For referring physicians
Urethral complications after phalloplasty and metoidioplasty: how I choose the operation
Stricture, fistula, retention and dribbling after a neourethra has been built, whether the phalloplasty was done here or elsewhere. Where the problem sits, what I fix first, and when the goal changes. The selection ladder is still being written down; the statements here trace to my papers and my operating room.
Where it sits
The anastomosis between the native urethra and the lengthened pars fixa, and the anastomosis between the pars fixa and the flap urethra, are where most strictures and fistulas sit. The California statewide dataset says half of all phalloplasty patients re-present with a complication within a year, so the referral is the ordinary case and not the exception. Before the urethra is repaired, I need the urethrogram, a cystoscopy, and the history of every stage, including which flap was used and whether a vaginectomy was done.
The vaginal remnant and the urethral diverticulum
Retention, dribbling, infections and a recurrent stricture in a man who has had a vaginectomy can all come from one thing: a retained vaginal remnant that has become a urethral diverticulum behind the pars fixa. It fills on voiding and drains afterward. I excise it robotically through the abdomen, freeing it from the bladder and the rectum, and in every case in our series the urethra was repaired in the same sitting. In a primary phalloplasty here, the vaginectomy is done robotically with the urethral lengthening, and a split pedicled gracilis flap is brought to the urethral closure.
The anastomotic stricture: one stage or two
An anastomotic stricture in tissue that has not been grafted before and has a blood supply gets a single-stage double-face buccal graft urethroplasty, dorsal inlay and ventral onlay. A stricture after a prior augmented urethroplasty, or in poorly vascularized tissue, gets a two-stage repair. In our bi-institutional series every man voided standing after either repair, with two recurrences in the single-stage group and none in the staged group at about three years. The neophallus has too little ventral tissue to support a graft on its own, which is why a local fasciocutaneous flap is raised to cover a ventral buccal graft.
The ALT urethra is built in stages on purpose
In the anterolateral thigh phalloplasty we do with NYU plastic surgery, the urethra is not tubed at the first stage. The flap goes up as a single tube, the pars fixa and vaginectomy come at the second stage with a split-thickness skin graft laid as a urethral plate, and the plate is tubed at the third. Twenty-one of the first 24 men were voiding standing.
When standing micturition stops being the goal
The salvage ladder runs from endoscopic management through single-stage and staged urethroplasty to a perineal urethrostomy, and the rung is chosen with the patient. The man who has been through several salvage attempts may prefer to stop, and that conversation belongs early rather than after the next failure. The prosthesis waits until the urethra is settled; the device side is on the erectile dysfunction page.
Videos by operation
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Graft and flap material for the neourethra
Urethroplasty after phalloplasty, vaginal remnant excision
Videos are being edited for the library.
Papers
- One or two stage buccal augmented urethroplasty has a high success rate in treating post phalloplasty anastomotic urethral stricture. Urology. 2021. PubMed 34119502
- Robotic excision of vaginal remnant/urethral diverticulum for relief of urinary symptoms following phalloplasty in transgender men. Urology. 2019. PubMed 31790784
- Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty. Ther Adv Urol. 2016. PubMed 27904649
- Anterolateral thigh phalloplasty with staged skin graft urethroplasty: technique and outcomes. Urology. 2023. PubMed 37054922
- Use of a split pedicled gracilis muscle flap in robotically assisted vaginectomy and urethral lengthening for phalloplasty: a novel technique for female-to-male genital reconstruction. Plast Reconstr Surg. 2020. PubMed 32195856
- Outcomes following metoidioplasty and phalloplasty gender affirming surgery with urethral lengthening: a modified Delphi consensus study. Urology. 2025. PubMed 40780517
- Incidence, complications, and long-term outcomes of gender-affirming phalloplasty: analysis of a large statewide population-based dataset. Urology. 2024. PubMed 38340965
- Urologic complications after phalloplasty or metoidioplasty. Clin Plast Surg. 2018. PubMed 29908632
- Urologic sequelae following phalloplasty in transgendered patients. Urol Clin North Am. 2017. PubMed 27908366
- Management of vaginoplasty and phalloplasty complications. Urol Clin North Am. 2019. PubMed 31582033
- Gender-affirming phalloplasty: a postoperative protocol for success. Plast Reconstr Surg Glob Open. 2022. PubMed 35747259
- Patient-centered outcomes on preparing for and undergoing gender-affirming phalloplasty: a qualitative, descriptive study. BMJ Open. 2025. PubMed 40122562
- Prosthetic considerations in neophallic reconstruction. Curr Sex Health Rep. 2017. DOI 10.1007/s11930-017-0126-1