Urethral Stricture after Phalloplasty

What is a urethral stricture after phalloplasty?

A urethral Stricture is narrowing in the channel that carries urine from the bladder to the tip of the neo-phallus.

How do you treat a urethral stricture after phalloplasty?

It depends on the type of phalloplasty that was done in the first place.  For very bad strictures accompanied by infection or other problems I’ll typically do a perineal urethrostomy first to allow the infection to clear and the body to begin to heal.  At the same time we begin by creating a new urethra.

My doctor told me to leave a catheter in or to catheterize myself to prevent a urethral stricture after phalloplasty – is this a good idea?

Probably not. Generally, strictures after phalloplasty occurs because the blood supply to the area is not healthy and this causes scar tissue or the stricture to form.  Leaving a catheter in for a prolonged period of time does not changes this underlying problems – the idea that the scar tissue will heal around the catheter is, in my experience, incorrect.  In fact, by leaving a catheter in for a prolonged period of time, patients increase the risk of dangerous infections and the likelihood that the underlying problem will go untreated.

What is a perineal urethrostomy?

A perineal urethrostomy is the creation of an opening behind the scrotum in front of the rectum.  The disadvantage of this procedure is that patients have to sit to urinate and occasionally the urine hits the thighs and causes spraying. The advantage is that it permits patients to recover from whatever damage the urethra stricture may have caused

What is a urethral hook-up in a phalloplasty?

A urethral hook-up is a procedure to attached the two ends of the urethra that had been created during an earlier stage of phalloplasty.  The end closer to the bladder is usually made of urethra created from vaginal tissue that had been made into a tube, the penile end of the urethra is made of skin or other graft tissue.  These two ends are attached to each other so you can urinate through the end of the new phallus.

How do you repair the rest of the urethra in transmen who have a stricture after a phalloplasty?

Fixing the entire urethra particularly if the phallus is very long can be difficult. I typically repair the stricture in multiple stages. The first stage involves creating a perineal urethrostomy and laying down a graft into the future bed of the urethra.  The graft I usually use is called a buccal mucosal graft (link to the buccal graft section). If a longer urethral stricture needs to be repaired then the graft can be taken from both sides of the mouth. Usually about 5 to 8 cm of tissue can be taken from each side so a total length of between 10 to 16 cm can be repaired.

The second stage occurs about 6 months later when the graft that has been previously laid down is tubularized and made into a full urethra.  This allows men to stand to urinate.

What are the risks of surgery to repair a stricture after phalloplasty?

One issue that arises especially if patients have a very long penis is that there is not enough tissue to create a whole new urethra.  This leaves the urethra shorter than the rest of the penis.  Patients can still stand to urinate and use a urinal but the opening of the urethra may be along the shaft of the penis rather than the tip.  Another risk of surgery is that the urethra can stricture down again.  If this happens, it might need repair again.