(113) WHY DO NEOURETHRAL STRICTURES COMMONLY OCCUR AT THE PROXIMAL NEOURETHRA? A NOVEL THEORY, AND SIGNIFICANT REDUCTION IN STRICTURE INCIDENCE AFTER INITIATING USE OF A NEW POST-SURGERY DEVICE

Abstract Introduction Transgender men (TM) seeking phalloplasty must choose between phalloplasty with- (P + UL) and without urethral lengthening (P-UL). Those seeking P + UL must be counselled about the risks of neourethral strictures (NUS) and urethrocutaneous fistulae (UCF), whose incidence is reported at 25-63% and 22-75%, respectively. A decision-making tool to aid in surgical decision-making has not been described. Because tissue ischemia commonly causes NUS and UCF, strategies must be implemented to prevent this. Objective 1) Develop a decision-making tool comparing P + UL/P-UL. 2) Evaluate what proportion of our TM choose P + UL/P-UL before and after implementation of our decision-making tool. 3) Develop a means to reduce neourethral ischemia postoperatively. 4) Evaluate NUS and UCF requiring surgical repair after P + UL, before and after initiating our “Manny Pack” protocol. Methods Single-center, retrospective, chart review of all patients undergoing phalloplasty from July/2017–May/2024. Subjects were divided based on urethral lengthening status before and after implementing our decision-making tool (comparison-table of each option’s pro’s/con’s). We report the incidence of NUS and UCF before and after initiation of our “Manny-pack” to support the neophallus for 3-months postoperatively. Results 67 patients underwent phalloplasty over ~6-years. 35/67(51.6%) patients underwent P + UL. After initiation of our decision-making tool, the proportion of TM choosing P + UL decreased significantly from 30/49(61.2%) to 5/18(27.8%) (p = 0.009). Our incidence of NUS and UCF was 3/32 (9.4%) and 7/32 (21.9%), respectively. After initiation of our “Manny-pack” (Fig. 1) protocol, the incidence of NUS and UCF requiring surgical intervention decreased to zero (0%). Conclusions Debut of our decision-making tool significantly increased the proportion of TM who chose lower-risk P-UL. Our “Manny Pack” supports the neophallus and proximal neourethra for 3-months after surgery with privacy, and promotes normal activity (Fig. 1). This is the first report to propose that supporting the phallus reduces kinking of the proximal neourethra, causing ischemia exactly where NUS typically occur. (Figure 2) The significantly decreased incidence of NUS and UCF requiring surgery that we observed supports this theory. Disclosure No.