(141) Colpectomy Reduces the Incidence of Urethral Fistulas After Female-to-Male Gender Affirming Surgeries: A Meta-Analysis
Authors: Hennig F , Lutnick E , Waisanen K , Farah G , Burke M 
Published: May 2023

Abstract

Introduction
The reported rate of urethral fistulas after female to male gender affirming surgeries (GAS) ranges from 10% to 68%. There remains a paucity of evidence addressing the widely accepted hypothesis that colpectomy reduces the risk of fistula formation.

Objective
We aim to use a meta-analysis to describe the correlation between colpectomy and the rate of urethral complications, including fistula and stricture after GAS in transgender men.

Methods
PRISMA guidelines were used to conduct a literature search of PubMed, Embase, Web of Science, and MEDLINE databases was conducted for studies containing words or synonyms for “trans-male”, “phalloplasty” or “metoidioplasty”, and “complications”. Inclusion criteria was specific for studies reporting postoperative incidence of urethral fistula and urethral stenosis or stricture. For those that met criteria, surgical technique, urethral complications, and outcomes were collected and analyzed using the random-effects model due to the heterogeneity of included study populations. Review Manager (Version 5.4.1) was used to perform subgroup meta-analysis between those GAS with prior or concurrent colpectomy or vaginectomy and those without. A p-value of &lt;0.05 was considered statistically significant.

Results
43 full-text articles meet inclusion criteria with a total of 3,929 patients. 542 (14%) of patients underwent GAS without a prior or concurrent colpectomy and 3387 (86%) underwent GAS with a colpectomy. 637 (16%) underwent metoidioplasty and 2291 (68%) underwent phalloplasty; the rest were unable to be grouped. The pooled odds ratio (OR) for urethral fistula was 0.12 (95% CI [0.06-0.21], I2 =96%, p &lt;0.00001) and 0.07 for urethral stenosis (95% CI [0.03-0.15], I2 =96%, p &lt;0.00001). Fistula event rate of 23.7% (930/3929) was slightly larger than the urethral stenosis event rate at 21.3% (585/2751). The OR of urethral fistula was 0.06 for GAS associated with colpectomy, compared to 1.01 with no associated colpectomy (p &lt;0.00001, I2 =97%). The OR of urethral stenosis was 0.06 for GAS associated with colpectomy, compared to 0.16 with no associated colpectomy (p &lt;0.41). Further subgroup analysis by procedure, showed similar findings in those who underwent phalloplasty, however no difference in the OR of fistula formation in those who underwent metoidioplasty (p &lt;0.00001, p=0.33 respectively). There was no significance in the OR of urethral stricture after GAS with or without colpectomy. 5 studies showed a 100% success rate in ability to void while standing, all of which had associated colpectomy. No studies without colpectomy were available for comparison. Two studies reported a success rate of 71% and 16% showing the variability in success amongst institutions.

Conclusions
GAS in transgender men, including phalloplasty and metoidioplasty, with prior or concurrent colpectomy were associated with lesser odds of developing urethral fistula compared to GAS without colpectomy. There was no significant difference between the odds of urethral stricture formation in GAS with or without colpectomy.

Disclosure
No