Long-Term Urologic Outcomes Using the Big Ben Method for Phalloplasty.

BACKGROUND

There are many ways to construct a urethra in gender-affirming phalloplasty, and comparing outcomes presents challenges because of the diversity of surgical techniques and staging methods in this low-volume procedure. A frequent criticism of phalloplasty is the high rate of urologic complications and associated impact on patient outcomes.

METHODS

This retrospective, single-surgeon study focuses on long-term outcomes of urethral creation using the Big Ben 2-stage method for urethral lengthening. This study was conducted in 73 patients between December of 2016 and September of 2023, who had at least 6 months' follow-up. Surgical outcomes-specifically, rates of urethral fistulas and strictures-were assessed along with patient-reported outcome measures obtained through distributed surveys.

RESULTS

Seventy-three patients underwent first-stage phalloplasty with the goal of urethral lengthening at the second-stage operation, with 96% achieving standing urination and 4% being converted to a perineal urethrostomy. The total percentage of patients experiencing a urologic complication was 27%. Of the 71 patients who did proceed with the second stage, 8% formed a stricture and 16.4% formed a urethrocutaneous fistula. One patient experiencing a stricture was converted to a perineal urethrostomy. There were no mucoceles or urethral, ureteral, or bowel injuries associated with the colpectomy/colpoclesis. Patient-reported satisfaction was high, with 96% expressing willingness to undergo the procedure again (response rate, 67%).

CONCLUSIONS

The Big Ben method demonstrated potential in reducing urethral stricture rates compared with alternative approaches. It further allows mitigation of complication severity and impact on quality of life, and has a high degree of patient satisfaction and ability to achieve the goal of standing urination. It is particularly well suited for a multidisciplinary academic setting.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.