(277) Proposal for a Clearer Definition and Classification of Urethral Complications Following Transmasculine Gender Affirmation Surgery
Authors: Lee W G , Li V , Ralph D , Christopher N 
Published: May 2023

Abstract

Introduction
The use of free flap microsurgical neophallus construction with integrated urethra have improved outcomes for transmasculine gender affirmation surgery (GAS) but there is no accepted gold standard. Many authors have described urethral complications but only in heterogenous and small cohorts. Anatomical nomenclature is also confusing.

Objective
We aim to describe urethral complications in the largest cohort of patients to date and propose a naming and classification system to improve reporting, research and management of this common problem.

Methods
All transmasculine individuals undergoing phalloplasty including a free flap urethroplasty, with staged urethral lengthening at our centre over five consecutive years (2014 – 2019) were retrospectively reviewed from a prospective database. Metoidioplasty was excluded. The incidence, timing and management of urethral complications were extracted from a prospective database. Statistical analysis was by Chi-squared test.

Results
Three hundred and seventeen individuals with median follow-up of 4.3 years (interquartile range 3.6– 5.0 years) were included. Types of phalloplasty include forearm flap, anterolateral thigh flap and abdominal flap with free flap urethroplasty. Almost half (43.5%) developed a urethral complication (fistula, stricture, severe post-micturition dribbling or urethral hair/stone); most commonly fistulae (48.5%) followed by strictures (37.4%). Complications were significantly higher in flaps with integrated urethra compared to staged combination free flap urethroplasty (39% compared to 10%, p&lt;0.0003). Forty-four individuals (12.4%) developed more than one complication (31% of complications). Overall, complications were mostly in the phallus (flap-related) (72.2%) followed by scrotal and perineal urethra. Repairs before and during routine second stage urethral lengthening were for phallus complications comprising fistulas and strictures. Strictures were more common than fistulas in contrast to individuals before urethral lengthening (p&lt;0.001). Staging the urethral lengthening allowed 81.6% of individuals to be asymptomatic while awaiting routine repair. Vaginectomy did not reduce the risk of urethral fistulae.

Conclusions
The largest series to date suggests that urethral complications continue to be common following phalloplasty and are mostly phallus or flap related. Complications may also be lower if a staged free flap urethroplasty is offered. We show that the nature of urethral complications in phalloplasty change depending on the stage of genital GAS and should be classified based on type, location and timing of occurrence. This classification standardises reporting and will help guide the approach for surgical correction. Complications in the phallus urethra relate to an issue with the free flap and requires a different approach compared to complications following urethral lengthening that are more likely in the scrotal or native urethra. Many complications occur prior to urethral lengthening (81.6%) and can be repaired routinely at that time. Furthermore, we propose that the urethral segments are called the phallus, scrotal and native urethra to allow for clear and concise nomenclature.

Disclosure
No