on BMI. Our alternative algorithm for an ideal phalloplasty based on BMI will be useful for objective flap choices.

Patients complaining of short penile length pose a challenge in urology practice. Those men who present seeking penile lengthening surgery usually overestimate 'normal' penile length, and may in often cases relate their penile length with the degree of masculinity and self-esteem. Penile prosthetic devices are the gold standard treatment of erectile dysfunction (ED) after failure of conservative options. Penile shortening is the most prevalent long-term complaint after successful inflatable penile prosthesis (IPP) placement. This has a significant impact on patient’s overall satisfaction and quality of life. Using PubMed, we performed a thorough literature review of the current procedures of preservation or enhancement of penile length as well as reported perioperative protocols in patients undergoing penile prosthesis (PP) insertion. Keywords used were “penile lengthening”, “penile enhancement”, “penile girth”, “inflatable penile prosthesis” and “glans augmentation”. Several surgical techniques can be offered in the setting of penile shortening concurrently with PP insertion, e.g., sub-coronal approach of PP placement, sliding technique, modified sliding technique (MoST), multiple-slide technique (MuST), and tunica mesh expansion procedure (TMEP). Adjuvant techniques can also improve subjective penile length include, ventral phalloplasty, suprapubic lipectomy, suspensory ligament release and use of expanding penile implants. Preoperative protocols including use of a vacuum erectile device, traction therapy also seem to improve postoperative outcomes, minimizing postoperative pain, and encouraging the early device use. Currently, there is no consensus among experts on a particular lengthening procedure or when they can be performed to optimize outcomes. Furthermore, it is imperative to set proper expectations before surgery, with extensive patient and partner counseling. When used in the properly selected patient, penile lengthening procedures show promising results with minimal complication rates.

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

Objective To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. Materials and Methods After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. Results In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. Conclusion Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

SUMMARY The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

Background: Our goal in the construction of the transman phalloplasty is not only to decrease the patient’s level of gender dysphoria, obviate the use of an external prosthesis, give the patient the ability to urinate in the standing position and orgasm but also to decrease urinary complications. Material and Methods: A retrospective review of transmen patients from June 2016 to June 2018 was performed on patients undergoing a two- stage mucosa only prelaminated neourethra radial forearm flap phalloplasty. The surgical technique is detailed in addition to patient demographics including co-morbidities, flap complications, and urinary sequelae.

Introduction A variety of factors that can influence patient satisfaction after inflatable penile prosthesis (IPP) surgery, including patient expectations before surgery, intraoperative complications, and perceived penile shortening and partner satisfaction after surgery. While patient satisfaction rates with IPP are high, there are several reported methods to further improve patient satisfaction with IPP. Objective Identifying factors responsible for patient satisfaction after IPP surgery from preoperative counseling, intraoperative techniques, and postoperative care and identifying ways to improve overall patient satisfaction. Methods A PubMed search was performed of all articles available on the database relating to penile prosthesis and patient satisfaction. Results The main outcome measure is patient satisfaction after IPP surgery. Patient satisfaction has been reported to be as high as 90%. Factors affecting postoperative satisfaction include preoperative counseling and expectations, patient comorbidities, partner satisfaction, and postoperative complications. One of the most common complaints is decreased penile length postoperatively. It is critical to accurately measure penile length before surgical intervention. Preoperative strategies to improve penile length with IPP include the use of penile traction therapy and vacuum erection device (VED). Several adjuvant procedures have been described and shown to safely increase penile length with concomitant IPP surgery, including ventral phalloplasty, suprapubic fat pad excision, and modified sliding technique—multiple slice technique. Postoperative penile rehabilitation program has been shown to improve penile length. The use of phosphodiesterase type 5 inhibitors in the postoperative period leads to increased glans engorgement and improved patient satisfaction. Conclusion Patient satisfaction with IPP is influenced by many factors, which can be categorized into 3 distinct patient care stages: preoperative, intraoperative, and postoperative. There are several techniques described in each patient care stage to improve perceived penile length including preoperative counseling and correct penile length measuring, preoperative penile stretching, the use of adjuvant surgical procedures, and postoperative penile rehabilitation. Shah T, Wang R, A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis. Sex Med 2021;9:350–357.

Purpose:Male patients with exstrophy-epispadias complex have a congenitally short penis. Adolescent and adult patients often desire penile reconstruction to enable penetrative intercourse. When pen...

Background Achieving an aesthetic phalloplasty result is important for patients with acquired or congenital defects of the penis, or with genital-related dysphoria. However, aside from length and girth, the aesthetic proportions of the male penis have not been defined. Objectives This study aimed to determine proportions of the male penis through photogrammetric analysis of nude male photographs and to verify these proportions with a crowdsourcing-based survey. Methods Nude male photographs (n = 283) were analyzed to define aesthetic proportions of the male penis. Photographs were analyzed for the position of the penis on the torso in relation to the umbilicus and for the ratio of the dorsal and ventral glans of the penis in relation to the entire shaft length. Proportions were then further studied by crowdsourcing 1026 respondents with Amazon mechanical Turk. Results The ideal position of the penis below the umbilicus is about 55% (6/11th) of the distance from the jugular notch to the umbilicus (measured average, 53.6%; survey-weighted average, 58.9%). The dorsal glans of the penis is about 33% (1/3rd) of the length of the entire shaft (measured average, 32.1%; survey-weighted average, 37.5%). The ventral glans of the penis is about 12.5% (1/8th) of the length of the entire shaft (measured average, 12.6%; survey-weighted average, 11.7%). Conclusions Measured proportions of the human penis follow exact fractions. Crowdsourcing data helped support photogrammetric analysis, with survey-preferred ratios within 5% of measured ratios. With further validation, these data can aid surgeons performing phalloplasty.

Introduction. Penile agenesis (aphallia) is an extremely rare congenital disorder. At present, about 100 cases of the anomaly have been described around the world. The incidence of this congenital anomaly is estimated to be one case per 2030 million births. One of the most commonly used reconstructive procedures today is the technique proposed by Roberto De Castro in 2007. In this article, we present a clinical case of aphallia in a boy who underwent phalloplasty. Materials and methods. A newborn boy presented with aphallia, combined with abnormal development of both kidneys. At birth, the child had difficult urination through the fistula at the edge of the anus. The meatotomy and urethral dilation were performed on the fifth day of the infant`s life. On day 28 of the child`s life, surgical intervention was performed to remove the left non-functioning kidney and a right cutaneous ureterostomy because of the recurrence of febrile urinary tract infection. At 13 months, the tissue expander was installed above the pubic bone. At 16 months, the child underwent the De Castro phalloplasty technique while in the supine position. Results. The child was examined 3, 6, and 12 months after the surgical treatment. Phalloplasty has had good outcomes as evaluated by parents and surgeons. At present, the boy is under the supervision of urologists, who plan to perform further surgical treatment of the urinary system. Conclusion. Phalloplasty, in the case presented, had a good cosmetic result. In our opinion, it proved to be the correct initial stage of treatment for aphallia, an extremely rare genital malformation.

Background Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate. Objective To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes. Methods We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique. Results For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2). Conclusion We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.

Total penile reconstruction is a challenging procedure considering the anatomy and physiology of the organ. A lot of penile reconstructions have been done in the past and many options have been considered, yet there are still problems associated with either function or aesthesis. Many options that were used are still leaving some dissatisfactory. The authors decided to use the anteromedial thigh flap for penile reconstruction which is not a common choice for total phalloplasty. The anteromedial thigh flap is a veritable tool in scrotoplasty. Thus, we present the use of double anteromedial thigh flaps for the reconstruction of the penis.

Bladder exstrophy is a complex of urogenital malformations, varying in severity from epispadias to classical bladder exstrophy. The main aim of correcting bladder exstrophy in childhood is to achieve urine continence with the prevention of upper urinary tract disorders and to provide penile reconstruction. However, by the time of puberty, it is not always possible to achieve optimal anatomical features of the penis, and usually, by the end of puberty, the penile length is no more than 7 cm, which subsequently leads to psychosocial and sexual problems during puberty. Neither patient, nor urologist in most cases do not satisfy final result of the treatment of exstrophy and a number of epispadias forms. A clinical case of the surgical rehabilitation of a patient after undergoing multi-stage surgical treatment for a congenital malformation of the genitourinary system is presented in the article. MATERIALS AND METHODS: At the admission, the size of the penis was 3 cm (microfallia), urethral meatus was located in the area of the penoscrotal junction. From 2016 to 2019, the patient underwent neofallos formation, urethroplasty, and implantation of prostheses in the neophallos. RESULTS: According to the results, urinary and sexual function was completely restored, as well as anatomical relationships and dimensional parameters of the genitals.

Background Gender-affirming surgery is becoming increasingly more common. Procedures including chest masculinization, breast augmentation, vaginoplasty, metoidioplasty, and phalloplasty routinely generate discarded tissue. The incidence of finding an occult malignancy or premalignant lesion in specimens from gender-affirming surgery is unknown. The authors therefore conducted a retrospective review of all transgender patients at their institution who underwent gender-affirming surgery to determine the incidence of precancerous and malignant lesions found incidentally. Methods A retrospective review of transgender patients who underwent gender-affirming surgery at the authors' institution between 2017 and 2018 performed by a single plastic surgeon and a single reconstructive urologic surgeon was conducted. Only transgender patients who underwent gender-affirming surgery that led to routine pathologic review of discarded tissue (mastectomy, vaginoplasty, vaginectomy as part of phalloplasty) were included. Charts were reviewed and patient demographics, duration of hormonal therapy, medical comorbidities, genetic risk factors for cancer, medications (including steroids or other immunosuppressants), pathology reports, and cancer management were recorded. Results Between 2017 and 2018, 295 transgender patients underwent gender-affirming surgery that generated discarded tissue sent for pathologic evaluation. During this period, 193 bilateral mastectomies, 94 vaginoplasties with orchiectomies, and eight vaginectomies were performed; 6.4 percent of all patients had an atypical lesion found on routine pathologic evaluation. Conclusions Gender-affirming surgery is increasingly more common given the increase in access to care. The authors' review of routine pathologic specimens generated from gender-affirming surgery yielded a 6.4 percent rate of finding atypical lesions requiring further evaluation. The authors advocate that all specimens be sent for pathologic evaluation.

Background Until recently, all available erectile devices were manufactured in accordance with the anatomy of a native penis and led to high explantation rates when implanted in the neophallus. Aim The aim of this study was to investigate surgical outcomes after implantation of the ZSI 475 FTM in the neophallus; this is the first erectile device specifically manufactured for implantation after phalloplasty. Methods This is a prospective observational study of patients undergoing implantation of the ZSI 475 FTM in the neophallus at a tertiary referral center since September 2017. Patients with a follow-up < 3 months were excluded from this analysis. Outcomes Intraoperative and postoperative complications were analyzed with descriptive statistics and explantation-free survival was assessed using a Kaplan-Meier survival analysis. RESULTS In total, 57 patients were included with a median (IQR) follow-up of 16 (10-21) months. No intraoperative complications occurred. Postoperative complications were seen in 18 of 57 (32%) patients and included cylinder protrusion (1/57, 1.8%), infection (8/57, 14%), malpositioning (4/57, 7.0%), mechanical failure (4/57, 7.0%), and urinary retention (1/57, 1.8%). A total of 13 of 57 (23%) devices were explanted which corresponds with an estimated explantation-free survival rate (SD) of 84% (4.9), 80% (5.6), and 80% (5.6) after, respectively, 6, 12, and 18 months of follow-up. Clinical implications By better addressing the specific needs after phalloplasty, this innovative erectile device might lead to improved cylinder protrusion, malpositioning, and mechanical failure rates, but device infection remains common. Strengths & limitations This is the largest study on this topic to date and the first to report prospective data. Main limitations involve the relatively small sample size and the limited follow-up. CONCLUSION Short-term cylinder protrusion, malpositioning, and mechanical failure rates are encouraging, although device infection remains a common problem. These complications resulted in a device explantation rate of 23%.

PURPOSE Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps. METHODS We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. RESULTS The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention. CONCLUSIONS Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

This nonsystematic review aims to discuss the contemporary literature about sexual (dys)function in transgender population from the biopsychosocial model point of view, focusing on those patients who underwent gender-affirming genital reconstruction (GAGR). We analyzed the questionnaires and diagnostic tools that have been used to evaluate sexual health-related issues, including the non-specific ones and the ones specifically designed for transgender individuals. All aspects of sexual function including desire, arousal, orgasm, and pain have been shown to be influenced by GAGR. Literature regarding sexual activity in trans women are diverse, showing increase, decrease, and no changes after genital surgery, while sexual satisfaction was shown to be highly related to self-image and self-esteem. Metoidioplasty and flap-based phalloplasty in trans men are successful in treating gender dysphoria, and improving quality of life which commonly lead to high satisfaction rates.

A phalloplasty is a complex genital reconstruction procedure of creating a neophallus. Several techniques to create a neophallus are described, based on different vascularized flaps, and each of them has its advantages and drawbacks. The aim of this study is to present musculocutaneous latissimus dorsi (MLD) flap as a viable option for total phalloplasty, with an interest in clinical outcomes and complications. A comprehensive literature review of all available reports about MLD flap phalloplasty was made. The following keywords were used on PubMed: latissimus dorsi musculocutaneous/myocutaneous free flap and phalloplasty. Research criteria revealed five articles and the results of 182 patients were analyzed. A total number of the patients, indications, operative technique, follow-up period, postoperative results, and complications were presented. In conclusion, MLD free flap presents a good choice for phalloplasty providing sufficient amount of tissue for safe implantation of penile prosthesis and successful penetrative sexual intercourse. The erogenous sensitivity is preserved with clitoris or glans penis incorporated into the base of the neophallus, and voiding in a standing position is achievable after urethral reconstruction. The main drawback is the lack of tactile sensation of the neophallus and the significant advantage is a well-concealed donor site.

Background: Testicular prostheses implantation may be used for neoscrotal augmentation in transgender men. In current literature, explantation rates range from 0.6% to 30% and most are a result of infection or extrusion. Information on the surgical path of individuals after prosthesis explantation is scarce. Aim: To assess the frequency and success rate of testicular prosthesis implantation after previous explantation due to infection or extrusion. Methods: All transgender men who underwent testicular prosthesis explantation between January 1991 and December 2018 were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording demographics, surgical and prosthesis characteristics, reoperations, and outcomes. Results: A total of 41 transgender men were included who underwent testicular prosthesis explantation in the study time period. Of these, 28 (68%) opted for new prosthesis implantation. Most explanted prosthesis had a volume ≥30cc and were replaced with an equally sized one. The postoperative course was uneventful in 19 out of 28 (68%) individuals. Explantation of one or both prostheses occurred in 7 out of 28 (25%) individuals, because of infection (n = 3, 11%) or extrusion (n = 4, 14%). Patients that experienced complications had more often a history of smoking (p = 0.049). The explantation rate was lower if a smaller or lighter prosthesis was reimplanted (p = 0.020). Discussion: Most patients opt for testicular prosthesis implantation after previous explantation due to extrusion or infection. Explantation rates are higher than after the primary implantation procedure. Results of current study can be used to inform individuals on postoperative outcomes.

Background Aesthetic augmentation phalloplasty is a set of procedures aimed at increasing penile length and/or girth; many of these procedures are investigational. This systematic review set out to summarize available literature on these procedures in patients with normal penile anatomy. Methods A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE/PubMed, Scopus, and Cochrane Databases were used to identify articles on aesthetic augmentation phalloplasty in cis-gender men without penile deformity from 1990 to 2018. Data on outcomes, complications, and patient-reported satisfaction were collected. Results Sixteen articles, involving 1192 patients, met our inclusion criteria. Mean age ranged from 23 to 44 years, and follow-up time ranged from 6 to 48 months. The quality of the studies was poor regarding methodology for patient selection and outcomes reporting. Surgical interventions included suspensory ligament incision, grafting, flaps, and penile disassembly. Augmentation was performed for length only in 16 percent of patients, girth only in 70.6 percent, and combined in 13.4 percent. Length gain ranged from 8 to 83 percent in the flaccid state and 12 to 53 percent in the erect state. Girth gain ranged from 16 to 56 percent in the flaccid state and 19 to 30 percent in the erect state. The pooled complication rate was 14.6 percent, with those undergoing combined augmentation having the highest complication rate. Patients were generally satisfied; reported satisfaction rates ranged from 50 to 100 percent. Conclusions Enhancement procedures are controversial and investigational. Data point to inconsistent methodology when reporting penile dimensions, outcomes, and patient satisfaction. Despite the reportedly high satisfaction rates, patients should be counseled regarding high complication rates. Best-practice guidelines will be critical to achieve safe and reliable outcomes.

The loss of a penis has a devastating effect on one’s life with significant psychogenic implications. The main goals of the surgery are to create cosmetically acceptable sensate phallus with a neo-urethra to allow voiding and enough bulk for the insertion of a penile prosthesis. We aim to evaluate the functional and esthetic results of a new single-stage sensate phallus using a deep external pudendal artery as a perforator/propeller (DEPAP) flap, with scrotal septal flap for the urethral reconstruction. A total of 12 male patients (mean age: 35 years), 10 with normal BMI and 2 overweight, presented with penile amputation underwent penile reconstruction with the unilateral DEPAP flap. The urethra was reconstructed, employing a scrotal septal flap, using the tube in the tube technique. Donor sites in both flaps were closed primarily. Penile prosthesis insertion was performed 6 months post-operatively. Sexual function evaluation was carried out using the International Index of Erectile Function (IIEF). Average operative time was 180 min. Flap survival and urethral reconstruction were uneventful, except for one case of distal tip necrosis of the flap which healed by secondary intention. Patients obtained sensate penis with good length and contour, allowing penile prothesis implantation and voiding in upright position. IIEF revealed satisfactory erection and penetrative intercourse, indicating favorable sexual functioning. The DEPAP flap, wreathen scrotal septal flap, has proven to be a highly reliable technique for single-stage phalloplasty, with excellent esthetic appearance, same skin color, providing a good contour and sensate pleasure. Donor site morbidity was negligible. Level of evidence: Level IV, therapeutic study.

As described by Straayer, the phantom penis in transgender men combines feelings of loss and potential and may contribute to self-authentication and pleasure following phalloplasty. To align their ...

Background The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals. Objective The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty. Material and methods Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years. Results Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%. Conclusion Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

To describe the surgical treatments available to transgender women and men desiring gender-affirming surgery (GAS). Transgender patients who undergo GAS have high satisfaction and improved quality of life. Masculinizing procedures include chest reconstruction, facial masculinization surgeries, hysterectomy with bilateral salpingo-oophorectomy, metoidioplasty, and phalloplasty. Feminizing procedures include facial feminization surgeries, chondroplasty and voice surgeries, breast augmentation, orchiectomy, and genital surgeries, such as vaginoplasty and vulvoplasty. Vaginoplasty can be performed with inversion of penile skin, sigmoid colon, or peritoneal flaps. The most common GAS surgery in the United States is chest masculinization surgery. Major complications after penile-inversion vaginoplasty are infrequent. A wide range of surgical options exist for the treatment of gender dysphoria. In recent years, systematic reviews and meta-analysis data have shown high satisfaction and more consistent complication rates for GAS. Limited, multicenter data exist regarding surgical techniques, outcomes, and complications.

Introduction A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis. Methods We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing. Results Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing. Conclusions Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

This case report highlights the importance of a wide differential diagnosis in transgender patients. A 77-year-old transgender (female-to-male) with recurrent urinary tract infections (UTI) and obstructive voiding difficulties presented with a perineal cyst. Further examinations, including computed tomography (CT) and puncture, revealed that the patient had a symptomatic Bartholin gland cyst, a phenomenon that normally only affects women. In his gender confirmation surgery (GCS) 30 years before, the patient’s female labia minora and Bartholin glands were used to lengthen the urethra for the phalloplasty. This explains the unusual location and the prolonged time to the correct diagnose. We decided to perform an incision of the fluid collection from perineal. A follow-up sonography after one month revealed a remaining cyst size of 6 mL, which was assumed to be residual fluid or newly produced liquid; however, the patient has not had any UTIs since the incision of the cyst. Our case seems to be the first description of a symptomatic Bartholin gland cyst in a trans man. This stresses the importance of an expanded understanding of sex/gender concepts, and underlines one of the many possible diagnostic pitfalls when treating trans people.

Gender affirmation surgery is increasingly prevalent; however, finding a surgeon continues to be difficult. Additionally, the majority of transgender patients utilize the internet for information before elective surgery. Therefore, it is imperative to explore potential online barriers in finding a gender affirming surgeon. The authors sought to use the Internet to search for gender affirming surgeons practicing in the USA, and therefore, reflect the process that patients potentially undergo. We highlight the barriers to information and care that we encountered. We conducted a comprehensive review of public online transgender surgery directories for currently practicing surgeons that provide facial feminization, facial masculinization, breast augmentation, chest masculinization, vaginoplasty, metoidioplasty, and/or phalloplasty in the USA. Each surgeon’s name, surgical specialty, the current practice’s name, state, and zip code, and procedures provided were recorded. Chi-square analysis was used for comparisons of categorical variables. There are currently 660 gender affirmation surgeons in the USA, with most specializing in plastic surgery, followed by otolaryngology and urology. In total, 30.5% of surgeons practice in the West, 25.6% in the Northeast, 25.3% in the South, and 18.6% in the Midwest. The most common surgery provided was chest masculinization (70.2%), followed by facial feminization (42.7%) and chest feminization (42.6%). Plastic surgeons are most likely to perform gender affirmation surgery compared to other specialties. Geographic distribution of surgeons, does not, however, match the distribution of patients. Additionally, we encountered significant hardship in confirming that a surgeon performs the procedure listed in their profile on popular online gender affirmation surgeon directories. V

Many men often have the need to enlarge their penises for psychological gain and to satisfy or to impress their partners. Many surgical techniques have been reported. However, none is the gold standard.To evaluate the efficacy and safety of human acellular dermal matrix allograft in augmentation phalloplasty technique.From March 2015 to September 2017, a total of 182 patients were prospectively recruited into our cohort after complete physical and psychological evaluation that deemed suitable for penile enhancement. Penis circumference was measured at the mid-length of the penis. Mean was 7.03 cm (6.93 ± 1.00 cm) and 12.1 cm (10.59 ± 1.15 cm) during flaccid and erection, respectively. All patients received human acellular dermal matrix graft under spinal or local anesthesia. The allograft was preconditioned in normal saline for 20 minutes, and mesh incisions were made to optimize blood flow. The width was equal to the circumference of both corpus cavernosa but without corpus spongiosum. The length of the graft was determined by measuring the length between the tip of the coronary sulcus and the root of penis. A complete incision below the coronary sulcus to the depth of the Buck's fascia was made. Then separate the dartos fascia from the Buck's fascia. The prepared graft was then placed on top of the Buck's fascia, with the blood-remained side facing the Buck's fascia. The graft was sutured using 4-0 absorbable polyglycolic acid suture to the Buck's fascia. Extra caution needed to be taken when fixing ventrally to avoid injuring the urethra. Once completed, the dartos fascia was restored, the dartos fascia and subcutaneous tissue were sutured with 4-0 absorbable suture, and skin closure is achieved subsequently.The post-operative course was without complications. At the follow-up after 1 year, the mean flaccid girth increased to 8.07 ± 1.06 cm (Compared to autologous dermis-fat graft and xenograft, augmentation phalloplasty using human acellular dermal matrix has several advantages: (1) it avoids harm harvesting site of the autograft; (2) the effects of dermis allograft can last at least 1 year; and (3) acellular dermal matrix is more likely to be accepted by people.De nombreux hommes ressentent le besoin de subir une augmentation du pénis pour des raisons psychologiques et pour impressionner leur conjointe. Il existe de nombreuses techniques chirurgicales, mais aucune n’est la norme de référence.Évaluer l’efficacité et l’innocuité de l’allogreffe par matrice dermique acellulaire dans la technique de phalloplastie.De mars 2015 à septembre 2017, 182 patients ont fait l’objet d’un recrutement prospectif après une évaluation physique et psychologique complète jugée convenable pour l’augmentation pénienne. La circonférence du pénis était mesurée à mi-longueur. La moyenne était de 7,03 cm (6,93±1,00 cm) flasque et de 12,1 cm (10,59±1,15 cm) en érection. Tous les patients ont reçu une greffe de matrice dermique acellulaire humaine sous anesthésie spinale ou locale. L’allogreffe était préconditionnée 20 minutes dans une solution physiologique, et des incisions en treillis étaient pratiquées pour optimiser la circulation sanguine. La largeur était égale à la circonférence des deux corps caverneux, mais sans le corps spongieux. La longueur de la greffe était déterminée par la mesure de la longueur entre le bout du sillon coronaire et la racine du pénis. Une incision complète était pratiquée sous le sillon coronaire jusque dans la profondeur du fascia de Buck, puis le fascia du dartos était séparé du fascia de Buck. La face sur laquelle se trouve le sang de la greffe préparée était ensuite placée sur le fascia de Buck. La greffe était cousue au fascia de Buck à l’aide d’une suture d’acide polyglycolique absorbable 4-0. Il fallait faire preuve d’une extrême prudence pour la fixer sur la face ventrale afin d’éviter d’endommager l’urètre. Une fois l’intervention terminée, le fascia du dartos était restauré, le fascia du dartos et les tissus sous-cutanés étaient cousus à l’aide d’une suture absorbable 4-0, puis la peau était refermée.L’évolution postopératoire s’est déroulée sans complications. Au suivi au bout d’un an, la circonférence flasque moyenne était passée à 8,07±1,06 centimètres (Par rapport à la greffe autologue de derme et de graisse et à la xénogreffe, la phalloplastie d’augmentation par matrice dermique acellulaire humaine comportait plusieurs avantages : 1) elle évite les dommages au foyer de prélèvement de l’autogreffe; 2) les effets de l’allogreffe du derme peuvent durer au moins un an; 3) la matrice dermique acellulaire est plus susceptible d’être acceptée.

Adult males with exstrophy-epispadias complex (EEC) are commonly dissatisfied with their genitalia and desire greater sexual normality. These patients have typically had several previous genital/pelvic procedures and there are specific considerations that must be taken into account if operative intervention is being considered. Genital reconstruction in the form of phalloplasty presents an option for improving sexual function. The majority of studies have focused on the radial free forearm flap (RFFF) phalloplasty with subsequent insertion of penile prosthesis (PP). Long-term cosmetic and functional satisfaction is high. Early urethral complications are common and PP-related complications are higher than in other patient populations. Genital reconstruction is a safe procedure for EEC males with good long-term functional and cosmetic satisfaction. RFFF phalloplasty represents the most complete surgical option and should be considered in carefully selected patients.

Aphallia is an extremely rare congenital malformation of unknown cause. The incidence is reported in the literature to be 1 in 10-30 million live births. Almost 100 cases have been described to date. Aphallia is associated with other congenital malformations (in particular urogenital and gastrointestinal anomalies) in >50% of cases. The diagnosis is made clinically and shows the complete absence of the corpora cavernosa and the corpus spongiosum with a urethral opening along the perineal midline (most frequently ventral to the anus and in the ventral rectal wall). Two case reports from the authors' department: The first child was a male newborn (46,XY) with penis agenesis and additional bilateral intraabdominal testis, an anorectal malformation (ARM) with a rectovesical fistula, as well as left renal duplication and grade III vesico-ureteral reflux on the right side. The second child was a male newborn (46,XY) with aphallia without further urological or anorectal malformation. Only right inguinal hernia was present. In the first patient, several corrective surgeries were performed in the further course in view of the additional malformations. With regard to the aphallia, the various temporary treatment options (scrotal or parascrotal phalloplasty or penis prosthesis) were discussed with the parents. Masculinizing surgery by means of definitive phalloplasty was planned once the patient has reached puberty. Due to the technical demands of phallus reconstruction, feminization is still favored in some countries in the literature, which nowadays, however, cannot be justified medically or legally.

Background Phalloplasty often requires free tissue transfer. There is ample literature describing flap-related outcomes, but the microsurgical technique used, including choice of recipient vessels, has been an overlooked yet important topic. In this study, the authors review the outcomes of their experience with the deep inferior epigastric artery and locoregional veins and outline technical modifications that occurred during the study period. Methods A retrospective chart analysis of patients who underwent microsurgical phalloplasty between September of 2016 and July of 2019 was performed. Variables included flap design, donor site, and recipient vessels. The outcome measures were return to the operating room for flap compromise and partial or complete flap loss. Results Forty-two phalloplasties using the deep inferior epigastric artery were identified. There were six take-backs for flap compromise, and four patients required venous revision, one of whom lost his urethral flap on postoperative day 9. There was a decrease in take-back rate from 30 percent in the first 20 patients to 0 percent in the second 22 patients in the study period. A total of 11.9 percent of patients had partial flap loss. This decreased from 15 percent to 9 percent in the two groups. Conclusion After an initial learning curve, the combination of deep inferior epigastric artery, deep inferior epigastric vein, and great saphenous vein combined with specific technical modifications such as targeted coagulation of the vasa nervorum of the clitoral nerve has proven to be a reliable technique. Clinical question/level of evidence Therapeutic, IV.

Objectives There are multiple approaches to vaginectomy for the purpose of masculinizing gender-affirming genital surgery including mucosal fulguration and excision. The outcomes of the approaches are not well described. We aim to describe the surgical outcomes of gender-affirming vaginectomy and colpocleisis by complete mucosal excision. Methods We performed a case series study of 40 transmasculine patients who underwent gender-affirming vaginectomy and colpocleisis. Vaginectomy was performed by complete excision of the vaginal mucosa via a transperineal approach. We recorded perioperative outcomes and operative time. We performed a multivariate analysis to assess patient factors on operative outcomes. Results Forty vaginectomies were performed between September 2016 and April 2019, 27 (67.5%) in phalloplasty patients and 13 (32.5%) in metoidioplasty patients. Perioperative complications included 2 blood transfusions, 1 pelvic hematoma, and 1 Clostridium cifficile colitis. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased significantly with later surgery year. Conclusions This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.

Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.

Introduction Although an infrequent cause of small penile size in adult men, acquired penile shortening represents a particular reconstructive challenge due to preexisting penile anatomic deformities. Aim With numerous techniques being performed, the purpose of our study is to assess available literature on length enhancement procedures used for acquired penile shortening deformities. Methods A systematic review was performed using the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-analyses. Medline/PubMed, Scopus, and Cochrane Databases were used to identify papers on augmentation Phalloplasty in non-transgender males with acquired penile shortening from 1990 to 2018. Main Outcome Measure Outcomes, complications, and patient-reported satisfaction were analyzed. Results 12 articles, involving 931 patients and 8 primary procedures, met our inclusion criteria. The majority of articles had level of evidence of 4 (83%) and Newcastle Ottawa Scale score of 6 (92%, moderate risk of bias). All studies reported mean penile length gain; however, inconsistent methodology was used when measuring penile dimensions. Mean length gain ranged from 0.6 to 6.4 cm. Overall, the mean complication rate for all techniques ranged from 0% to 50%. Post-operative satisfaction was reported in 10 (83%) studies, 7 of which used a validated scale. Patients were generally satisfied, with reported satisfaction rates ranging from 77% to 100%. Clinical Implications While numerous procedures have been described, the significant limitations in the available data preclude identifying a single superior procedure. Strengths & Limitations The significant heterogeneity in the reported literature is a limitation of this study and highlights the need for standardized reporting. However, this study is the first to analyze augmentation phalloplasty literature in the setting of acquired penile shortening. Conclusion Augmentation phalloplasty techniques for acquired penile shortening are evolving and are continuously being modified; best-practice guidelines are crucial to achieve safe and satisfactory outcomes in this population.

OBJECTIVE. The purpose of this article is to provide an overview of common gender affirmation surgical therapies, define key anatomy, and describe select complications using multidisciplinary, multimodality approaches. CONCLUSION. Gender affirmation therapy may be tailored to the needs of each individual patient. There are three major categories of gender affirmation surgery: genital reconstruction (comprising vaginoplasty and either metoidioplasty or phalloplasty), body contouring, and maxillofacial contouring (facial feminization or masculinization). If encountered in diagnostic imaging, routine evaluation should take into consideration normal postsurgical anatomy and key associated unique complications.

Introduction Management of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases. Materials and methods A total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction. Results Follow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula. Conclusions Severe penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

Objective This study aimed to evaluate the long-term outcomes of phalloplasty and explore the clinical significance and selection of methods for penile reconstruction. Methods The same surgical team performed primary phalloplasty in 166 nontranssexual patients using different surgical approaches between September 2000 and September 2020. All patients had at least 6 months of follow-up. Surgical techniques, complications, and outcomes were retrospectively recorded. Results A total of 166 patients with indications such as penile trauma (n = 68 [41%]), amputation injury (n = 15 [9%]), iatrogenic (n = 13 [8%]), penile aplasia (n = 54 [32%]), genital ambiguity (n = 15 [9%]), and Peyronie disease (n = 1 [0.6%]) underwent different techniques of phalloplasty. Four patients (2.4%) had total flap necrosis, and 17 (10%) had partial flap necrosis. The total urethral complications rate was 32.5% (54 of 166); however, all the patients were able to void while standing after successful corrective surgery. Conclusions Individualized selection of appropriate penile reconstruction methods tailored to the cause of penile defect, patients' personal needs, thickness of donor site, and the blood supply of the flap are conducive to achieving satisfactory treatment results, reducing complications, and improving patient satisfaction. We believe that a scapular flap has certain advantages in nontranssexual patients, whereas other flaps also have their own indications.