Optimizing neurorrhaphy to improve sensation in phalloplasty: a systematic review

Phalloplasty aims to construct a functional and aesthetic phallus in transgender and gender diverse and cisgender patients with absence or loss of penile tissue. Sensation is a critical outcome in postoperative quality of life, impacting placement of erectile devices, sexual function, and overall well-being. Despite this, there is currently a lack of consensus on strategies to optimize sensation in phalloplasty. A comprehensive search of Medline and Embase databases was conducted with keywords related to phallic sensation in penile reconstruction. 237 abstracts were identified, and 28 articles, with 178 patients, met inclusion for final analysis. Studies consistently demonstrate improved sensation with neurorrhaphy; however, significant heterogeneity exists in the reported number of nerve coaptations and coaptation techniques as well as donor and recipient nerve selection. Reported sensory outcomes are mostly limited to presence or absence of sensation (tactile and/or erogenous or unspecified) and/or orgasmic ability. The lack of granularity in reported outcomes makes it challenging to draw robust evidence-based conclusions regarding optimal surgical techniques for maximizing sensory outcomes. Additionally, there is minimal discussion of approaches beyond solely performing nerve coaptations. Based on literature review, histomorphometric data, and our experience in phalloplasty and peripheral nerve surgery, we present a comprehensive approach to optimizing sensory outcomes in phalloplasty based on four key factors: nerve topography, selecting optimal nerve coaptations, considering the impact of sensory end-organ receptors, and integration of sensory re-education protocols targeting cortical plasticity and sexual rehabilitation.