Many female-to-male GRS patients ask about having the ability to urinate while standing. The ability to void while standing is not recommended because of its propensity for complications. This is because a longer urethra must be constructed which will traverse the entire length of the new penis (the “neophallus”). The main problem is the location where the new segment of urethra is attached (anastomosed) to the existing urethra.
At this site there is usually a circumferential anastomosis where the new segment is sutured to the end of the existing urethra. This area doesn’t always heal ideally and complications can arise. A fistula (and leak of urine) can occur if an opening develops in the anastomatic site. Or, stenosis (partial or total closure) of the urethra can occur if the anastomatic area contracts and shrinks, partially or totally obstructing the flow of urine, while, at the same time, causing increased stasis and pressure of urine in the bladder. Both of these situations, fistula and stenosis, require at least one and sometimes multiple surgical procedures to correct and this necessitates additional hospitalizations and expense.
The neophallus itself is constructed from one or more flaps of skin and subcutaneous fat which are “tubed” to resemble a penis. Many different techniques are used by different surgeons to create the neophallus. The incidence of complications utilizing most of today’s techniques varies from 30% to 70% of cases, which is not acceptable to most surgeons or patients.
The so-called “state-of-the-art” technique currently being used by some surgeons is a “free flap” of tissues removed from the forearm or the leg and attached at the proper location by means of microvascular anastomoses of the arteries and veins of the transferred tissues to those at the recipient site. Unfortunately, in addition to the possibility of complications at the anastomatic sites of the involved arteries, veins and urethra, this technique also creates a significant deformity of the arm or leg.
Some patients may decide not to have a phalloplasty procedure, opting for a metoidioplasty/clitoral release instead. This involves elevating the existing clitoris containing an attached urethra made from adjacent mucosal tissue or skin. This procedure permits the ability to stand while urinating but, unfortunately, the neophallus is a micropenis, perhaps only one to two inches long and not appearing like an average normal penis. True, you can stand to void, but you do not possess a penis which looks normal or can function normally. There is also a high rate of complication associated with the urethral lengthening procedure. Although this mini penis may have sensitivity, it is not capable of having normal sexual intercourse. Many surgeons will not do this procedure because it does not create an anatomically normal penis. Many transmen are happy with metoidioplasty but some may feel that a normal sized penis which can also be used to have intercourse is an option to consider. When I perform metoidioplasty, I recommend doing it without the urethral extension in order to avoid the high risk of complications associated with the urethral lengthening procedure.
Dr. Leis Preferred Procedure
At the Center, we are using a relatively simple technique that creates a penis which looks natural and has sensation, and is capable of having intercourse. However, it does not include urethral lengthening and so you can not stand to void. This operation is simpler and less expensive than other techniques, involves only a one day hospitalization and sometimes can be done as an out-patient, has minimal risk of complications and no risk of stenosis or fistula. Many feel that a normal adult size penis is more masculinizing than being able to stand to void with a micropenis.
The female to male technique we currently use involves the creation of either two groin flaps or a heart-shaped flap of skin and subcutaneous tissue from the lower abdomen which is elevated from the muscle layer, then tubed and permitted to hang downward from the pubic area. To close the groin flap donor sites, adjacent tissues are elevated and easily approximated. The defect from the abdominal flap donor site is closed similarly to an abdominoplasty or tummy tuck procedure: the upper abdominal skin is elevated and mobilized downward to the pubic area where it is sutured closed. The skin of the labia majora is stretched (the plastic surgical technique of “tissue expansion”) and a testicular implant is placed in each labia which now looks and feels like a scrotum with testicles. If desired, a more natural looking scrotum can be created by joining the labia together in the midline (scrotoplasty). Also, the neophallus can be made to look circumcised or uncircumcised. In addition, the clitoris can be left in place or mobilized to the base of the penis and maintains its sensitivity. Because the lower abdominal arteries, veins and nerves have been preserved, the neophallus has good vascularity (blood supply) as well as sensitivity and sensation.
We prefer this technique over other existing techniques of penis construction because it is a one-stage procedure which results in a normal looking, sensate, penis which can function for intercourse, is associated with a low incidence of complications, and has no significant donor site defect or deformity.
We often do a total hysterectomy (removal of the uterus, fallopian tubes, and ovaries) at the same time as the phalloplasty. This has the benefit of having both procedures completed in one operation, with one hospitalization, one anesthesia, and one recovery period. There is no increase in rate of recovery time when both procedures are done together. There is also financial savings from having both at the same time, together with losing less time away from work or school.
If the hysterectomy is done prior to the phalloplasty, a horizontal abdominal incision should be avoided so as not to interfere with the blood supply to the lower abdominal tissues which will be used for the phalloplasty. We recommend that the GYN surgeon perform a vaginal laparoscopic or laparoscopic assisted hysterectomy if this procedure is performed prior to phalloplasty.