Single-stage Double-face Buccal Mucosal Graft Urethroplasty for Neophallus Anastomotic Strictures

OBJECTIVE: After gender-affirming phalloplasty the anastomosis between the perineal urethra (pars fixa) and the penile urethra is the most common site of stricture.¹ Excisional urethroplasty after phalloplasty is known to have high failure rates due to poor vascularization of neourethra.² Our objective is to demonstrate the feasibility of a single-stage repair of neophallus anastomotic strictures using a “double-face” urethroplasty technique. METHODS: All patients who presented with anastomotic neophallus strictures and underwent a “double-face” buccal mucosal graft (BMG) urethroplasty were identified. Preoperatively, all patients had retrograde urethrogram and voiding cystourethrogram. Intraoperatively, pars fixa was exposed through a perineal dissection. A ventral sagittal urethrotomy followed by a dorsal urethrotomy was carried 1-2 cm beyond the stenotic area. An Asopa-type BMG inlay was performed by securing an appropriately sized BMG dorsally.³ A separate ventral graft was placed in a “double-face” technique described by Palminteri.⁴ Surrounding tissue analogous to Martius flap was rotated medially to support the ventral graft. Retrograde urethrogram and voiding cystourethrogram and voiding trials were performed three weeks postoperatively. Patients were followed for stricture recurrence and patient-reported outcome measures. RESULTS: Thirty-one patients presented for neophallus stricture repair between December 2014 and December 2019. Of these, 9 underwent a single-stage repair of an anastomotic stricture after radial forearm flap phalloplasty, 8 were available for follow-up. At a mean follow-up of 31 months (10-56), there were 2 (25%) stricture recurrences treated with perineal urethrostomy in 1 patient and staged urethroplasty in another. Ultimately, 7 of 8 patients reported the ability to void in upright position and all reported an improvement in their condition following surgery. Mean International Prostate Symptom Score postoperatively was 3.1 (0-11), International Prostate Symptom Score -QOL 0.9 (0-3). CONCLUSION: A single-stage double-face BMG urethroplasty is a feasible option for select patients with post-phalloplasty anastomotic strictures,⁵ demonstrating promising early surgical success rates and high patient satisfaction on patient-reported outcome measures.