Urethroplasty in female-to-male transsexuals.

OBJECTIVE: Female-to-male transformation includes total phallic reconstruction. Construction of a neourethra is necessary to achieve the goal of voiding while standing; however urethral fistula and stricture formation occur in a significant percentage of patients.
METHODS: 25 patients with primary female transsexualism underwent phalloplasty with a free radial forearm flap, vaginectomy and urethroplasty in a one-stage procedure. In 16 of these patients the fixed part of the neourethra ("bulbar urethra") was constructed from a vaginal flap. In 9 patients flaps of the labia minora (5 patients) or the "urethral plate" (4 patients) were used.
RESULTS: In 14 (58%) patients fistulas and/or strictures in the newly constructed urethra occurred. 11 (69%) of 16 patients in whom the "bulbar urethra" was constructed from a vaginal flap experienced fistulas and/or stricture formation. Fistulas and/or strictures occurred in 3 of 5 patients with labia minora flaps and none of 4 patients with the urethral plate procedure. Repair of fistula and strictures was performed by primary closure of fistulas, staged urethroplasty with local pedicle flaps or distant tissue grafts using buccal mucosa (2-6 procedures).
CONCLUSION: One-stage total phalloplasty and urethroplasty is associated with a significant rate of fistulas and strictures. However, these complications can be corrected by the techniques used in modern urethral surgery.