Infotrans

Phalloplasty

Who can undergo the surgery?

According to the recommendations reported in the bibliography section, people who match the following criteria can undergo phalloplasty surgery:

  • Gender incongruence is marked and sustained;
  • Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access health care;
  • Demonstrates capacity to consent for the specific gender-affirming surgical intervention;
  • Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options;
  • Other possible causes of apparent gender incongruence have been identified and excluded;
  • Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed;
  • Stable on their gender affirming hormonal treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).

In Italy, the following criteria have also to be matched:

Even if it is not an explicit criterion, regular visits, agreed on the basis of individual needs, with a psychologist and / or medical specialist (e.g. endocrinologist) are recommended.

When the necessary criteria for carrying out the surgery are met (see above), the person concerned must:

  • identify a specialized clinical center (Infotrans.it offers a list of public or public-private partnership structures, present on the national territory, able to provide this type of services in the section "Service Map")
  • make an interview with the specialist and schedule a medical visit to:
    • examination of the build and genitals
    • any second level exams such as Doppler ultrasound or CT angiography / magnetic resonance imaging for the vascular study of complex reconstructive flaps
    • gynecological visit and Pap test. For more information about the Pap test, it’s possible to visit ISSalute.it website under "Pap test"

It is not necessary to discontinue hormone therapy.
In general, if taking any prescription medication, this should be discussed with the specialist. It may be necessary to stop taking it even several days before the surgery. Drug therapy may be resumed at the doctor's discretion.
 

Phalloplasty uses tissues taken from other parts of the body to shape the penis and provides for the possibility of implanting prostheses for erection. Different surgical methods allow to achieve different goals but also involve different consequences and risks. It is necessary to clearly plan with the person what expectations can actually be achieved.
The most used phalloplasty techniques are:

Abdominal suprapubic pedicled flap, Pryor’s Technique
This surgery allows you to create a phallus of about 12-14 cm using the skin of the abdominal area above the pubis. The advantages of this intervention are the speed of the procedure (about 2 hours) and the good aesthetic results. However, the phallus will have reduced sensitivity and at the end of the first reconstructive step it will be impossible to urinate standing up due to the lack of a urinary canal. A total urethral reconstruction by a radial artery forearm free flap surgery can be performed in a further step. After abdominal suprapubic pedicled flap, a minimum of two other operations will be necessary for the creation of the scrotum, glans, removal of the vagina and, at a later stage, the positioning of the penile prosthesis (insertion in the phallus of a prosthesis similar to those used for impotence male with the possibility of making the organ rigid and suitable for sexual intercourse with penetration). During hospitalization, drugs will be administered to promote the fluidity of the blood inside the phallus.

Radial artery forearm free flap
This surgery is more complex than the one previously described. The surgery involves a removal of skin from the arm (more precisely from the forearm) with all the vessels that nourish it. The flap of skin is then used to create a phallus with the urethra inside. Radial artery forearm free flap phalloplasty currently represents the best solution available as regards genital reconstructive surgery, although it is burdened (like all microsurgical reconstructive flaps) by a risk equal to 5% of serious vascular complications (total loss of the phallus). The advantage lies in the ability to urinate standing up and in the greater sensitivity of the penis obtained. The skin tissue lost in the forearm is restored with skin removed from the thighs. As in phalloplasty with Abdominal suprapubic pedicled flap, a minimum of two other operations will subsequently be necessary for the creation of the scrotum, glans, removal of the vagina and, at a later stage, the placement of the penile prosthesis. The operation involves the placement of a bladder catheter (a cannula that allows urine to be eliminated) to be removed at least 4 weeks after surgery. Please note that the total reconstruction of the urinary canal (urethroplasty) is burdened by a considerable incidence of complications (fistulas and stenosis) which may require a further surgical revision up to 30% of cases. During hospitalization, daily medications are carried out and drugs are administered to promote the fluidity of the blood inside the phallus. The donor arm is also medicated.

Anterolateral thigh flap

This surgery involves a removal of skin from the thigh with all the vessels that nourish it. The flap of skin is then used to create a phallus with the urethra inside. Phalloplasty with anterolateral thigh flap represents a valid alternative to radial artery forearm free flap technique, although it is also burdened (like all microsurgical reconstructive flaps) by a 5% risk of serious vascular complications (total loss of the phallus). The advantage over phalloplasty with abdominal suprapubic pedicled flap lies in the excellent aesthetic result, the ability to urinate standing up and the greater sensitivity of the penis obtained. However, the technique should be reserved for thin patients (with limited adipose tissue at the level of the thighs) and hairless patients at the sampling site (alternatively a definitive preoperative epilation must be considered). The loss of tissue in the thigh is covered with skin taken from the other thigh. As in radial artery forearm free flap phalloplasty, a minimum of two other operations will subsequently be required for the creation of the scrotum, glans, removal of the vagina and, subsequently, the placement of the penile prosthesis. The surgery involves the placement of a bladder catheter (a cannula that allows urine to be eliminated) to be removed after at least 4 weeks. It should be noted that the total reconstruction of the urinary canal (urethroplasty) is burdened by a considerable incidence of complications (fistulas and stenosis), which could require a further surgical revision in up to 30% of cases. During hospitalization, daily dressings are carried out and drugs are administered to promote the fluidity of the blood inside the phallus. The thighs are also medicated.

Metoidioplasty
The metoidioplasty involves the creation of a phallus by exploiting the increase in volume of the clitoris obtained with hormonal treatment with testosterone. This surgery involves the removal of the vagina, the creation of a new urethra (neourethra) and the creation of the scrotum by closing the labia majora in a single step. Different techniques can be used to reconstruct the neo urinary canal using local tissues (vulva) or using tissues taken from the oral mucosa (the inside of the mouth). This surgery has the sole purpose of allowing the person to urinate standing up, albeit with a phallus that does not exceed 4-5 cm on average. This phallus does not allow penetration. Metoidioplasty involves the placement of a bladder catheter to be removed after about 28 days. 
Metoidioplasty can also be burdened by a high incidence of complications in the urinary canal (up to 30% of cases), which may require further surgical revisions. No specific dressings are required, however it will be necessary to dress the surgical wound with disinfectant.

Hospitalization for abdominal phalloplasty and metoidioplasty takes about 4-5 days, for phalloplasty with radial artery forearm free flap and anterolateral thigh flap up to 10 days.

 

This varies significantly from person to person. If one lives at a great distance from the place of surgery, it will be considered that after the surgery it may be necessary to medicate in the hospital even every week for 2-3 weeks. In most cases, a check-up is expected after 30-40 days.

 

  • Infections that can be managed with use of antibiotics
  • Bleeding complications. These are bleedings (loss of blood) even abundant with need sometimes of transfusion
  • Stenosis (narrowing) of the urethra and fistula (abnormal canal that connects two adjacent and normally separated anatomical structures) can be treated without the need for surgery: stenosis by prolonged dilation and fistula by spontaneous closure. However, if persistent they require further surgery.
  • Partial or complete skin necrosis of the phallus. Sometimes an insufficient blood supply to the neophallus tissues can lead to a partial or complete loss of the organ that requires further surgery.
  • Scarring disorders (i.e. the appearance of abundant and raised scars) which sometimes require further surgery.
  • Displacement or rejection of testicular implants. Silicone testicular implants can be moved or "rejected" requiring surgery.

National Health Service (NHS): no cost.
Private practice: at the discretion of the health provider.
Purely aesthetic interventions (for example tattoos to cover surgical wounds) are on the person’s behalf. 

Coleman E, Radix AE, Bouman W,  et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022; Sep 6;23(Suppl 1):S1-S259.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. Erratum in: J Clin Endocrinol Metab. 2018; 103(2): 699. J Clin Endocrinol Metab. 2018; 103(7): 2758-2759.