Urethral Complications in Transmasculine Genital Reconstructive Surgery (TMGRS): A Systematic Review
Christopher D. Ortengren, MD1, Gaines Blasdel, BS2, Ella A. Damiano, MD1, Peter Scalia, PhD MSc3, John F. Nigriny, MD1, William Bihrle, III, MD1, Benjamin Boh, DO1, Pamela Bagley, PhD MLIS4, Heather B. Blunt, MSILS4, Glyn Elwyn, MD PhD1, Mang Chen, MD5, Jeremy B. Myers, MD6, Rachel A. Moses, MD1.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2New York University, New York, NY, USA, 3Geisel School of Medicine at Dartmouth, Hanover, NH, USA, 4Dartmouth College, Hanover, NH, USA, 5G.U. Recon, San Francisco, CA, USA, 6University of Utah, Salt Lake City, UT, USA.
BACKGROUND: The purpose of this systematic review is to evaluate urethral related outcomes in Transmasculine Genital Reconstructive Surgeries (TMGRS) with urethral lengthening (UL), which includes metoidioplasty and phalloplasty.METHODS: A systematic review was planned in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines by 4 independent reviewers and one content expert. A search for metoidioplasty and phalloplasty related literature was preformed utilizing MEDLINE, Cochrane Library, Web of Science, EMBASE, Preprint, Google Scholar, Trial Registries, and Conference Proceedings. The search was registered with Open Science Framework. Publication quality was assessed using the Methodological Index for Non-Randomized Studies criteria (MINORS). Primary outcomes extracted included demographics, phallus length, standing micturition, phalloplasty type, glanular meatus, mucocele, urethral stricture, and fistula. Results and ranges of outcome probabilities were summarized in a qualitative analysis using descriptive statistics. Studies or specific patient cohorts within studies were excluded if patients did not have a vaginectomyRESULTS: Using Population, Intervention, Comparison and Outcomes tool, 2,881 articles were identified with 12 articles meeting criteria. All articles were retrospective reviews with an average(avg) patient age of 33(SD5) years with a MINORS score of 4.3/16. Evaluated phalloplasty cohorts include those who underwent the Radial Forearm Free Flap (RFFF), Anterolateral Thigh Flap (ALT), or Musculocutaneous Latissimus Dorsi Flap (MLD) with vaginectomy. Six metoidioplasty studies yielded the following results: N=874, avg length of follow up (LOF) 31 months, phallus length 5.6-7cm, standing micturition 48%-100%, stricture 1.4% - 63%, fistula 8%-50%, and mucocele 1%- 12%. Four RFFF phalloplasty studies yielded: N= 288, avg LOF 18(SD9) months, phallus length 11cm(1 study), standing micturition 99%(1 study), glanular meatus 70%-100%, stricture 11%-81%, and fistula 10%-79%. Three studies were identified for ALT flap: N=85, avg LOF 50(SD36) months, standing micturition 56-100%, glanular meatus 75 - 100%, stricture 20%-38%, and fistula 20%-25%. One study met criteria for MLD flap: N= 129, avg LOF 43 months, phallus length 14.6cm, glanular meatus 15% (or 63% with 2+ planned surgeries), stricture 27%, and fistula 26%.CONCLUSIONS: Despite a continued increase in TMGRS performed with UL, in this comprehensive systematic review we demonstrate urethral related complications remain high. Further, the existing published literature remains heterogeneous and of limited methodologic quality.
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