Established and experimental techniques to improve phalloplasty outcomes: Optimization of a hypercomplex surgery
Erin Carter, MS1, Curtis Crane, MD2, Richard Santucci, MD2.
1Boston University School of Medicine, Boston, MA, USA, 2The Crane Center for Transgender Surgery, Austin, TX, USA.
Introduction: An increasing number of transgender and gender non-conforming patients are seeking genital gender-affirming surgeries across the US. Phalloplasty is the most complex of these surgeries, in that it combines many different smaller procedures into one or more stage(s). Each of these components have different risk profiles, and phalloplasty as a whole has a wide variety of possible complications. Some targets for improvement in outcomes concern urethral fistula/stricture, efficacy of reinnervation of the phalloplasty flap, postoperative flap monitoring, and donor site morbidity. In the setting of no established “gold standard”, we sought describe interventions—some experimental, some established—that can be applied to improve outcomes of this ultracomplex surgery.
Materials & Methods: We reviewed the entirety of the English-language literature regarding established techniques for prevention of common complications after phalloplasty and complex flap surgery in general. We also identified promising reports on experimental techniques to further minimize urethral complications, enhance nerve regeneration, improve postoperative flap monitoring, control of postoperative bleeding, and manage flap donor site morbidity.
Results: Our high-volume phalloplasty group has achieved industry-low urethral complication rates of 22% by technical optimization of the urethroplasty portion of phalloplasty. We use transcutaneous visual light spectroscopy (Tstat™) monitoring for intraoperative decision-making and postoperative flap surveillance. We use collagen matrix sheets [Integra® Wound Matrix (Thin)] to improve aesthetic and functional outcomes at the flap donor site. We use thrombin-gelatin hemostatic matrix (Floseal™) to eliminate the need for scrotal drains and limit scrotal hematoma. We continue to investigate the role of extracellular matrix nerve connection sheaths (Axoguard™) to improve the efficiency of nerve regeneration to the flap. Further evaluation of dehydrated human amnion/chorion membrane allograft (Amniofix™) to decrease urethral fistula/stricture is planned.
Conclusions: One stage phalloplasty is a massive surgical endeavor (~ 200 RVUs per case) requiring several experienced surgeons working over 6-12 hours. Through a combination of surgical technique improvement and incorporation of promising new technology, we have attempted to optimize the results of this massive free-flap surgery. Ultimately, with continued innovation and sharing of improved surgical techniques, it may be possible to better standardize care and improve outcomes of this complicated and increasingly common surgery.
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