Key points

Introduction

In recent years, the issues of the transgender population have become more visible in the media worldwide. It has been estimated that approximately 355 individuals per 100,000 population consider themselves transgender or experience gender dysphoria to a varied degree, and approximately 9.8 per 100,000 would seek affirmation therapy. Complete transformation to the new gender involves several pharmaceutical and surgical steps. Transgender patients at various stages of their transformation will present to urologic clinics requiring general or specialized urologic care. Knowledge of specifics of reconstructed anatomy and potential unique complications of the reconstruction will become important in providing urologic care to these patients.

Our review of literature combined with the authors’ personal experience suggest that in patients undergoing male-to-female transformation, the genitourinary complications are uncommon: recto-neovaginal fistula (1%) and meatal stenosis (5%). Thus, in this review, we have concentrated on describing the more common urologic complications after female-to-male reconstructions.

Introduction

In recent years, the issues of the transgender population have become more visible in the media worldwide. It has been estimated that approximately 355 individuals per 100,000 population consider themselves transgender or experience gender dysphoria to a varied degree, and approximately 9.8 per 100,000 would seek affirmation therapy. Complete transformation to the new gender involves several pharmaceutical and surgical steps. Transgender patients at various stages of their transformation will present to urologic clinics requiring general or specialized urologic care. Knowledge of specifics of reconstructed anatomy and potential unique complications of the reconstruction will become important in providing urologic care to these patients.

Our review of literature combined with the authors’ personal experience suggest that in patients undergoing male-to-female transformation, the genitourinary complications are uncommon: recto-neovaginal fistula (1%) and meatal stenosis (5%). Thus, in this review, we have concentrated on describing the more common urologic complications after female-to-male reconstructions.

Urologic issues in female-to-male transgender patients

One goal of neophallus construction in female-to-male transgender surgery is to achieve the ability for the individual to void while standing. Although some patients use external “urinary assist” devices from the native urethra to facilitate urination while standing, many undergo neourethra construction, as the ability to stand to void is a high priority among female-to-male transgender individuals. More than 98% reported a desire to stand to void. The management of urologic sequelae is important after neourethra construction, as fistulae, strictures, and persistent vaginal cavities are common complications.

Anatomy of metoidioplasty and phalloplasty

Female-to-male transgender patients are typically offered 2 options for genital reconstruction: metoidioplasty versus phalloplasty. Metoidioplasty in its many forms involves lengthening of native urethra by means of local vaginal and labial flaps to create a neophallus long enough for urination in a standing position. The techniques are similar to proximal hypospadias repair in pediatric patients. At the end of the operation, the labia minora is tubularized to form the distal urethra, the clitoris is freed from the attachments and elongated to form the glans, and the labia majora is used to create a neoscrotum and to cover the shaft of the neophallus. As a result, the urethra after metoidioplasty consists of 2 parts: the proximal native urethra with its meatus connected to a distal neourethra created from the labia minora.

Metoidioplasty is an attractive option for patients who would want to avoid more invasive phalloplasty options that involve distant tissue flaps and grafts. The complications are typically minor and may involve ventral fistulae, infrequent stricture at the level of neourethra, and remnant vaginal cavity. The main disadvantage of this procedure is limited length and girth of the resultant neophallus, precluding its use for intercourse.

In contrast, phalloplasty is offered to patients who desire to achieve both voiding and sexual functions. As expected, this is a more invasive option, involving a combination of local and distant tissue transfer techniques. The urethra of the male-to-female transgendered patient after phalloplasty can be divided into distinct segments, from proximal to distal: native (female) urethra, fixed urethra, anastomotic urethra, phallic urethra, and meatus. The fixed urethra is the portion of the urethra formed after lengthening the native urethra via local vaginal or labial flaps, extragenital flaps, and grafts of skin or mucosa. The phallic urethra can be constructed through a variety of techniques, including prelamination, prefabrication, tube-in-tube techniques, and pedicle flaps.

Fistula

Urethrocutaneous fistula is the most common urethral complication. The fistula rate of radial forearm free flap phalloplasty ranges from 22% to 75%. Urethral fistulas commonly occur at points of anastomosis: between the phallic urethra and fixed urethra, and between the fixed urethra and the native urethra, although fistulae can occur anywhere along the neourethra. Fistulas occur most commonly at or just proximal to the anastomosis between the phallic urethra and fixed urethra due to vascular insufficiency of the flap, and the decreased lumen of the phallic urethra. The change in caliber of the lumen from fixed to phallic urethra may cause a relative obstruction of the urinary stream distal to the site of the fistula. The small-caliber lumen of the phallic urethra may be due to tissue shrinkage or insufficient size of the urethra at the time of construction. Spontaneous closure of the fistula tract has been reported, with Fang and colleagues reporting spontaneous closure of the fistula within 2 months in as many as 35.7% of patients.

Persistent vaginal cavity

In our combined experience, fistulae proximal to the anastomosis commonly communicate with large remnant vaginal cavities and are unlikely to close spontaneously if there is distal obstruction ( Fig. 1 ). We suspect that in the presence of distal obstruction, pressurized urine finds its way through the ventral suture lines of the fixed urethra and into the obliterated vaginal cavity after previous vaginectomy or colpocleisis. If this persistent cavity is found, we routinely perform complete cavity excision and obliteration at the time of the fistula repair. Surprisingly, in our experience, pathologic analysis showed normal vaginal epithelium in all cavity specimens, despite the previous history of vaginectomy.

Examples of persistent vaginal cavity. ( A ) Retrograde urethrogram of patient with anastomotic stricture of the neophallic urethra and large persistent vaginal cavity. ( B ) Cystoscopic view of remnant vaginal cavity ( below ) and native urethral meatus ( above ). ( C ) Intraoperative view of another patient with both anastomotic stricture and persistent vaginal cavity (urethral catheter is seen in native urethral meatus).

Stricture

Urethral stricture is another common urologic complication with reports of incidence varying from 25% to 58%. Although stricture can occur in any segment of the urethra, the most common location of stricture formation is at the anastomosis of the fixed and phallic portion of the neourethra ( Fig. 2 ). Lumen and colleagues characterized stricture formation after phalloplasty and determined that urethral stricture occurred at the anastomosis in 40.7%, phallic portion in 28%, the meatus in 15.3%, fixed segment in 12.7%, and multifocal in 7.6%. Ischemia is thought to be the etiology of strictures at all levels. Fistula formation also may contribute to dense scar formation and kinking of the tissues, especially at the anastomosis of the phallic to fixed portions. At the meatus, contracture of the anastomosis between the skin of the glans and the neourethral tissue can lead to meatal stenosis. Mean stricture length in this series was 3.6 cm (range: 0.5–15 cm). Fistula and urethral stricture may occur simultaneously. In a series of 1-stage urethroplasty by Rohrmann and Jaske, 40% of patients developed fistula and strictures, with the fistula usually proximal to the stricture.

( A ) Combined voiding and retrograde urethrograms of patient with short anastomotic stricture of a neophallic urethra. The location of the stricture is at the junction of fixed urethra and phallic urethra. ( B ) Retrograde urethrogram of patient with neophallus showing extensive penile stricture from anastomosis to neomeatus.

Proper management of urologic sequelae of phalloplasty is mandatory given that urinary fistulae and urinary obstruction due to urethral stricture can have grave consequences, such as chronic infection, sepsis, and renal failure, as well as compromised quality of life. If the patient is in urinary retention, urinary drainage must be performed, with placement of a suprapubic catheter. The extent of subsequent urinary reconstruction will depend on the individual’s health and preferences.

Patient evaluation

A patient with urologic sequelae after phalloplasty will often present with voiding complaints. This may include increased difficulty with urination, whether with decreased stream or increased need to strain to void, or a complete inability to void. If a urethrocutaneous fistula has formed, the patient may complain of urine or purulent drainage at a location other than the meatus. The drainage may occur at the time of micturition but may also occur afterward due to pooling of the urine in the urinary tract or persistent vaginal cavity. The patient may also complain of dysuria or suprapubic pain.

The first step in patient evaluation is careful physical examination. The suprapubic area and neophallus should be examined for evidence of infection, such as erythema and induration. The areas are also palpated for fluctuance to determine if there are any fluid collections that require drainage. Ultrasound may be performed to evaluate for the presence of an abscess. All areas are evaluated for fistulous openings, and the urethral meatus itself is examined for patency.

Infections should be treated before surgery. Cellulitis should be treated. If there is concern for urinary tract infection, a urine sample may be sent for urinalysis and urine culture. If the patient has a suprapubic tube, the urine sample may be sent from the tube. Indwelling catheters are often colonized, however, and organisms grown from these cultures may not be representative of infections. If the urine culture returns positive with clinical indication of infection, then culture-specific antibiotics should be given.

Suprapubic tenderness and flank pain can be the result of urinary retention and an overly distended bladder. A postvoid residual can be determined using a bladder scanner. If the patient is in urinary retention, drainage of the bladder should be performed. As the patient typically has a urethral stricture that precludes urethral catheterization, a suprapubic tube should be placed to ensure adequate urinary drainage.

Further anatomic evaluation can be performed via both retrograde urethrogram and if possible, voiding cystourethrogram to help delineate the location of the stricture or fistula. Examination under anesthesia is frequently useful given the complex urinary anatomy of a patient status post phalloplasty. A suprapubic tube can be placed at the time of this examination if the patient does not already have one in place.

Preoperative planning and preparation

Notation should be taken as to the patient’s previous surgeries and what potential flaps and grafts are available for use for urologic reconstruction.

The first step in managing a urinary fistula or stricture causing urinary obstruction would be to ensure that the patient’s urine is adequately diverted with a suprapubic catheter of adequate size. The suprapubic catheter should be placed 2 to 4 cm above the pubis. Placement of a 16-French or larger catheter facilitates the use of the suprapubic channel for antegrade cystourethroscopy to delineate the proximal urethra. Antegrade cystourethroscopy is easiest when the suprapubic tube is at the midline. Care must be taken to avoid damage to the vascular anastomosis to the neophallus.

The standard preoperative evaluation for urethral strictures and fistulae includes a retrograde urethrogram combined with antegrade and retrograde endoscopy to determine the extent of stricture and evaluate for presence of fistulization and pelvic cavity. The patient is brought to the operating room and the patient is placed in low lithotomy position and prepped and draped to allow access to the perineum as well as the suprapubic region. A layer of complexity is added in the patient status post phalloplasty as the neourethra created may be of a smaller caliber than the native urethra and unable to accommodate a standard 16-French flexible cystourethroscope. At the authors’ institutions, we use a flexible ureteroscope to navigate the neourethra. The retrograde urethrogram can be performed by injecting contrast via the ureteroscope. This technique has the advantage of allowing for direct visualization of the neourethra rather than attempting to blindly pass a catheter into a possibly tortuous neourethra. A guidewire is used to gradually advance the ureteroscope. Once contrast is injected, fluoroscopic images are obtained to delineate the anatomy of the stricture and fistulae. If the suprapubic tract is mature, antegrade cystoscopy may be performed to delineate the anatomy proximal to the stricture point. Location, length, and caliber of the stricture as well as location of any fistulae are key factors to determine. Any fluid collections or abscesses that have formed due to obstruction should be adequately drained. If a fistula does not heal on its own, often excision of the fistula tract with closure and coverage with a flap is required.

Before any reconstructive effort, the risks of each possible intervention should be discussed in detail with the patients, including risks from harvesting new flaps and grafts, and from performing urethroplasty, redo vaginectomy, or fistula repair. The possibility of multistage procedures should be discussed, as well as remote possibility of total or partial loss of the neophallus. The most important consideration in choice of reconstruction is the patient’s preference and desire to void upright. Some may choose to avoid heroic reconstructive measures and may elect for the simpler option of perineal urethrostomy.