Formation of Neo-urethra

This used to be a major problem for pubic phalloplasty patients. However, since the advent of the radial artery urethroplasty (RAU) technique, we can now get just as good quality type of neo-urethra as for a radial artery phalloplasty. Patients can now easily void from the tip of a pubic phalloplasty if required. Prior to the RAU technique, we used a multi-stage urethroplasty technique using labial flaps and skin grafts but most patients ended up with a urethral meatus (urinary opening) about a third to half way up the underside of the phallus due to complications. 

Radial Artery Urethroplasty

A better technique of incorporating a urethra into a phalloplasty is to use a variant of the radial artery phalloplasty using a much smaller flap as it is just used to form the urethral section rather than the full phallus.
This is a more complex procedure with a correspondingly longer stay in hospital and recovery times than the labial urethroplasty but it does have much better outcomes.  It allows us to bring the neo-urethra to the tip of the phallus without the complications associated with the labial urethroplasty.  It does however result in scarring on the arm but this is a much smaller scar than for a full radial artery phalloplasty.  A useful side effect of the surgery is that because there is a nerve supply to the neo-urethra in 50% of cases, there may be some sensation to the tip of the phallus after this surgery.

Join-Up Urethroplasty

Whether the neo-urethra has been formed following a pubic phalloplasty or at the time of radial artery phalloplasty a join-up urethroplasty is needed before urine can flow through the new opening.  This involves taking a strip of vaginal skin and the other non-hairy inner labial skin and using them to connect the native urethra (existing urine tube) to the previous opening next to the clitoris. 

Catheters

Catheters are used for two main purposes.  Firstly, they allow the patient to pass urine while the new urethra is healing. They also have an important role in keeping the size and shape of the neo-urethral lumen (passageway) in much the same way as a sleeper does after a piercing.

If they are removed too early then the lumen can narrow. However, being foreign bodies, catheters become completely colonised with bacteria within two weeks and can also cause mechanical irritation and therefore damage to the neo-urethra. A good compromise seems to be to leave the catheter in for between seven and ten days in phallic neo-urethras that have not yet been connected to the bladder. A shorter period is more desirable if possible. 

In the join-up urethroplasty (or metoidioplasty) two catheters are used. One is put through the abdomen into the bladder (suprapubic) and one through the neo-urethra to keep the lumen open. The luminal one is removed at seven days but the patient must void only through the suprapubic catheter until about day 21. This is to stop the urine dissolving the absorbable sutures that are used to make the urethral hook-up too early. At this point the patient performs a trial void through the neo-urethra and if all is well then the suprapubic catheter is removed. 

Fistulae and Strictures

If there is a urine leak or fistula it is commonly just inside the vaginal opening where the neo-urethra joins the native urethra. About 50% of minor leaks (a few drops) will heal spontaneously as long as the distal urethra (downstream segment) is not narrowed. We leave patients for a minimum of three months to allow this to happen and also to allow the tissues to thicken up so that a repair is more likely to succeed. There is no point attempting to repair it earlier as it will invariably make the hole even bigger. Rather than undergoing further surgery, some patients manage small fistulae by blocking them with a clean fingertip during voiding (ie: as if playing the flute) which is perfectly acceptable. If there is a lot of hairy skin inside the neo-urethra then small hair follicle infections can form abscesses which rupture to the outside forming new fistulae.  This is why we try to use as little hairy skin as possible.

Similar principles apply if there is a stricture. The stricture needs to mature so that it does not narrow further after the repair has been performed. This may require a suprapubic catheter being inserted to divert the urine for a few weeks first. Some patients manage with regular self-dilation and generally as long as a size 14F catheter can get past the stricture, it is good enough to pass urine through. If a repair is necessary then we use local skin flaps, if available, otherwise buccal mucosa or posterior auricular skin.

Redo fistula repairs have an increasingly poorer success rate so if a 3rd repair is needed, it is done in conjunction with a vaginectomy which has an almost 0% fistula rate.

Vagina

We do not offer a total vaginectomy service as this is risky surgery with significant bleeding problems. Because a piece of the front wall of the vagina is used both in metoidioplasty as well as join-up urethroplasty the vaginal opening in all patients with a neo-urethra will be much narrowed. For the small number of patients who intend to continue using their vaginas we would suggest that they do not have the urethra formed. For those who wish to use the vagina after a neo-urethra has been formed, they will need to carefully dilate the vagina once the neo-urethra has healed but this is not always successful. For patients who need to continue having cervical smears but have very narrow vaginal openings, we can sometimes widen this sufficiently to allow smears to be taken comfortably but not really enough for intercourse.

For patients who require vaginectomy we offer ablation vaginectomy whereby the skin lining the inside the vagina is removed by electro-vaporization using heat treatment (high energy ‘pure cut setting’ electrocautery). 

The vaginal skin is the source of the bulk of unwanted genital secretions. This is much less risky than a total vaginectomy and has fewer complications than the mucosal excision vaginectomy technique we used to prefer. Once the vaginal opening is closed to give a male perineum appearance, the raw muscular sides of the vagina stick to each other and obliterate the vaginal space over a few months. If required this procedure is normally performed at the time of the join-up urethroplasty though it can be performed at any stage other than with the implantation of a penile prosthesis. Occasionally a small piece of the vaginal skin is retained inside and may present as a new cyst in the perineum a year or two later. This is easily treated by re-vaporization.

Other sources of genital secretion are the peri-urethral glands, which are normally incorporated into the neo-urethra during the join-up urethroplasty, and Bartholin’s glands at the old vaginal entrance. The latter can also be a cause of a perineal cyst after ablation vaginectomy and is easily treated by excision.

Clitoris

Sexual sensation is extremely important to most patients. The best way to preserve sensation in the clitoris is to leave it where it is. However it does sit between the two testicular prostheses and is impossible to conceal.

With the radial artery phalloplasty or ALT phalloplasty patients, it is now routine practice to disconnect one of the two large nerves from the clitoris and attach it to the nerves that come with the phallus for erogenous sensation. Most patients perceive clitoral sensation as unchanged even with just one nerve left. 

Most patients want a completely male perineal appearance and request that the clitoris be buried under the skin. We mobilise it by releasing the pink skin underneath and burying it much higher up just under the skin near the base of the phalloplasty. The top layer of skin has to first be removed from the clitoris as otherwise patients will have recurrent abscess formation at the site. It typically takes about a month or so for the hidden clitoris to stabilise and the nerve endings to re-connect. Typical patients’ comments are ‘50% harder to find it to stimulate but orgasms normally’. It is important not to put on a lot of weight after as the clitoris may disconnect from the skin and become very inaccessible.

Scrotoplasty

If there is insufficient labia majora skin to insert a testicular prosthesis into directly or if the patient’s thighs are large then a formal scrotoplasty is needed to bring the neo-scrotum in front of the thighs.

The best cosmetic appearance is obtained by forming the scrotum at the time of vaginectomy and join-up urethroplasty with burying of the clitoris.  If the clitoris is not buried or a vaginectomy not performed then the scrotum is inevitably bifid, appearing somewhat split in two. A single scrotal sac is made which we then ask patients to stretch as much as possible before the Stage 3 operation.

Glans Sculpting, Testicular Prostheses Etc

Regardless of which sort of phalloplasty has been undertaken, once the urinary tract has been completed patients move on to implantation of prostheses if required. Before the penile prosthesis itself is implanted we undertake glans sculpting and carry out any final shaping that is necessary, excising skin tags or “dog-ears” and tidying up scars as necessary. The reservoir of the penile prosthesis may be implanted at this stage together with a testicular prosthesis on occasion.  Currently these procedures are normally performed at the same time as the join-up urethroplasty though in the past this was a separate stage of surgery.

Glans Sculpting

We use a modified Norfolk technique using a full-thickness skin graft rather than split skin grafts. A circumferential skin flap (Fig 13a) is raised like the brim of a hat which is then rolled in (Fig 13b). The use of a full thickness skin flap allows a nice helmet or mushroom head to be created (Fig 13c). Skin graft is then wrapped fairly tightly around the bare fat below the head to cause a slight constriction as it heals to accentuate the bulbousness of the head. The appearance is that of a circumcised penis. As with all skin grafts the results are unpredictable but most patients have an acceptable cosmetic result. We used to use split-thickness skin grafts as in other units but have found that the cosmetic appearance in our hands is better with full thickness skin. Also we believe the results are better when the glans sculpting is done separately from the Stage 1 phalloplasty surgery as we don’t need to worry about disturbing the blood supply of the newly formed phallus then.

Testicular Prostheses

Patients with erectile devices normally have a single large/medium testis prosthesis on one side and an erectile pump on the other as there is no space for two testes and a pump. The size we put in depends on the looseness of the hairy outer labial skin and we try to use a large prosthesis if possible. If a join-up urethroplasty has been previously performed then there may be less available skin on the side that has been operated on. Another consideration is the amount of space between the thighs. Often two perfectly positioned testes will migrate once the patient returns to normal activity resulting in one testis going lower and the other upwards to the phallus. If space is at a premium then a medium prosthesis is inserted to keep the two about level. In terms of appearance the medium and large look about the same size postoperatively!

We use solid silicone gel prostheses which are pretty much rupture-proof and should last a lifetime. Their shape is oval rather than round in keeping with a real testicle.

Excise Excess Skin

We will excise any untidy bits of skin usually at the end of wound lines and frequently use these bits of skin as skin graft for the glans sculpting rather than excising a new piece of skin. Many patients want to have the natural curve at the side of their hips flattened. This is not due to our surgery but due to their natural shape and requests for this to be done by us are declined as it is not part of our phalloplasty service.