P70. Risk Management and Flap Related Outcomes in Phalloplasty for Patients With Co-morbid Conditions

PURPOSE: Even in the ideal candidate the creation of an adult-sized phallus carries significant risks related to flap transfer. No consensus exists on which patient factors may indeed increase the risk of severe complications; and when alternative lower risk options (shaft-only) should be considered. We present our 8-year experience offering phalloplasty for patients with relevant comorbid conditions. METHODS: IRB approval was obtained. Database review of patients undergoing phalloplasty from September 2016 to July 2024. Patients with ASA classification ≥2, BMI ≥30, diabetes, immunosuppression, and massive weight loss were included in the high-risk cohort (HRC). Primary outcome of this study was unplanned return to the operating room (OR) for: acute flap compromise, reconstruction following partial flap loss, delayed incision and drainage (I&D) of hematoma and infection. RESULTS: A total of 180 patients had phalloplasty and 110 met inclusion criteria for being high risk. In both the HRC and LRC 30% of patients had a lower risk shaft-only surgery. Of which, all 9 abdominal were in the HRC. A total of 46 (25.6%) patients had at least one (mean 1.2) additional unplanned surgery HRC 32 (29.1%) vs. LRC 14 (20.0%)). Etiology for return to the OR HRC vs. LRC: acute takeback (20.9%/17.1%); sequelae partial flap loss (7.3%/1.4%), delayed hematoma (7.3%/5.7%), and infection (5.5%/2.9%) I&D. CONCLUSION: This study highlights our experience in gender-affirming phalloplasty for patients with co-morbidities. A trend toward higher complications in the HRC was observed, emphasizing the need for preoperative optimization to improve risk and care.