Download PDF
CC BY-NC-ND 4.0 · J Reconstr Microsurg Open 2024; 09(01): e34-e42
DOI: 10.1055/a-2257-4986
Original Article

Complications Following Gender-Affirming Phalloplasty: A NSQIP Review

Bashar Hassan
1   Department of Plastic and Reconstructive Surgery, Center for Transgender Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Madyson Brown
1   Department of Plastic and Reconstructive Surgery, Center for Transgender Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Lily Guo
2   Chicago Medical School, Rosalind Franklin University, Chicago, Illinois
,
Mona Ascha
1   Department of Plastic and Reconstructive Surgery, Center for Transgender Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Breanna Jedrzejewski
3   Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, Portland, Oregon
,
Andrew Cohen
4   Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore
,
Gabriel Del Corral
5   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Baltimore, Maryland
,
Fan Liang
1   Department of Plastic and Reconstructive Surgery, Center for Transgender Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Background Gender-affirming phalloplasty has a complication rate as high as 76.5%. This is the first study to determine the predictors of 30-day complications following phalloplasty using a national registry.

Methods The National Surgical Quality Improvement Program database (2012–2021) was queried for transgender men and Current Procedural Terminology codes pertaining to flap or microsurgery procedures to select for single- and first-stage phalloplasty cases. Included were patients with a length of total hospital stay ≥ 5 days and operating time > 4 hours to select for primary phalloplasty cases. The primary outcome was incidence of major and minor complications, and the secondary outcome was indication for unplanned reoperation. Bivariate analysis and multivariate logistic regression were performed to determine significant predictors of complications.

Results Of 90 patients, 18 (20.0%) patients developed at least one complication. The most common complication was unplanned reoperation (n = 10, 11.1%) due to hematoma evacuation (n = 3, 30.0% of reoperations, 3.3% of all patients). A total of 43 (47.8%) underwent single-stage phalloplasty, and 47 (52.2%) underwent first-stage phalloplasty. Compared with patients without complications, those with minor complications are more likely to have had single-stage phalloplasty (n = 37 [45.1%], n = 6 [75.0%]; p = 0.145), but the association was not statistically significant. Longer operating time was associated with greater odds of major complications (adjusted odds ratio [aOR] 95% confidence interval [CI] 1.01 [1.002–1.018]). Patients who smoked within 1 year of surgery had 123 times the odds of 30-day minor complications (surgical site infection, urinary tract infection, wound dehiscence, pneumonia) compared with nonsmokers (aOR [CI] 123.3 [1.4– > 100.0]).

Conclusion There were no significant differences in complication rates between single- and first-stage phalloplasties. Patients should be counseled about the overall risk of 30-day complications following phalloplasty. Reducing operating time, smoking cessation, and strict preoperative nicotine testing may assist in mitigating odds of 30-day complications following phalloplasty.

Keywords

phalloplasty - complications - predictors - transgender and nonbinary

This study was presented at:

The American College of Surgeons Maryland Chapter Annual Meeting, April 1, 2023, Baltimore, Maryland.

The 68th Annual Meeting of the Plastic Surgery Research Council, April 13–16, 2023, Cleveland, Ohio.

The 101st Annual Meeting of the American Association of Plastic Surgeons, April 29–May 2, 2023, Chicago, Illinois.


Supplementary Material



Publication History

Received: 04 April 2023

Accepted: 25 November 2023

Accepted Manuscript online:
30 January 2024

Article published online:
26 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Herman JL, Flores AR, O'Neill KK. How Many Adults and Youth Identify as Transgender in the United States?. The Williams Institute; Los Angeles, California: 2016
    Google Scholar
  • 2 Canner JK, Harfouch O, Kodadek LM. et al. Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surg 2018; 153 (07) 609-616
    CrossrefPubMedGoogle Scholar
  • 3 Lane M, Ives GC, Sluiter EC. et al. Trends in gender-affirming surgery in insured patients in the United States. Plast Reconstr Surg Glob Open 2018; 6 (04) e1738
    CrossrefPubMedGoogle Scholar
  • 4 Tran BNN, Epstein S, Singhal D, Lee BT, Tobias AM, Ganor O. Gender affirmation surgery: a synopsis using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases. Ann Plast Surg 2018; 80 (4, suppl 4): S229-S235
    CrossrefPubMedGoogle Scholar
  • 5 Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: a systematic review. Turk J Urol 2017; 43 (03) 229-236
    CrossrefPubMedGoogle Scholar
  • 6 Frey JD, Poudrier G, Chiodo MV, Hazen A. A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male transgender genital reconstruction: is the “ideal” neophallus an achievable goal?. Plast Reconstr Surg Glob Open 2016; 4 (12) e1131
    CrossrefPubMedGoogle Scholar
  • 7 Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty: a review of techniques and outcomes. Plast Reconstr Surg 2016; 138 (03) 594-615
    CrossrefPubMedGoogle Scholar
  • 8 Wu CA, Jolly D, Boskey ER. et al. A systematic review of staging and flap choice in gender-affirming phalloplasty. Journal of Reconstructive Microsurgery Open. 2022; 07 (02) e13-e26
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Falcone M, Preto M, Timpano M. et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature. Int J Impot Res 2020; 33 (07) 737-745
    CrossrefPubMedGoogle Scholar
  • 10 Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol 2010; 57 (04) 715-722
    CrossrefPubMedGoogle Scholar
  • 11 Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile reconstruction: the pedicled anterolateral thigh flap. Plast Reconstr Surg 2009; 124 (01) 163-166
    CrossrefPubMedGoogle Scholar
  • 12 Orandi A. Phalloplasty and saphenous vein urethroplasty. Invest Urol 1965; 3 (02) 111-116
    PubMedGoogle Scholar
  • 13 Remington AC, Morrison SD, Massie JP. et al. Outcomes after phalloplasty: do transgender patients and multiple urethral procedures carry a higher rate of complication?. Plast Reconstr Surg 2018; 141 (02) 220e-229e
    CrossrefPubMedGoogle Scholar
  • 14 Wang AMQ, Tsang V, Mankowski P, Demsey D, Kavanagh A, Genoway K. Outcomes following gender affirming phalloplasty: a systematic review and meta-analysis. Sex Med Rev 2022; 10 (04) 499-512
    CrossrefPubMedGoogle Scholar
  • 15 Schardein JN, Zhao LC, Nikolavsky D. Management of vaginoplasty and phalloplasty complications. Urol Clin North Am 2019; 46 (04) 605-618
    CrossrefPubMedGoogle Scholar
  • 16 Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int 2008; 101 (10) 1297-1300
    CrossrefPubMedGoogle Scholar
  • 17 Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol 2018; 199 (01) 206-214
    CrossrefPubMedGoogle Scholar
  • 18 Huayllani MT, Boczar D, Saleem HY. et al. Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature. Ann Transl Med 2021; 9 (07) 608
    CrossrefPubMedGoogle Scholar
  • 19 Frey JD, Poudrier G, Thomson JE, Hazen A. A historical review of gender-affirming medicine: focus on genital reconstruction surgery. J Sex Med 2017; 14 (08) 991-1002
    CrossrefPubMedGoogle Scholar
  • 20 Chaya BF, Berman ZP, Boczar D. et al. Gender affirmation surgery on the rise: analysis of trends and outcomes. LGBT Health 2022; 9 (08) 582-588
    CrossrefPubMedGoogle Scholar
  • 21 Scott KB, Thuman J, Jain A, Gregoski M, Herrera F. Gender-affirming surgeries: a national surgical quality improvement project database analyzing demographics, trends, and outcomes. Ann Plast Surg 2022; 88 (5, suppl 5): S501-S507
    CrossrefPubMedGoogle Scholar
  • 22 User Guide for the 2021 ACS NSQIP Procedure Targeted Participant Use Data File (PUF): ACS NSQIP; 2022. Accessed April 2, 2023, at: https://www.facs.org/media/tjcd1biq/nsqip_puf_userguide_2021_20221102120632.pdf
    PubMed
  • 23 Cook NR. Statistical evaluation of prognostic versus diagnostic models: beyond the ROC curve. Clin Chem 2008; 54 (01) 17-23
    CrossrefPubMedGoogle Scholar
  • 24 IBM SPSS Statistics 28 Brief Guide. Accessed April 2, 2023, at: https://www.ibm.com/support/pages/node/6442933
    PubMedGoogle Scholar
  • 25 Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery 1993; 14 (09) 592-598
    CrossrefPubMedGoogle Scholar
  • 26 Heston AL, Esmonde NO, Dugi III DD, Berli JU. Phalloplasty: techniques and outcomes. Transl Androl Urol 2019; 8 (03) 254-265
    CrossrefPubMedGoogle Scholar
  • 27 Chen ML, Safa B. Single-stage phalloplasty. Urol Clin North Am 2019; 46 (04) 567-580
    CrossrefPubMedGoogle Scholar
  • 28 Medina CA, Fein LA, Salgado CJ. Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men. Int Urogynecol J Pelvic Floor Dysfunct 2018; 29 (10) 1463-1468
    CrossrefPubMedGoogle Scholar
  • 29 Santucci RA. Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence. Clin Anat 2018; 31 (02) 187-190
    CrossrefPubMedGoogle Scholar
  • 30 Chan LK, Withey S, Butler PE. Smoking and wound healing problems in reduction mammaplasty: is the introduction of urine nicotine testing justified?. Ann Plast Surg 2006; 56 (02) 111-115
    CrossrefPubMedGoogle Scholar
  • 31 Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg 2017; 140 (04) 551e-558e
    CrossrefPubMedGoogle Scholar
  • 32 Nikolavsky D, Hughes M, Zhao LC. Urologic complications after phalloplasty or metoidioplasty. Clin Plast Surg 2018; 45 (03) 425-435
    CrossrefPubMedGoogle Scholar
  • 33 Fang RH, Lin JT, Ma S. Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 1994; 15 (05) 349-352
    CrossrefPubMedGoogle Scholar
  • 34 Gösseringer N, Mani M, Cali-Cassi L, Papadopoulou A, Rodriguez-Lorenzo A. Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: experience in a Swedish medical center. Microsurgery 2017; 37 (05) 416-420
    CrossrefPubMedGoogle Scholar
  • 35 Studinger RM, Bradford MM, Jackson IT. Microsurgical training: is it adequate for the operating room?. Eur J Plast Surg 2005; 28 (02) 91-93
    CrossrefPubMedGoogle Scholar
  • 36 Wong AK, Joanna Nguyen T, Peric M. et al. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2015; 35 (01) 6-12
    CrossrefPubMedGoogle Scholar
  • 37 Hassan B, Abou Koura A, Makarem A. et al. Predictors of surgical site infection following reconstructive flap surgery: a multi-institutional analysis of 37,177 patients. Front Surg 2023; 10: 1080143
    CrossrefPubMedGoogle Scholar
  • 38 Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg 1984; 74 (02) 251-258
    CrossrefPubMedGoogle Scholar
  • 39 Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg 1993; 92 (02) 276-283 , discussion 284
    CrossrefPubMedGoogle Scholar
  • 40 Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg 1982; 9 (01) 21-26
    CrossrefPubMedGoogle Scholar
  • 41 Blaschke E, Bales GT, Thomas S. Postoperative imaging of phalloplasties and their complications. AJR Am J Roentgenol 2014; 203 (02) 323-328
    CrossrefPubMedGoogle Scholar
  • 42 Sinove Y, Kyriopoulos E, Ceulemans P, Houtmeyers P, Hoebeke P, Monstrey S. Preoperative planning of a pedicled anterolateral thigh (ALT) flap for penile reconstruction with the multidetector CT scan. Handchir Mikrochir Plast Chir 2013; 45 (04) 217-222
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Hart A, Rainer WG, Taunton MJ, Mabry TM, Berry DJ, Abdel MP. Cotinine testing improves smoking cessation before total joint arthroplasty. J Arthroplasty 2019; 34 (7S): S148-S151
    CrossrefPubMedGoogle Scholar