Staged Phalloplasty in Gender-Affirming Surgery Has Lower Rates of Postoperative Complications

ACC 

Introduction
Gender-affirming surgery utilizes various techniques that can be performed as a single, multispecialty procedure or as multiple, single-specialty, staged procedures. The primary components of transmasculine gender-affirming surgery include hysterectomy, phalloplasty, and urethroplasty, with other procedures such as scrotoplasty, vaginectomy, oophorectomy, and implants performed based on patient preferences.¹ Rates of complications in phalloplasty are high, especially those which affect voiding and sexual function.²⁻³ This study aimed to assess the types and frequency of complications in single and staged phalloplasty and provide treatment recommendations for providers.
Methods
This retrospective cohort study was conducted at a single institution from March 2019 to December 2022. Patients were 18 years or older at the time of surgery, had a diagnosis of gender dysphoria, and underwent phalloplasty. Patients were assigned groups based on whether they had a single or staged procedure. Single procedures involved the phalloplasty, hysterectomy, and urethroplasty in one surgery. Staged procedures had each procedure performed as separate surgeries. Staged procedures only accounted for phalloplasty performed by plastic surgery. Complications were defined as need for reoperation, urethral stricture, urethral fistula, necrosis of neophallus, infection, wound dehiscence, and flap loss. A univariate analysis was conducted.
Results
Thirty-two patients underwent phalloplasty, with 21 from the South, 4 from the Midwest, 3 from the Northeast, and 4 from the West. There were 19 (59.4%) patients receiving single procedures and 13 (40.6%) patients receiving planned staged procedures. The mean operative time for single procedures was 15.1 ± 3.8 hours, and the mean operative time for staged procedures was 6.5 ± 4.8 hours (p<0.001). Overall complication rates were higher in the single procedure group (68.4%) than in the staged procedure group (8.3%) (p<0.001). Urethro-cutaneous fistulas were the only specific complication that significantly differed between the groups. Single procedures had a rate of 42.1%, while staged procedures had a rate of 8.3% (p<0.05). In the single procedure group, reoperations were performed in 57.9% of cases whereas only 8.3% of staged procedures required reoperation (p<0.01). Single procedures were associated with a longer time from surgery to discharge (9.1 ± 5.7 days) than staged procedures (4.5  1.6 days) (p<0.005).
Discussion
Staging hysterectomy, urethroplasty, and phalloplasty for gender-affirming surgery in transgender men appears to provide clear benefits. Staged procedures have better surgical outcomes as evidenced by a decrease in overall complication rates, urethro-cutaneous fistula rates, and reoperation rates. Although single procedures may be preferred for patients traveling long distances, their increased rates of complications necessitate frequent reoperations, attenuating their potential benefits. Larger, multi-institutional studies are needed to better understand the differences in complications from single and staged procedures.

References
1. Wu CA, Jolly D, Boskey ER, Ganor O. A systematic review of staging and flap choice in gender-affirming phalloplasty. Journal of Reconstructive Microsurgery Open. 2022;07(02). doi:10.1055/s-0042-1748884
2. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. Urethral complications after gender reassignment surgery: A systematic review. International Journal of Impotence Research. 2020;33(8):793-800. doi:10.1038/s41443-020-0304-y
3. Bryson C, Honig SC. Genitourinary complications of gender-affirming surgery. Current Urology Reports. 2019;20(6). doi:10.1007/s11934-019-0894-4

Gender Affirmation

Reconstructive

Plastic Surgery 2023