Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty

Ther Adv Urol. 2016 Dec;8(6):331-337. doi: 10.1177/1756287216673959. Epub 2016 Oct 17.


Background: Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty.

Methods: A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined.

Results: A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31-47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 ± 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6-13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis.

Conclusions: Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

Keywords: buccal mucosal grafts; fasciocutaneous flaps; phalloplasty.