Urethroplasty following total phallic reconstruction

Total phallic reconstruction is often complicated by recalcitrant strictures particularly at the native-to-neourethral anastomosis, which may ultimately require definitive repair. Presumably these strictures form as a result of relative ischemia at the anastomosis of tissues of native urethra to fasciocutaneous tube flap, which is exacerbated by kinking at the neophallus base. The traditional approaches to urethroplasty, such as end-to-end anastomosis, and penile or preputial skin grafts and flaps, are not available for this population. Therefore, extragenital grafts and flaps become important for managing repair of urethral strictures in the neophallus. In addition, an unusual recipient bed of fat and fascia complicates the repair of these strictures. We review our experience with 15 patients who underwent penile reconstruction.

A total of 15 patients 17 to 50 years old had a radial forearm flap except 1 who had a fibula based flap. Nine urethroplasties were performed on 8 patients who were followed for a mean of 31.8 months. The approaches comprised 3, 2-stage mesh graft urethroplasties, 1 full-thickness skin tube graft, 1 bladder mucosa tube graft, 1 vagina labial pedicle tube flap and, most recently, 3 buccal mucosa onlay grafts. The length of strictures ranged from 3 to 12 cm. Urethroplasty was performed 2 to 34 months after phallic construction.

Urinary flow rates in patients with buccal mucosa urethroplasty averaged 18 cc per second and no strictures recurred. These results are superior to those of other urethroplasty techniques in this patient population.

A full array of surgical options must be available to the reconstructive surgeon but buccal mucosa grafting seems to be a promising approach to strictures in this patient population.