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Objective Methods Results Conclusion To review the available literature on variant genital gender‐affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes.A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five‐criteria quality assessment checklist.In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self‐dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias.This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender‐diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures. [ABSTRACT FROM AUTHOR]

Gender-affirming surgery (GAS) is increasingly being performed. GAS is tailored to the patient leading to a diverse spectrum of radiologic post-operative findings. Radiologists who are unfamiliar with expected anatomic alterations after GAS may misdiagnose important complications leading to adverse patient outcomes. This collaborative multi-institutional review aims to: Describe relevant embryology and native anatomy. Describe relevant Gender-Affirming Surgery (GAS) techniques and expected neo-anatomy with associated complications, including common terminology. Review expected imaging appearance of neo-anatomy/postoperative findings. Review multi-modality [ultrasound, plain film, retrograde urethrogram, computed tomography] emergent imaging findings. Understand unique patient evaluation and imaging protocol considerations in the GAS population. Discuss pearls and pitfalls of imaging in the acute post-GAS setting. [ABSTRACT FROM AUTHOR]

Nail growth disturbance commonly takes place after trauma or relevant diseases, such as infections and tumors. However, abnormal growth of the nail plate sometimes occurs without an obvious causative factor. This report presents the case of a patient who underwent male genital reconstruction with a radial forearm free flap for gender affirmation. Although the entire process was smooth, with no accidental events, the second, third, and fourth phalangeal nail plates of the hand from which the flap was harvested showed no evident growth of the fingernail 2 months postoperatively. Nail production was preserved in the remaining fingernails. Typical symptoms, such as redness, swelling, and tenderness, were noted upon clinical observation. Eventually, nail production restarted 5 months after surgery. Steroid and antibiotic treatment was attempted to reduce periungual inflammation. Additionally, close observation with psychological support was conducted. [ABSTRACT FROM AUTHOR]

Hypospadias is a common congenital anomaly in males and frequently the patient undergoes multiple surgeries and may have complications. The treatment of severe "iatrogenic strictures" presenting in adulthood resulting from childhood hypospadias surgeries continues to be a challenge. The complexity of these cases is increased manifold due to the reasons of delayed presentation of many decades, varying lengths of the stricture, as well as poor healing capacity due to scarred territory from previous surgical attempts and associated complicating factors of renal failure and fistulae. In this paper, a case of reconstruction of a severe urethral stricture in a hypospadias cripple using a pedicled anterolateral thigh flap is reported. [ABSTRACT FROM AUTHOR]

Introduction The aim of this study was to evaluate the outcomes of different urethroplasty procedures as well as two novel techniques, invented in our center, in management of urethral complications after total phallic reconstruction. Material and methods Different urethroplasty procedures were conducted according to the urethral pathology for 36 cis-male patients with urethral complications after total phallic reconstruction including meatoplasty, visual internal urethrotomy, staged Johanson urethroplasty utilizing either buccal mucosal graft or skin graft (Tiersche-Duplay principle), non-transecting urethroplasty (Hieneke-Miiklulicz principle), excision and primary anastomosis, as well as two novel techniques: urethral closure under a suprapubic tunnel and abdominal pedicled skin flap urethroplasty. Each patient was routinely evaluated one month after surgery and every 3 months for 12 months, with clinical evaluation, uroflowmetry and post-void residual urine. Results With a total of 41 procedures for the 36 patients, 32 patients (88.8 %) could eventually void while standing. The success rate was highest for staged Johanson urethroplasty using split thickness skin graft, staged abdominal pedicled skin flap and excision and primary anastomosis, respectively, while it was lowest for visual internal urethrotomy (0% success) and non-transecting anastomotic urethroplasty (50% success). For staged versus one-stage procedures prospective analysis, 17 out of 26 one-stage procedures (65.4%) succeeded while 13 out of 15 staged procedures (86.6%) succeeded. Conclusions Urethral complications following phalloplasty require complex procedures demanding a high level of surgical expertise. Abdominal pedicled skin flap urethroplasty is a viable option for long and recalcitrant urethral strictures. [ABSTRACT FROM AUTHOR]

Hypospadias is a common congenital anomaly in males and frequently the patient undergoes multiple surgeries and may have complications. The treatment of severe “iatrogenic strictures” presenting in adulthood resulting from childhood hypospadias surgeries continues to be a challenge. The complexity of these cases is increased manifold due to the reasons of delayed presentation of many decades, varying lengths of the stricture, as well as poor healing capacity due to scarred territory from previous surgical attempts and associated complicating factors of renal failure and fistulae. In this paper, a case of reconstruction of a severe urethral stricture in a hypospadias cripple using a pedicled anterolateral thigh flap is reported.

Introduction: Penile size and circumference are extremely important issues for many men, dissatisfaction with these parameters makes many patients seek medical help every year. Method: We performed penile filling with hyaluronic acid on 52 men and described the technique applied. Results: Patients initially had 9.71 cm (+ SD 1.06) of penile circumference and after hyaluronic acid application, 12.61 cm (+ SD 1.03) of penile caliber with p<0.001 and 95% CI. Hyaluronic acid average volume was 15.55 mL (+ SD 3.31). Discussion: When performing penile enlargement with hyaluronic acid, safety must be considered. Penile enlargement with HA main limitations, are difficulties associated with injection technique and beginners' learning curve. Conclusion: Hyaluronic acid proved to be safe and effective way to perform these procedures and new studies will be necessary for long-term evaluations. [ABSTRACT FROM AUTHOR]

The burgeoning field of gender affirmation surgery (GAS) has become increasingly complex, challenging plastic surgeons to meet high standards for their patients. During the COVID-19 pandemic, the emphasis on remote learning ushered in the increased use of surgical simulation training, offering residents the opportunity to trial challenging procedures before treating patients. This systematic review seeks to summarize current simulation training models used in GAS. A systematic review was conducted according to PRISMA-P guidelines using the following databases: PubMed , Medline , Scopus , Embase , Web of Science , and Cochrane. Inclusion criteria were English-language peer-reviewed articles on surgical simulation techniques or training related to the field of gender surgery. Skills and techniques taught and assessed, model type, equipment, and cost were abstracted from articles. Our search criteria identified 1650 articles, 10 of which met the inclusion criteria for data extraction. Simulation models included those that involved cadavers (n = 2), synthetic benchtop (n = 5), augmented/virtual reality (n = 2), and 3D-printed interfaces (n = 1). The most common procedure involved breast or pectoral reconstruction and/or augmentation (n = 5), followed by vaginal reconstruction (n = 3). One simulation model involved facial GAS. All models focused on surgical technique and anatomy, three on suture skills or knot-tying, and one on surgical decision-making. The evolving field of GAS requires that plastic surgery trainees be knowledgeable on surgical techniques surrounding this scope of practice. Surgical simulation not only teaches residents how to master techniques but also helps address the sensitive nature of GAS. [ABSTRACT FROM AUTHOR]

Objective: To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender‐affirming surgery (GAS). Methods: A narrative review was performed using the following keywords: 'gender‐affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. Results: The most common feminising genital GAS performed is a vaginoplasty. The main post‐surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. Conclusion: Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow‐up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender‐inclusive environment for all patients. [ABSTRACT FROM AUTHOR]

This review discusses issues and concerns in the management of aphallia, updating status of a post-pubertal individual who required further surgery after having initial surgery for aphallia as an infant. Through this case, which discusses an 18-year-old young adult who had penile agenesis, who desired further phalloplasty involving glanuloplasty and implantation of an erectile device, we highlight the importance of periodic evaluation and close follow up. Surgery during infancy or early childhood to create a penis is important for gender development in a boy, especially if there were functional testes during fetal life, even if this surgery would only be the first stage. There is a strong probability of subsequent surgery after initial phalloplasty before puberty, even with the use of currently refined techniques. Here we discuss the changing techniques that document the ongoing, continued refinement of these procedures, highlighting that further outcome data are needed to identify ways to further optimize current techniques. [ABSTRACT FROM AUTHOR]

Abstract Background Phalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis. Methods In this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed. Results The results gathered included the physician’s view on the model’s accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons’ undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility. Conclusions This study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

Background: Phalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis. Methods: In this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed. Results: The results gathered included the physician's view on the model's accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons' undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility. Conclusions: This study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application. [ABSTRACT FROM AUTHOR]

This case report presents two female-to-male (FTM) patients, aged 21 and 35 years, respectively, who underwent phalloplasty and urethral reconstruction at our institution. The patients' requests included a phallus >9 cm, concealed donor-site scars, and the ability to void while standing. In the first case, a 4.5×13-cm radial forearm free flap (RFFF) taken from the nondominant side was retrieved and anastomosed to the deep inferior epigastric artery and vein. Simultaneously, a 10×16-cm pedicled anterolateral thigh (ALT) flap was relocated to the genital area and wrapped around the RFFF after nerve coaptation. The second case involved a 5.5×14-cm RFFF and a 20×13-cm pedicled ALT flap using a similar procedure. Both cases had stable double flaps with no complications, and Foley catheters were removed at 14 days and 3 months after surgery, respectively. Double-flap phalloplasty is thus a viable option for patients with a short forearm circumference or a preference for a less visible forearm scar. [ABSTRACT FROM AUTHOR]

An aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective. [ABSTRACT FROM AUTHOR]

L'objectif de cet article est de faire un point sur la technique de phallopoièse par lambeau antébrachial radial libre dans le cadre de la chirurgie de réassignation sexuelle femme à homme avec un accent particulier sur les détails techniques chirurgicaux et sur la prévention des complications postopératoires. À l'aune de nos 30 dernières années d'expérience de prise en charge des personnes transgenres femme à homme et d'une lecture critique de la littérature, nous présentons de manière exhaustive notre technique de phallopoièse par le lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme. La technique de phallopoièse par lambeau antébrachial radial libre réalisant la construction du néo-urètre et du néo-phallus en un temps opératoire selon le principe de « tube dans un tube » permet d'obtenir non seulement un aspect esthétique du néo-phallus ressemblant à une verge normale avec des sensibilités tactiles et érogènes mais également un néo-urètre fonctionnel et une rigidité pénienne satisfaisante à l'aide d'implants permettant d'uriner debout et d'avoir des rapports sexuels. C'est une procédure chirurgicale complexe nécessitant non seulement une grande qualité d'exécution des tous les gestes chirurgicaux mais également des soins postopératoires de haut niveau. Malgré les raffinements techniques apportés durant ces dernières décennies, les séquelles esthétiques au niveau du site donneur du lambeau restent critiquables et les complications postopératoires, notamment vasculaires et urologiques, demeurent élevées. Une optimisation de la technique chirurgicale de ce procédé sera nécessaire dans le futur afin de minimiser les complications postopératoires et d'établir un véritable « gold standard » technique de la phallopoièse pour les personnes transgenres femme à homme. The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals. [ABSTRACT FROM AUTHOR]

La chirurgie génitale de masculinisation dans le cadre d'une incongruence de genre se caractérise par la reconstruction d'organes génitaux masculins selon de multiples techniques chirurgicales — phalloplasties par lambeau libre, par lambeau pédiculé ou métaoïdioplastie — que cet article se propose de décrire. Une revue de la littérature de type narrative s'intéressant à ces chirurgies chez les homme trans a été réalisée. Chaque technique comporte des avantages et inconvénients spécifiques, et ne produit pas les mêmes résultats que ce soit en termes de risques chirurgicaux, taille du phallus reconstruit, sensibilité, fonction sexuelle et fonction urinaire. Cette décision chirurgicale doit donc être partagée avec la personne concernée selon une compréhension approfondie de ses attentes et objectifs. Un suivi à long terme est recommandé. Genital surgery for masculinisation in the context of gender incongruence is characterised by the reconstruction of male genitalia using multiple surgical techniques — free flap phalloplasty, pedicled flap phalloplasty or metaoidioplasty — which this article aims to describe. A narrative review of the literature on these trans surgeries was carried out. Each technique has specific advantages and disadvantages, and does not produce the same results in terms of surgical risks, size of the reconstructed phallus, sensitivity, sexual function and urinary function. This surgical decision must therefore be shared with the person concerned, based on a clear understanding of their expectations and objectives. Long-term follow-up is recommended. [ABSTRACT FROM AUTHOR]

Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0–6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty. [ABSTRACT FROM AUTHOR]

Background Gender-affirming phalloplasty has a complication rate as high as 76.5%. This is the first study to determine the predictors of 30-day complications following phalloplasty using a national registry.

Introduction and hypothesis: The objective was to comprehensively analyze YouTube™ videos focusing on genital gender-affirmation surgery (GAS) from the perspective of urologists and gynecologists and to utilize results to create educational videos for transgender individuals with accurate and engaging content. Methods: A YouTube search was performed using the keywords "Metoidioplasty," "Phalloplasty," "Gender affirmation surgery," "Transgender surgery," "Vaginoplasty," and "Male-to-female surgery." Video results that were duplicated, non-English, of low relevance, non-audio, and/or short duration (under 2 min) were excluded. The upload source was classified as university/nonprofit physician or organization, health information websites, medical advertisement/for-profit organizations, or individual patient experience. Viewer engagement metrics were obtained for each video. Each video was evaluated using the DISCERN, Global Quality Score (GQS), and Patient Education Materials Assessment Tool for audio-visual content (PEMAT A-V) tools. Results: A total of 273 videos were evaluated. Viewer engagement metrics of videos from the patient experience group were higher than those of both universities/nonprofit physicians and medical advertisement/for-profit groups. DISCERN and GQS scores were significantly lower in videos uploaded by the patient experience group than in each of the other upload sources. More videos covered female-to-male (FtM) transition (168, 61.5%) than covered male-to-female (MtF; 71, 26.0%), and both (34, 12.5%). MtF transition videos had significantly higher total view counts than videos from the other groups (p<0.001). The like counts of videos were significantly higher in both MtF transition and FtM transition groups than for videos explaining both types of transition within the same video. The total DISCERN score was significantly lower in FtM transition videos than in the other content groups. Two educational videos were prepared, informed by the tools and results of this study, and hosted on YouTube. Conclusions: The findings suggest that genital GAS videos with less technical content have higher audience engagement. This information should be used to aid medical organizations when creating YouTube content to provide accurate information to larger audiences in the transgender community. [ABSTRACT FROM AUTHOR]

Nous présentons ici le cas d'un patient de 38 ans ayant bénéficié d'une phalloplastie faite par lambeau perforant thoracodorsal avec conformation par enroulement en double tube. Alors que la chirurgie de reconstruction de verge a vu une efflorescence de différentes techniques opératoires, la chirurgie de réassignation femme-homme qui en découle voit ces procédés se résumer a deux ou trois options. Si le temps préopératoire fait classiquement l'objet d'une discussion avec le patient d'un allongement des voies urinaires ou non ou encore d'une implantation secondaire ou non, le choix du site donneur reste trop systématisé. Le prélèvement d'un lambeau n'est pas sans risque. L'attention est trop souvent portée sur le site reconstruit au détriment du site prélevé. Dans le cas présent, la laxité de la région dorsale avec possibilité de fermeture directe nous a fait retenir le prélèvement d'un lambeau perforant thoraco dorsal. La fonction musculaire du site donneur est préservée et l'aspect esthétique affiné par fermeture directe. La finesse du lambeau obtenu a permis la conformation par enroulement en double tube tel que décrit par Chang. La revue de la littérature rapporte un cas de phalloplastie par lambeau perforant thoracodorsal avec allongement des voies urinaires par greffe. Aucun cas n'est décrit avec conformation en double tube à notre connaissance. This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty. [ABSTRACT FROM AUTHOR]

Objective: Dissection of the dorsal nerves of the clitoris (DNC) is an important step in most gender-affirming phalloplasty techniques. Understanding DNC anatomy also facilitates safe vulvar and clitoral surgery. However, the surgical anatomy of the DNC has only recently been thoroughly described in the literature, and dissection of the DNC has not traditionally been a routine part of genitourinary surgical education.1,2 With procedures involving the DNC (e.g. gender-affirming phalloplasty) increasing in frequency, surgical resources are needed to better illustrate and teach this critical dissection. In this video, we demonstrate a safe, efficient and reliable approach to dissection of the DNC. Patients and surgical procedure: This video is a demonstration of an approach to dissection of the dorsal nerve of the clitoris in a gender-affirming phalloplasty procedure. Results: The DNC is a critical structure for erogenous and sexual function and its dissection should always be approached cautiously to avoid injury. The DNC is formed from branches of the pudendal nerve and travels below the inferior public ramus along the posterior edge of the clitoral crus [3]. Inferior to the pubic symphysis, at the angle of the clitoral body, the dorsal clitoral nerves enter the deep component of the suspensory ligament of the clitoris.1,2 At the base of the clitoral body the dorsal nerves are superiorly suspended away from the clitoris before they descend inferiorly along the clitoral body. At this level, the DNC are large, approximately 2–3.2 mm, traveling at 10-11 and 1-2 o'clock positions along the clitoral body. We approach the DNC at this level by releasing the suspensory ligament of the clitoris and dissecting through the clitoral fascia. Conclusions: Dissection of the dorsal nerve of the clitoris (DNC) is a critical step in many gender-affirming phalloplasty procedures. A thorough understanding of its surgical anatomy is also necessary for safe vulvar surgery. In this video, we demonstrate a safe, efficient and reliable approach to dissection of the DNC.

1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty. [ABSTRACT FROM AUTHOR]

Background: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. Aim: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. Methods: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. Outcomes: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. Results: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. Clinical Implications: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. Strengths and Limitations: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. Conclusions: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution. [ABSTRACT FROM AUTHOR]

Alfredo Berrettini,1 Irene Paraboschi,1 Massimo Di Grazia,1 Michele Gnech,1 Guglielmo Mantica,2 Dario Guido Minoli,1 Erika Adalgisa De Marco,1 Gianantonio Manzoni,1 Marco Capece,3 Alessandro Palmieri,3 David Ralph,3 Vincenzo Mirone3 1Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy; 2Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy; 3Department of Urology, Azienda Ospedaliera Universitaria “Federico II”, Napoli, ItalyCorrespondence: Irene Paraboschi, Department of Pediatric Urology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milano, Italy, Tel +393313229495, Email irene.paraboschi01@gmail.comAbstract: We present the first case of a patient born with congenital fusiform megalourethra who underwent the successful placement of an inflatable penile prosthesis (IPP) and mesh phalloplasty due to primary erectile dysfunction (ED). After an extensive psychosexual assessment and a preoperative MRI scan, an IPP was successfully implanted. The procedure was carried out through a penoscrotal approach, which offered excellent exposure to the crura and the proximal ends of the corpora cavernosa. Following the incision and the dilatation of both corpora cavernosa, the penile cylinders were inserted and a mesh phalloplasty was performed, to replace the erectile tissues lacking in the distal corpora cavernosa. After reservoir and pump placement, the device was tested, and no mechanical issues were recorded. The postoperative course was uneventful, and, at the 2-year follow-up, the patient reported highly satisfactory results, with valid functional erections.Keywords: congenital fusiform megalourethra, inflatable penile prosthesis, phalloplasty, erectile dysfunction

Aims: Transmasculine genital reconstructive surgery involves the creation of a neourethra by way of metoidioplasty or phalloplasty. We aim to describe approaches in identifying complications associated with these procedures as well as the various reparative techniques that can be utilized to reestablish the neourethral tract. Methods: We prepared a guide to diagnostic and procedural interventions for urologic complications following transmasculine genital reconstructive surgery based on our clinical experience as well as those of our colleagues. We reviewed all current peer‐reviewed publications based on this topic. Results: These procedures have a considerable revision rate for urologic complications, which include urethrocutaneous fistulae, persistent vaginal remnant, and urethral strictures. These complications often present simultaneously and require appropriate workup and treatment. Conclusions: Several reconstructive techniques can be employed to restore the neourethral tract, as we describe in detail. [ABSTRACT FROM AUTHOR]

Aims: The history of phallus construction parallels the advances made in plastic and reconstructive surgery whereby the era of microsurgery revolutionized numerous techniques. In 1993, we reported our early experience in phalloplasty. While the originally presented technique was a modification of the original design reported by Chang and Hwang, we now present further modifications of the past 30 years. Methods: Through critical review of our technical modifications, as well as others', we present a comprehensive review of elements of the radial forearm free flap phallus construction. Results: A radial forearm free flap is harvested and tubed to form the following components: urethra, shaft, and glans of the neophallus. When excess adipose tissue exists, the excess thickness is accommodated by increasing the proximal width of the flap. To optimize the venous drainage, the radial and ulnar superficial veins as well as the radial deep veins are included within the flap; however, venous flow is optimized through creation of an arteriovenous fistula within neo‐glans. To lengthen the native urethra, labia minora and vaginal mucosal flaps are employed at a preliminary stage during vaginectomy. New coronoplasty modifications offer esthetic refinements. Updates in scrotal reconstruction and implantation of erectile devices complete the total genitourinary reconstruction. Conclusions: Phallus construction has evolved significantly over time. While numerous techniques exist, no standard of care has been identified. Continue surgical evolution will provide modern solutions for problems most often encountered to improve overall outcomes for transgender and gender‐diverse patients pursuing masculinizing genitourinary reconstruction. [ABSTRACT FROM AUTHOR]

Aims: Gender‐affirming surgery consists of a group of surgical procedures for patients presenting with gender incongruence. Patients may seek treatment of anatomic areas including the face, chest, breast, and genitalia. The aim of this scoping review is to provide a general understanding of wound healing to optimize outcomes and manage complications. Methods: A scoping review was performed to include wound healing principles, outcomes related to gender‐affirming surgery, and management of postsurgical wounds. Results: Based on the review performed and clinical experience, strategies to manage complications are recommended. These include an understanding of wound healing principles, patient optimization, and postoperative management. Conclusions: A comprehensive understanding of wound healing principles, perioperative optimization, and postoperative management of wounds assists the provider in mitigating and managing complications. [ABSTRACT FROM AUTHOR]

Aims: The benefits of gender affirmation surgery have long been established, and with improved access to care, these operations are being performed with increased frequency. As these surgeries continue to be performed, the surgical techniques continue to evolve. Phalloplasty, or the creation of a phallus, remains one of the most complex surgical endeavors in which a variety of factors influence surgical decision making. This article aims to present the lesser known and less frequently performed means of phalloplasty in gender affirming genitourinary reconstruction. Methods: A literature review of relevant articles, whether case series or more comprehensive, was performed to describe some of the more obscure and less frequently utilized flaps for phalloplasty. Results: The most performed or widely accepted technique is that of the radial forearm free flap, but numerous other options decorate the surgical landscape. With limited and unreliable outcomes data, a standard of care is difficult to establish. Conclusions: Ultimately, phalloplasty reconstruction should aim to achieve standing micturition and penetrative intercourse, resolute tactile and erogenous sensation, desirable aesthetics of the phallus, and acceptable donor site morbidity. Although some procedures are more commonly performed, the standard for phalloplasty has not been established. Ultimately, approaching this reconstructive puzzle with persistent creativity will unearth more reliable options in the future. [ABSTRACT FROM AUTHOR]

Purpose of Review: Currently, there are a lack of systematic and standardized methods to evaluate sensation in individuals who have undergone masculinizing gender affirmation surgery (GAS). An individual's choice to pursue phalloplasty or metoidioplasty is driven by consideration of cosmetic satisfaction, urethral function, phallic rigidity, and penetrative ability. Regardless of the chosen procedure, phallic sensation is desired for satisfactory sexual function, pleasure, and overall well-being. The purpose of this review is to evaluate the current literature on sensory outcomes after masculinizing GAS and to identify gaps in knowledge that may benefit from further research. Recent Findings: There is great variability in the collection and reporting of sensation, orgasm, and sexual function data. Due to design limitations and potential bias, all included studies received "low" or "very low" GRADE of evidence. Tactile and erogenous sensation were the most common types of sensation reported. Although most studies report that their participants are eventually able to achieve erogenous and tactile sensation, it is difficult to draw firm conclusions due to significant variability in methodology and results. Additionally, there is limited available literature poised to compare sexual function outcomes between phalloplasty techniques and donor tissue sites. Percentages of participants able to orgasm via masturbation ranged from 71.8 to 100%, while orgasming with sexual intercourse ranged from 69.5 to 100%. Fewer than half of studies discussed the ability for penetrative sex. Between these studies, the ability to engage in penetrative sex ranged from 39.5 to 75%. Only two studies reported the length of time post-operatively to orgasmic ability; both reported that participants were able to orgasm by 1 year post-op. Summary: Overall, there are a wide variety of surgical techniques for GAS described in the literature. The data on sensation, orgasm, and sexual function remains limited, but the authors of this manuscript feel that this study highlights gaps that future researchers may seek to fill. [ABSTRACT FROM AUTHOR]

Background Phalloplasty is a challenging procedure in the field of repair and reconstruction. Traditional skin flap methods with prostheses or autologous tissue implantation are still common; however, with this method the reconstructed phallus is static and has a high risk of complications. Aim We aimed to use novel methods for phalloplasty to mimic the normal structure of the phallus while maintaining the patient's ability to obtain sufficient hardness and subjective controllability. Methods The neophallus comprised the bilateral pedicled neurovascular gracilis muscle, which provided neophallus volitional control; the pedicled fascia lata, which mimicked the tunica albuginea; the pedicled anterolateral thigh flap, which was used to reconstruct the neourethra and neoglans; and the thin split-thickness skin grafted on the surface of the fascia lata. The urethral anastomosis was performed simultaneously. The appearance and function of the neophallus, as well as patient satisfaction, were evaluated postoperatively. Outcomes The biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata was successfully performed in 4 patients. Results During follow-up at 10-21 months after the procedure, all 4 patients could complete sexual intercourse and were satisfied with the appearance and self-controllability of the neophallus. The size of the neophallus stabilized within 6 months. The tactile, deep touch sensation, and pain sensations of the neophallus partially recovered. All of the patients could stand to urinate. Clinical Implications We used the gracilis muscle combined with the fascia lata to mimic the basic structure of the corpus cavernosum and tunica albuginea and successfully reconstructed the biomimetic dynamic neophallus. Strengths and Limitations This is to our knowledge the first report of biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata to mimic the complex structure of the phallus and enable the achievement of erection. However, due to the small number of patients included in this study, the data have no statistical significance. More cases are needed to obtain conclusive data and examine the long-term clinical effects of this procedure. Conclusion Using novel methods for phalloplasty, we successfully maintained the patient's ability to obtain sufficient hardness and subjective controllability without the use of implants, and the preliminary clinical results are encouraging. [ABSTRACT FROM AUTHOR]

Introduction Following phalloplasty, urological problems, such as urethral fistula and urethral stricture, are frequent. Even in the best hands, an "all cause" urological complication rate of 36% is observed. There are no reports in literature regarding urethral polyps after excision and primary anastomosis in cases of Total Phallic Reconstruction. Methods Retrospective study that identified patients who previously had Radial Free Forearm Flap Total Phallic Reconstruction (Phalloplasty) and underwent monopolar resection of anastomotic urethral polyps after excision & primary anastomosis urethroplasty between August 2020 and August 2022 in Department of Urology, Kasr Al-Ainy-Cairo University hospitals. Results A total of 3 patients were identified with anastomotic urethral polyp, median age was 25 years. Monopolar endoscopic resection of urethral polyps was done. All patients voided freely with good flow (Median Q-Max 34.4 ml/s, range 26.0-54.1 ml/s) after catheter removal and residual urine volume by ultrasound was insignificant. During follow up, one patient suffered from recurrent anastomotic urethral stricture while the other two cases continued to void freely with no urinary obstructive symptoms or significant residual urine. Median follow up was 12 months (range 6-24 months). Discussion Urethral complications after phalloplasty are frequent but treatment recommendations are lacking in the literature. Studies concerning urethroplasty after phalloplasty are scarce in the literature. While reviewing the literature, no case reports were found regarding urethral polyps after anastomotic urethroplasty in patients who had underwent Total Phallic Reconstruction. Conclusion Urethral polyp excision using monoploar energy is feasible and can be safe to use in patients after Total Phallic Reconstruction, but due to the lack of similar cases in literature no recommendation can be made regarding this approach and further research is still required. [ABSTRACT FROM AUTHOR]

Objective: Penile reconstruction or phalloplasty following penectomy can be offered where the functional penile length is inadequate for a man to void while standing or to have sexual intercourse. Phalloplasty is usually staged due to the complex surgical techniques required. This narrative review describes the technical concepts and summarises the contemporary outcomes following phalloplasty in this challenging cohort. Methods: A retrospective review of the English literature was performed between January 1946 till November 2021. The data were synthesised and complemented by the expert opinion of the authors with 20 years of experience in this field. The flaps are ideally designed with an integrated urethra or alternatively, a further free flap urethroplasty can be offered. Phalloplasty is further complicated following penectomy by scarring from the previous surgery and the potential loss of structures that would normally be present at the recipient site. Results: There are limited published data with a total of 19 men recorded in the literature. Only the radial artery forearm free flap and anterolateral thigh flap have been described in this cohort of patients. Functional outcomes including standing micturition, sensation in the neophallus, and the ability to orgasm are good. Overall quality of life and satisfaction was also good despite the high risk for long-term complications of the neophallus and donor site. Conclusion: Phalloplasty following penectomy requires microsurgical transfer of a free flap or a pedicled flap to reconstruct a neophallus. An erectile device is inserted at a later stage to facilitate sexual intercourse, if desired. Surgical scarring from penectomy and the potential loss of vasculature that would normally be present at the recipient site may further complicate reconstruction. Surgical and functional outcomes are acceptable based on the limited published experience to date.

Abstract Background Aphallia is a rarest of rare congenital anomaly the incidence being 1 in 10 to 30 million live births. Seen at birth, it leaves the parents and family disturbed. Immediate counselling though done; it may take time for the parents to come to a decision. Case presentation A newborn was brought for genital examination and since the penis was not present and the scrotum with testes were normal, aphallia was suspected. At 1 month after all the necessary investigations, isolated aphallia without any other congenital anomalies was confirmed. The options offered were gender reassignment before the age of 18 months or staged phallo and urethroplasty. Parents are so far undecided. Conclusions Aphallia results from failure of the genital tubercle to develop, leading to the absence of all the penile components. Diagnosis of aphallia includes the absence of the phallus, male karyotype and normally developed scrotum with normal testicles. Usually, this anomaly is associated with multiple other anomalies involving the urinary, gastrointestinal and musculoskeletal systems. Management of this condition is challenging and requires a multidisciplinary approach. In addition to managing the associated anomalies, the options to treat aphallia will depend on the type, severity of associated anomalies, family background and socioeconomic status of the family. Psychological counselling along with surgery (in the form of gender reassignment or phalloplasty) are the mainstays of treatment. The literature of this anomaly and the treatment is reviewed.

Objective: To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history. Materials and Methods: We conducted a single‐centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans‐male patients undergoing gender‐affirming surgery and cis‐male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision‐anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri‐ and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires. Results: The mean (±sd) follow‐up duration was 5.5 (±3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis‐male vs 71.8% for trans‐male patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public. Conclusions: Urethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results. [ABSTRACT FROM AUTHOR]

• Many classification systems present. • Variable correction techniques. • What new information is contained in this article? • Definition of BP in children. • Algorithm, simple technique of correction used prospectively. • Penopubic angle as crossroad of technique selection. Buried penis (BP) is a distressing condition for both the child and his caregivers. A lot of techniques are available for the management of such condition. External phallopexy represents a simple technique designed for selected cases. This study aimed at reexploring the technique of "3 stitches phallopexy" in the context of correction of selected cases with BP, validating a prospectively designed algorithm for BP management, and detecting the parental satisfaction and possible complications of this technique. This was a prospective study performed over a 2 years' period on cases diagnosed with BP. Patients were excluded if they have previous urethral repair e.g., hypospadias or epispadias, BP with normal penopubic angle, micropenis, and insufficient skin coverage after phallopexy simulation test. A questionnaire with 0–12 points score was used for assessment of satisfaction by caregivers. 28 cases were included, with a mean age at the procedure of 5.03±2.6 years. The mean BMI was 15.25±1.1. The intraoperative flaccid penile length measurement was 4.74±1.62 cm, and the mean gained extra-length with phallopexy simulation test was 1.8±0.63 cm. The mean operative time was 20±7 minutes. No wound infection was noted. 2 cases were concerned about the stitch marks at the penopubic junction skin. No recurrence of symptoms was reported after at least 6 months (mean11±4 months) follow up. The mean preoperative satisfaction score was 4.7±1.2, while at the 6 months follow up visit it rose to 10.8±0.67. External phallopexy represents a simple technique for managing buried penis, with minimal complications during follow up period and satisfactory cosmetic outcome. [ABSTRACT FROM AUTHOR]