Transmen Have More Complications After Phalloplasty, Review Finds

Compared to cismale patients, transgender men have higher rates of complications after phalloplasty, according to a study published in February in Plastic and Reconstructive Surgery.

Transmen are also less likely to void while standing and enjoy full sexual function after phalloplasty, but their overall satisfaction rates are similar to those of cismen.

Phalloplasty is a surgical method used to either create or repair a functional penis. Transmen undergoing a female-to-male transition have one created. Natal males may have phalloplasty if they have been born without a penis or sustained a penile injury.

The goal of phalloplasty is develop a realistic-looking penis that can function well for both urination and sexual activity. Many techniques exist; the most frequent is the radial forearm free flap method, which uses tissue from the patient’s forearm to create or restore the penis.

One aspect of phalloplasty that may also be performed in some cases is a urethroplasty, during which a new urethra is constructed. Urethroplasty is classified as primary (conducted in one surgical procedure) or staged (performed through multiple, successive surgeries).

To date, there has been limited information comparing phalloplasty outcomes for cismale and transmale patients. It has also been unclear whether primary or staged techniques of urethroplasty result in more complications.

For the current study, a review of the medical literature was performed, and scientists compiled the results of 50 papers published through December 2015. Researchers focused specifically on urethral and flap complications as well as three patient outcomes: ability to urinate while standing, ability to engage in sexual activity, and overall satisfaction.

Nineteen studies involving 869 patients focused on transmale phalloplasty, and the remaining thirty-one (482 patients) discussed cismale procedures.

As the table below illustrates, complications related to both the urethra and the donor flap area were more common in transmale patients. In addition, more complications were reported after staged procedures.

  Urethral Complications Flap Complications
All Patients 33.3% 10.2%
Transmen 39.4% 10.8%
Cismen 24.8% 8.1%
Primary Urethroplasty 31.3% 8.6%
Staged Urethroplasty 34.8% 16.7%

The higher complication rates seen in transmen might be due to the complexity of creating a new penis as opposed to restoring one. Also, staged procedures may have more complications because several procedures are involved, and men who are chosen for staged procedures may have more complex features than those undergoing a single-stage procedure.

Outcomes data showed that transmen were less likely to void while standing and engage in sexual activity compared to cismen. Still, satisfaction rates were similar between the two groups. Similar to the complications data, primary urethroplasty appeared to have better overall outcomes than staged urethroplasty.

  Ability to Urinate While Standing Ability to Engage in Sexual Activity Patient Satisfaction
All Patients 79.0% 61.2% 84.3%
Transmen 73.0% 51.1% 81.5%
Cismen 82.8% 71.4% 83.8%
Primary Urethroplasty 86.8% 77.0% 90.1%
Staged Urethroplasty 63.2% 43.8% 77.8%

The authors acknowledged several limitations, including the variety of reconstructive procedures, follow-up periods, and need for revision surgery discussed in the individual studies. Flap design and surgeon experience may also affect patient outcomes.

However, the study does tie results together to help clinicians better understand phalloplasty concerns, they said, adding that the findings “ultimately centralize current phalloplasty data and serve as a resource for physicians studying and optimizing this procedure.”


American Society of Plastic Surgeons

“Complications of Penile Reconstruction Surgery Differ for Transgender Patients”
(Press release. January 30, 2018)

Plastic and Reconstructive Surgery

Remington, Austin C., BA, et al.
“Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?”
(Full-text. February 2018)

Urethral Complications Flap Complications
All Patients 33.3% 10.2%
Transmen 39.4% 10.8%