Penile reconstruction for genital gender affirmation surgery Best functional and aesthetic outcome following phalloplasty with the radial forearm flap Mr. Wai Gin (Don) Lee St. Peter’s Andrology Centre University College London Hospital London (GB)
waigin.lee@nhs.net
Mr. Nim Christopher St. Peter’s Andrology Centre University College London Hospital London (GB) nim@ andrology.co.uk
Prof. David Ralph St. Peter’s Andrology Centre University College London Hospital London (GB) david@ andrology.co.uk
European centres for gender affirmation surgery Most European centres were invited to contribute their data and thirteen responded in time for publication (see Table 1). Amsterdam (NL) was the first centre established for genital GAS in 1980. They remain the largest centre in Europe for phalloplasty (8 surgeons) and have contributed significant innovations to this field5. London (UK) currently has the highest volume for phalloplasty and was the first to combine two tissue flaps for penile and urethral reconstruction in 2003. The number of centres has increased by 63% in the last 3 years. Most centres offer several different flaps for phalloplasty to accommodate the requirements of each transmasculine individual. Funding Models of funding differed significantly between centres. Centres in the United Kingdom, Germany, France, the Netherlands and Italy offer genital GAS fully funded by the government or health service for residents. Other centres like Belgium require a co-payment by the patient while some others were only available to those who self-fund or are privately insured. Some centres (e.g., London and Belgrade) also offer genital GAS to individuals from abroad on a self-funded or insured basis. Options for penile reconstruction The ideal neophallus should be aesthetically appealing and sensate (to both tactile and erogenous stimulus) while allowing standing micturition and penetrative intercourse6. This should be achieved in a single operation with minimal donor-site morbidity. Disappointingly, there is no single technique that currently meets all the above requirements.
Table 1: Centres in Europe that offer phalloplasty gender affirmation surgery Unit (Country)
Year
Specialty (n)
Amsterdam (Netherlands) Frankfurt (Germany) Lyon (France)
1980
Urology (6) Plastics (2) Urology (2) Plastics (4) Urologist (3) Plastics (1) Urology (2) Plastics (1) Urology (4) Plastics (2) Urology (3) Plastics (1) Urology (2) Plastics (1) General Surg (1) Urologist (1) Plastics (1) Urology (2) Urology (1) Plastics (2) Urology (1)
1989 1990
Belgrade 1 1992 (Serbia) Ghent (Belgium) 1993 London (UK)
2001
Belgrade 2 (Serbia)
2003
Munich (Germany) Turin (Italy) Lille (France)
2016
Warsaw (Poland) Belgrade 3 (Serbia) Freiburg (Germany)
2018
2018 2018
2019 2020
Urology (2) Plastics (1) Urology (2) Plastics (2)
Volume (n/year) Type of flaps for phalloplasty 80 RF, ALT, SCIP, AF, combination flaps 20 RF, ALT
Staged join-up
25
Yes
72
RF, MLD, ALT, AF (preexpanded) MLD, ALT, AF
40
RF, ALT
No
110
Yes
40
RF, ALT, AF, combination flaps MLD
100
RF, ALT, SCIP/groin
Yes
20 5
RF, ALT, AF RF, ALT, AF, DIEP
Yes
15
RF, ALT, AF
Yes
12
RF, MLD, AF
Both
*
RF
Yes
No (mostly) No (mostly)
Yes
Yes
Abbreviations: RF, radial forearm free flap; ALT, anterolateral thigh flap; SCIP, superficial circumflex iliac artery perforator flap; AF, abdominal flap; MLD, musculocutaneous latissimus dorsi flap; DIEP, deep inferior epigastric artery flap Centres in Europe and the United Kingdom have been Transmasculine individuals can choose between micro * has not started phalloplasty service at the forefront of genital gender affirmation surgery (metoidioplasty) or full-size (phalloplasty) penile (GAS) for transmasculine individuals over the recent reconstruction. Both options offer advantages and Index of gender affirmation surgery units (alphabetical order) decades. Originating from China, the grounddisadvantages, and it is the role of the reconstructive Amsterdam: Amsterdam University Medical Centre breaking use of microvascular free-flap transfer from surgeon to guide and tailor the approach to the Belgrade 1: Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade University the radial forearm (RF) by Chang and Hwang1 for individual. Not all individuals will want, require or Belgrade 2: Sava Perovic Foundation penile reconstruction led to a renaissance in this field qualify for all procedures. Belgrade 3: Andromedic Academy Belgrade, Belgrade University in 1984. Subsequently, significant advances have Frankfurt: Agaplesion Markus Krankenhaus continued predominantly in European centres. Phalloplasty Freiburg: University Medical Centre Freiburg, Department for Urology, Unit for Gender Surgery Phalloplasty offers the most complete genital Alternative tissue flaps and reconstructive Ghent: Ghent University Hospital refinements have been developed and our transformation currently available (see Figs. 1 and 2). Lille: Service d’ Urologie, Andrologie et Transplantation Rénale, Hôpital Claude Huriez understanding of the staging and outcomes of genital A full-size neophallus is necessary to engage in London: St Peter’s Andrology Centre GAS have progressed considerably since that time. penetrative intercourse. Most centres in Europe prefer Lyon: Urology department, Hôpital Lyon Sud. Plastic surgery department, Hôpital de la Croix distant tissue flaps that require microsurgical Rousse techniques (free flaps) or transfer of the flap while This article discusses the role of genital GAS and Munich: Centre for Reconstructive Urogenital Surgery, Urologische Klinik München Planegg summarises some of the centres in Europe and the UK preserving the original blood supply (pedicled flaps). Turin: Urology clinic, Citta della salute e della scienza, University of Turin that offer genital GAS for transmasculine individuals. The primary advantage of free flaps is that the urethra Warsaw: Warsaw/Bydgoszcz The contemporary techniques offered by these centres can be integrated in the flap design resulting in a are briefly discussed, and the functional outcomes single stage, well-vascularised “tube-within-a-tube” Table 2: Comparison of functional and aesthetic outcomes of commonly used flaps for phalloplasty reported. urethra. Several centres (see Table 1) perform urethral join-up (or lengthening) at the time of phalloplasty. Flap Sensation Donor site morbidity Colour match Single stage urethra* Bulky Role of genital GAS RF Best Visible No Yes No Radial forearm free flap Incongruence between the gender identity of an ALT Yes Hidden Yes Some Yes individual and their sex assigned at birth is The most common flap for phalloplasty in Europe MLD Poor Hidden No No Yes distressing with significant repercussions, such as the (and the world) is the RF free flap1 (see Table 1). The risk of self-harm and suicide. Half of transgender and RF flap is considered the gold standard because of the OF Yes Long term weakness No No No and instability gender non-binary (transmasculine) individuals have thin, pliable forearm skin, which is often hairless in attempted suicide2 and they are subject to the urethral segment. Also, the flap has a reliable AF Variable Hidden Yes No Yes stigmatisation, physical abuse and sexual assault. vascular pattern with a long pedicle and multiple Scapular No Hidden No Yes No Most choose to transition physically to align with their sensory cutaneous nerves to facilitate flap transfer. gender identity more closely by use of gender The primary disadvantages are the visible donor site Abbreviations: RF, radial forearm free flap; ALT, anteriolateral thigh flap; MLD, musculocutaneous latissimus affirming hormone therapy and surgery. on the forearm and the neophallus colour mismatch dorsi flap; OF, osteocutaneous fibula free flap; AF, abdominal flap with the surrounding skin. The neophallus may also *single stage/without further flap surgery Genital GAS further ameliorates gender dysphoria lack girth in individuals with less subcutaneous fat. experienced by transmasculine individuals who are results in a generous neophallus (see Table 2). The on gender affirming hormone therapy. Body Alternative tissue flaps The anterolateral thigh (ALT) flap (pedicled or free), neophallus colour match is better than for the RF free satisfaction scores are higher following surgery and flap but hair removal of the urethral segment is gender affirming hormone therapy compared to musculocutaneous latissimus dorsi flap (free) and The abdominal (pedicled) flap (AF) continues to play a hormone therapy alone3. Furthermore, individuals superficial circumflex iliac artery perforator (SCIP) invariably required prior to phalloplasty. The thicker subcutaneous fat in the thigh may also complicate role in phalloplasty and is offered in most centres. The awaiting genital GAS were less satisfied compared to flap (pedicled) are alternatives to the RF flap. In particular, the ALT flap is gaining in popularity tubularisation of the neophallus and urethra in some flap is ideal for those who wish to minimise donor those who did not wish to have genital GAS. Hence, site morbidity or would prefer a shorter operative and transmasculine individuals should not be deprived of because it is a pedicled flap (around 90% of the time) individuals. The donor site wound in the upper thigh that does not require microsurgical anastomosis and remains significant although it is better hidden. recovery time. The AF should also be considered in surgery if they desire it. individuals with multiple co-morbidities that may complicate free flap phalloplasty. Assessment for genital surgery Transmasculine individuals seeking genital GAS Osteocutaneous flaps such as the fibular flap have should meet the World Professional Association for fallen out of favour due to significant donor site Transgender Health Standards of Care4. Revised morbidity and insufficient penile rigidity due to guidelines (version 8) are due for release in 2021. problematic proximal bone fixation. A permanent Individuals should have persistent and documented erection is also less desirable. gender dysphoria and be of adult age in their country. They need to have received 12 months of continuous Combination flaps gender affirmation hormone therapy (unless Some centres combine two different flaps to reduce contraindicated) and have lived in a gender role that the donor-site morbidity and defects resulting from is congruent with their gender identity for a similar the transfer of a single large flap with integrated period. urethra. A free flap urethroplasty is also useful to construct a well-vascularised urethra in a neophallus that would otherwise not have an integrated urethra. EAU Section of Genito-Urinary Reconstructive Surgeons (ESGURS)
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European Urology Today
Figure 1: Radial forearm free flap phalloplasty with deflated penile prosthesis
Figure 2: Phalloplasty with fully inflated penile prosthesis
Continued on page 15
March/May 2021
