Phalloplasy and metoidioplasty: two viable surgical options for female to male gender confirmation surgery

INTRODUCTION: Genital gender affirming surgery (GGAS) has a crucial role among transgender patients with dysphoria. Phalloplasty is a technique for penile shaft creation and represents very demanding and complex procedure. Two primary options for GGAS are metoidioplasty, using enlarged clitoris, and flap phalloplasty, using extragenital tissue. Flaps can be pedicled or free, and obtained from different donor sites such as forearm, thigh, upper back, and abdomen. In case of free flaps microsurgical anastomosis of blood vessels and nerves is necessary, making them more complex and potentially leading to severe complications. The primary goals of all phalloplasty procedures include achieving a visually and functionally satisfactory phallus with a neourethra allowing for standing voiding, adequate length of the phallus for successful penetrative intercourse, preserved tactile and orgasmic sensation, and acceptable donor site morbidity.EVIDENCE ACQUISITION: The nonsystematic literature review on PubMed/MEDLINE focusing on the phalloplasty procedures, involving metoidioplasty, radial forearm free flap, musculocutaneous latissimus dorsi free flap, anterolateral thigh flap and suprapubic flap phalloplasty was conducted.EVIDENCE SYNTHESIS: Overall outcomes of GGAS have not to be standardized, and the lack of adequate studies and standardized protocols make assessment between outcomes of different phalloplasty techniques hardly possible.CONCLUSIONS: The overall complication rate after metoidioplasty is lower than any type of phalloplasty procedure. The literature data on surgical flaps for phalloplasty in transgender patients demonstrates the challenges involved in phallic reconstruction. There is no universal flap choice that can be applied to every patient. Therefore, the surgical approach should be chosen based on the surgeon’s experience and the patient’s preferences.