Keywords
phalloplasty - complications - predictors - transgender and nonbinary
Approximately 0.6% of the U. S. population are identified as transgender and nonbinary
(TGNB).[1] Subsequent to relaxed insurance criteria, there has been increasing demand for gender-affirming
surgery, including metoidioplasty and phalloplasty.[2]
[3]
[4] Around 69.2% of phalloplasty procedures are performed for gender-affirming purposes[5] whereby nascent female genital structures are removed and flaps are used for creation
of masculine genitalia. It is most frequently performed for transgender men but can
also be applied to patients requiring reconstruction after penile trauma or oncologic
resection.[6]
[7]
Phalloplasty encompasses the creation of the phallic shaft and penile urethroplasty.
As a way to decrease complication rate and improve esthetics, different phalloplasty
techniques have been proposed, and the staging of phalloplasty components has been
described. Single-stage phalloplasty is a combination of phallic shaft creation, urethral
lengthening, glansplasty, perineal reconstruction, vaginectomy, and scrotoplasty.[8] A multistage or staged phalloplasty separates these components, namely, shaft creation
from urethral lengthening, and is performed over the course of several months. There
is still a lack of consensus in regard to whether phalloplasty should be staged, the
ways by which staging can occur, and the ideal flaps for shaft creation. The most
frequently used flap is the radial forearm free flap (RFFF), though other flaps such
as the free or pedicled anterolateral thigh (ALT) flap and latissimus dorsi flap have
been employed as well.[7]
[9]
[10]
[11]
[12] Surgical decision-making is contingent on patient goals for surgery such as standing
micturition, penetrative intercourse, and donor-site scar placement.
Phalloplasty remains a complex procedure with high complication rates regardless of
stage or flap choice.[7]
[8]
[13]
[14] The most common complications following phalloplasty include urethral fistulas,
persistent vaginal cavities, and neourethral strictures, resulting in urinary and
sexual dysfunction.[13]
[15] Additionally, flap complications can include hematoma, necrosis or wound dehiscence,
cellulitis, vascular/arterial thromboses, and infection.[16] Multistage procedures have demonstrated poor urethral and flap-related outcomes,
with complication rates of 34 and 10%, respectively.[17]
[18] In a large review comparing flap choice in gender-affirming phalloplasty, urethral
strictures and fistulas were more common in RFFF, but flap failure rates were higher
in the pedicled ALT phalloplasty.[8] With the high rate of complications across phalloplasty techniques, understanding
risk factors for these complications could improve patient outcomes and clinical decision-making.[8]
[13]
[19]
Previous studies have used the American College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP) database and shown that older age, body mass index,
and longer total operating times to be independent predictors of 30-day postoperative
complications following any masculinizing bottom surgery, including hysterectomy.[20]
[21] However, the high variability in the type of procedure performed and the decision
whether or not to stage phalloplasty were not ascertained. In addition, the analyses
did not differentiate between primary phalloplasty for second- or third-stage phalloplasty,
metoidioplasty, or revision surgery, making it difficult to draw conclusions for each
approach. Herein, we use the ACS NSQIP database to conduct a retrospective study examining
predictors of complications following single and staged phalloplasties with phallus
creation. Although different stages are performed using different techniques, our
cohort was limited to stages encompassing microsurgical phallus creation to homogenize
our patient population in terms of procedural risks and complications. We hypothesize
that longer operating times will predict postoperative complications. Our findings
will help guide surgical planning, informed decision-making, and patient counseling.
Methods
Dataset
This study was reviewed and approved by the Johns Hopkins University Institutional
Review Board. We queried the ACS NSQIP from years 2012 to 2021 for transgender men
who underwent single- or first-stage phalloplasty. Information in NSQIP is longitudinal
data collected by surgical clinical reviewers on patient demographics, comorbidities,
surgical characteristics, and postoperative outcomes up to 30 days postoperatively.[22]
Inclusion and Exclusion Criteria
Transgender men who underwent single or staged phalloplasty with phallus creation
were identified using the flow diagram shown in [Fig. 1]. Staged phalloplasty with phallus creation was referred to as “first of a multistage
phalloplasty” throughout the text.
Fig. 1 Flowchart of our study population selection process. CPT, Current Procedural Terminology;
NSQIP, National Surgical Quality Improvement Program.
The codes used for the selection of our study population are shown in [Supplementary Table S1]. First, TGNB patients were identified using International Classification of Diseases
(ICD)-9 and ICD-10 codes pertaining to gender dysphoria. Second, patients who underwent
masculinizing genital surgery were identified using Current Procedural Terminology
(CPT) codes. Third, these patients were grouped according to hysterectomy and phalloplasty.
Finally, patients who underwent phalloplasty were stratified according to the stage
of phalloplasty. Single- and first-stage phalloplasty cases had CPT codes pertaining
to flap surgery or microsurgery. Patients with a length of total hospital stay ≥ 5
days and operating time > 4 hours were included in our final study sample to ensure
proper patient selection of primary phalloplasty cases. Patients who underwent metoidioplasty
or multistage phalloplasty beyond the first stage did not have CPT codes pertaining
to flap surgery or microsurgery and were excluded from our analysis. The reason for
the exclusion of the latter group of patients is that the CPT codes included in NSQIP
do not allow the differentiation between metoidioplasty, second-, and third-stage
phalloplasty cases. Furthermore, we wanted to homogenize our patient population in
terms of procedural risks and complications.
Patient Stratification
Patients who were included in our final analysis were stratified based on stage of
phalloplasty (single- and first-stage phalloplasties) using different combinations
of principal and concurrent CPT codes ([Supplementary Table S1]). Single-stage phalloplasty cases had CPT codes pertaining to flap surgery or microsurgery,
urethroplasty, and vaginectomy simultaneously. First-stage phalloplasty cases had
CPT codes pertaining to flap surgery or microsurgery without urethroplasty. First-stage
phalloplasty cases were further stratified according to concurrent procedures: first
stage with flap alone; first stage with flap, scrotoplasty, and vaginectomy; first
stage with flap and scrotoplasty, without vaginectomy; and first stage with flap and
vaginectomy, without scrotoplasty.
Outcomes and Covariates
The primary outcome of our study was the incidence of at least one major and at least
one minor complications within 30 days following single- and first-stage phalloplasties.
Major complications analyzed were myocardial infarction, cardiac arrest requiring
cardiopulmonary resuscitation, stroke, acute renal failure, pulmonary embolism, deep
venous thrombosis, sepsis, septic shock, bleeding requiring transfusion, unplanned
intubation, unplanned reoperation, unplanned readmission within 30 days, and prolonged
hospital stay beyond 30 days postoperatively. Minor complications analyzed were urinary
tract infection, surgical site infection (SSI), pneumonia, and wound disruption without
reoperation.
The secondary outcome of the study was the indication for unplanned reoperation, a
major complication, within 30 days of phalloplasty. As defined by NSQIP, unplanned
reoperation is “a return to the operating room that was not planned at the time of
the primary procedure.”[22]
Patients who developed at least one major complication versus those who did not and
patients who developed at least one minor complication versus those who did not were
compared based on the following demographics, comorbidities, and surgical characteristics.
These included flap type (latissimus dorsi flap; ALT flap), phalloplasty stage (single
stage; first of multistage), and phalloplasty concurrent procedures (single stage;
first stage with flap alone; first stage with flap and scrotoplasty, without vaginectomy;
first stage with flap and vaginectomy, without scrotoplasty). Complete definitions
of variables collected by NSQIP can be found in the User Guide for the ACS NSQIP Procedure
Targeted Participant Use Data File.[22]
Statistical Analysis
We performed univariate exploratory analysis for all patients, patients who developed
any major complication, and patients who developed any minor complication. Normally
distributed numerical data were reported using the mean ± standard deviation, while
nonnormally distributed numerical data were reported using the median and interquartile
range (IQR).
We performed bivariate analysis to compare demographics, comorbidities, and surgical
characteristics between patients who developed at least one major complication versus
those who did not and patients who developed at least one minor complication versus
those who did not. Continuous variables were compared between patient cohorts using
the independent t-test, while categorical variables were compared using the chi-square and Fisher's
exact tests. Bivariate and multivariate logistic regression were performed using variables
that had a p < 0.2 on bivariate analysis to predict significant predictors of major and minor
complications following single- and first-stage phalloplasties. The crude odds ratio
(cOR), adjusted odds ratio (aOR), and 95% confidence interval (CI) were used to measure
the strength of association in the logistic regression models. The discriminatory
capacity and the calibration of each regression model were assessed using the area
under the receiver operating characteristic curve and the Hosmer–Lemeshow's test,
respectively.[23] Statistical analysis was performed using IBM SPSS Statistics 28.[24] The p < 0.05 was considered statistically significant.
Results
Demographics and Surgical Characteristics
A total of 90 patients were included in our final analysis ([Fig. 1]). [Table 1] shows patient demographics, comorbidities, and surgical characteristics of our study
population.
Table 1
Patient demographics, comorbidities, and surgical characteristics of all patients,
patients who developed any major complication compared with those who did not, and
patients who developed any minor complication compared with those who did not
|
Variable
|
Overall (n = 90)
|
Any major complication (n = 16)
|
No major complication (n = 74)
|
p-Value
|
Any minor complication (n = 8)
|
No minor complication (n = 82)
|
p-Value
|
|
|
Age, median (IQR), y
|
30.0 (24.0–39.0)
|
28.5 (20.5–44.5)
|
30.5 (24.8–38.3)
|
0.829
|
41.5 (27.0–45.8)
|
29.5 (23.8–38.0)
|
0.036
|
|
BMI, median (IQR), kg/m2
|
25.8 (23.5–30.4)
|
24.1 (22.3–30.6)
|
26.2 (23.7–30.4)
|
0.498
|
23.3 (21.3–29.0)
|
26.0 (23.6–30.6)
|
0.189
|
|
Total operating time, median (IQR), min
|
379 (315–465)
|
483 (383–562)
|
365 (301–442)
|
0.011
|
435 (367–557)
|
374 (312–459)
|
0.047
|
|
Length of total hospital stay, median (IQR), d
|
6 (5–7)
|
7 (6–9)
|
6 (5–7)
|
0.035
|
8 (6–10)
|
6 (5–7)
|
0.152
|
|
Diabetes mellitus
|
2 (2.2)
|
1 (6.3)
|
1 (1.4)
|
0.326
|
1 (12.5)
|
1 (1.2)
|
0.171
|
|
Current smoker (within 1 y preoperatively)
|
9 (10.0)
|
3 (18.8)
|
6 (8.1)
|
0.196
|
4 (50.0)
|
5 (6.1)
|
0.003
|
|
Hypertension
|
8 (8.9)
|
3 (18.8)
|
5 (6.8)
|
0.147
|
1 (12.5)
|
7 (8.5)
|
0.540
|
|
ASA classification
|
I
|
29 (32.2)
|
6 (37.5)
|
23 (31.1)
|
0.291
|
1 (12.5)
|
28 (34.1)
|
0.116
|
|
II
|
59 (65.6)
|
9 (56.3)
|
50 (67.6)
|
|
6 (75.0)
|
53 (64.6)
|
|
III
|
2 (2.2)
|
1 (6.3)
|
1 (1.4)
|
|
1 (12.5)
|
1 (1.2)
|
|
Phalloplasty categories-
|
Single stage
|
43 (47.8)
|
8 (50.0)
|
35 (47.3)
|
1.000
|
6 (75.0)
|
37 (45.1)
|
0.519
|
|
First stage: flap only
|
41 (45.6)
|
8 (50.0)
|
33 (44.6)
|
|
2 (25.0)
|
39 (47.6)
|
|
First stage: flap + scrotoplasty without vaginectomy
|
2 (2.2)
|
0 (0.0)
|
2 (2.7)
|
|
0 (0.0)
|
2 (2.4)
|
|
First stage: flap + vaginectomy/vulvectomy without scrotoplasty
|
4 (4.4)
|
0 (0.0)
|
4 (5.4)
|
|
0 (0.0)
|
4 (4.9)
|
|
Phalloplasty stage
|
Single stage
|
43 (47.8)
|
8 (50.0)
|
35 (47.3)
|
1.000
|
6 (75.0)
|
37 (45.1)
|
0.145
|
|
First of multistage
|
47 (52.2)
|
8 (50.0)
|
39 (52.7)
|
|
2 (25.0)
|
45 (54.9)
|
|
Flap type-
|
Latissimus dorsi
|
1 (1.1)
|
0 (0.0)
|
1 (1.4)
|
0.504
|
0 (0.0)
|
1 (1.2)
|
1.000
|
|
Anterolateral thigh
|
32 (35.6)
|
4 (25.0)
|
28 (37.8)
|
|
3 (37.5)
|
29 (35.4)
|
|
Not reported
|
57 (63.3)
|
12 (75.0)
|
45 (60.8)
|
|
5 (62.5)
|
52 (63.4)
|
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; IQR,
interquartile range.
The median (IQR) age was 30.0 (24.0–39.0) years. Of 90 patients, 43 (47.8%) underwent
single-stage phalloplasty, and 47/90 (52.2%) underwent first-stage phalloplasty. When
further stratified by concurrent procedure, 41/90 (45.6%) patients underwent first-stage
phalloplasty with flap alone, 2/90 (2.2%) underwent first-stage phalloplasty with
flap and scrotoplasty, without vaginectomy, and 4/90 (4.4%) underwent first-stage
phalloplasty with flap and vaginectomy, without scrotoplasty ([Table 1]). The median (IQR) operating time for overall phalloplasty procedures, regardless
of staging, was 379 (315–465) minutes. Compared with single-stage phalloplasty procedures
which had a median (IQR) operating time of 419 (368–489) minutes, first-stage phalloplasty
procedures had significantly shorter median (IQR) operating time of 323 (284–398)
minutes (p < 0.001).
A total of 18 (20.0%) patients developed any complication: the majority (n = 16/18 (88.9%) developed a major complication, and 8/18 (44.4%) developed a minor
complication. Patient demographics, comorbidities, and surgical characteristics were
compared between patients who developed any major complication versus those who did
not and patients who developed any minor complication versus those who did not in
[Table 1]. Patients who developed any major complication within 30 days of phalloplasty were
significantly more likely to have longer operating times (median [IQR] 483 [383–562],
365 [301–442] minutes; p = 0.011) and length of total hospital stay (median [IQR] 7 [6–9], 6 [5–7] days; p = 0.035) compared with patients who did not develop any major complication postoperatively.
Patients who developed any minor complication within 30 days of phalloplasty were
significantly more likely to have had longer operating times (median [IQR] 435 [367–557],
374 [312–459] minutes; p = 0.047) and to have smoked within a year of surgery (n = 4/8 [50.0%], n = 5/82 [6.1%]; p = 0.003). Compared with patients without complications, those with minor complications
are more likely to have had single-stage phalloplasty (n = 37 [45.1%], n = 6 [75.0%]; p = 0.145), but the association was not statistically significant ([Table 1]).
Postoperative Complications
[Fig. 2] shows the frequency (%) of major and minor complications within 30 days of phalloplasty
in our study population.
Fig. 2 Frequency (%) of postoperative major and minor complications following phalloplasty.
SSI, surgical site infection; UTI, urinary tract infection.
The most common major complication was unplanned reoperation (n = 10/90 [11.1%]). The most common minor complication was SSI (n = 5/90 [5.6%]) followed by wound disruption (n = 3/90 [3.3%]).
Predictors of Complications
[Table 2] shows the bivariate and multivariate logistic regression evaluating predictors of
major and minor complications.
Table 2
Bivariate and multivariate regression evaluating patient demographics and surgical
characteristics associated with major and minor complications following single- and
first-stage phalloplasties
|
Demographics and surgical characteristics
|
Major complications
|
Minor complications
|
|
cOR (CI)
|
aOR (CI)
|
cOR (CI)
|
aOR (CI)
|
|
Age
|
–
|
–
|
1.071 (1.001–1.146)
|
1.01 (0.91–1.11)
|
|
BMI
|
–
|
–
|
0.89 (0.75–1.06)
|
0.84 (0.64–1.11)
|
|
Total operating time
|
1.011 (1.004–1.018)
|
1.01 (1.002–1.018)
|
1.004 (1.000–1.008)
|
1.007 (0.997–1.016)
|
|
Length of total hospital stay
|
1.572 (1.126–2.194)
|
1.275 (0.837–1.943)
|
1.56 (1.08–2.26)
|
1.2 (0.6–2.3)
|
|
Diabetes mellitus
|
–
|
–
|
11.57 (0.65– > 100)
|
>100 (0.0– > 100)
|
|
Smoking
|
2.6 (0.6–11.8)
|
2.6 (0.4–17.0)
|
15.4 (2.9–80.6)
|
>100 (1.4– > 100)
|
|
Hypertension
|
3.2 (0.7–15.0)
|
1.06 (0.1–8.3)
|
1.5 (0.2–14.2)
|
0.01 (0.0–5.3)
|
|
ASA class
|
ASA class II
|
–
|
–
|
3.2 (0.4–27.7)
|
22.1 (0.2– > 100)
|
|
ASA class III
|
–
|
–
|
28.0 (0.9– > 100)
|
>100 (0.7– > 100)
|
|
First stage
|
–
|
–
|
0.3 (0.1–1.4)
|
0.13 (0.0–4.3)
|
|
C-statistic
|
–
|
0.8
|
–
|
0.95
|
|
Hosmer–Lemeshow
|
–
|
0.828
|
–
|
0.99
|
Abbreviations: aOR, adjusted odds ratio; CI, 95% confidence interval; cOR, crude odds
ratio; C-statistic, concordance statistic or area under the receiver operating characteristic
curve.
Note: Significant 95% CIs are in bold.
On both bivariate and multivariate logistic regression, longer total operating time
(cOR [95% CI] 1.011 [1.004–1.018], aOR [95% CI] 1.01 [1.002–1.018]) was significantly
associated with greater odds of major complications within 30 days of phalloplasty.
Smoking was associated with greater odds of 30-day minor complications on bivariate
(cOR [95% CI] 15.4 [2.9–80.6]) and multivariate logistic regression (aOR [95% CI]
123.3 [1.4– > 100]). Compared with single-stage phalloplasty, first-stage phalloplasty
was associated with decreased odds of minor complications on bivariate (cOR [95% CI]
0.3 [0.1–1.4]) and multivariate logistic regression (aOR [95% CI] 0.13 [0.0–4.3]),
but the association was not statistically significant ([Table 2]).
Indications for Unplanned Reoperation
The frequency (%) of indications for unplanned reoperation is shown in [Fig. 3].
Fig. 3 Frequency (%) of indications for unplanned reoperation following phalloplasty.
Within 30 days of phalloplasty, hematoma evacuation was the most common indication
for unplanned reoperation (n = 3, 30.0% of unplanned reoperations, 3.3% of all patients). Only one patient (n = 1/90 [1.1%]) experienced flap failure following phalloplasty.
Discussion
Phalloplasty represents a collection of procedures to construct esthetic and functional
masculine genitalia.[25]
[26] Although patients' surgical goals vary, patients often desire a physiologic-appearing
and functional masculine genitalia characterized by an average-sized phallus and a
pouch-like scrotum, in addition to the ability to void while standing and achieve
penetrative intercourse.[25]
[27] It requires surgical expertise to manage the high rate of postoperative complications.[14]
[15]
[16]
[28]
[29] Existing evidence does not confirm a significant difference in complication rates
with either flap choice or phalloplasty staging. Understanding other risk factors
for these complications could improve patient outcomes and clinical decision-making.[8]
[13]
[14]
[19] Hence, we conducted a retrospective study using the ACS NSQIP database to examine
predictors of complications following single- and first-stage phalloplasties.
We found a 20% overall 30-day complication rate following phalloplasty regardless
of phalloplasty staging or flap used. In our study population, 18% of patients developed
a major complication and 9% developed a minor complication within 30 days of single-
or first-stage phalloplasty. Longer operating time and smoking were significantly
associated with greater odds of major and minor complications, respectively. The association
with smoking is unsurprising given the effect of nicotine on impedance of wound healing.[30] Additionally, smoking causes vasoconstriction where resultant ischemia may contribute
to stricture formation down the line.[31]
[32] This highlights the importance of patient counseling on immediate postoperative
complications and the importance of nicotine testing in the preoperative management
of patients interested in phalloplasty.
Complications occur in up to 50 to 76% of phalloplasty procedures and can be grouped
into flap-related and urethral complications.[7]
[13]
[14] A pedicled or free flap is used to reconstruct the shaft of the neophallus.[7] In transgender men, the overall flap complication rate has been reported to be around
10.8%, with risks including flap failure, flap necrosis, and donor-site morbidity.[7]
[13]
[26] Urethral lengthening is the component of phalloplasty that aims to allow standing
micturition via the neourethra. However, with a urethral complication rate of 39.4%,
even patients of experienced surgeons are regularly afflicted by urologic dysfunction.[13]
[26]
[29]
[33] A recent review by Wang et al found high rates of urethral complications in gender-affirming
phalloplasty: 31% of patients developed fistulas and 25% developed strictures.[14] A major limitation of our study is the inability to capture urethral complications
that develop beyond 30 days of surgery due to the 30-day window of NSQIP.
Our results also demonstrate that longer operating time is significantly associated
with greater odds of major complications following phalloplasty. This is congruent
with a study by Chaya et al who similarly utilized the ACS NSQIP database and found
that total operating time was an independent predictor of 30-day postoperative complications
following masculinizing bottom surgery.[20] However, the study analyzed all patients with masculinizing bottom surgery together,
including hysterectomy, metoidioplasty, and other genital reconstruction procedures.
Longer operating time was also identified as a predictor of complications for microsurgical
flap reconstruction.[20]
[34]
[35]
[36]
[37] In a previous study by Wong et al on 639 patients who underwent microsurgical free
flap reconstruction, those with longer operating times were twice as likely to develop
flap failure.[36] In our study population, only one patient experienced flap failure following phalloplasty.
The association between longer operating time and postoperative complications here
may be attributed to surgeon expertise and the steep learning curve associated with
phalloplasty.
Urethral lengthening at the time of shaft reconstruction defines the single-stage
phalloplasty.[38]
[39]
[40] Since longer operating time was associated with greater odds of major complications
in our study population, it was expected that single-stage phalloplasty (which encompasses
various phalloplasty procedures and necessitates longer operating time) would be associated
with greater odds of major complications compared with first-stage phalloplasty. However,
there was no significant difference in the incidence of major or minor complications
between the two staging techniques, despite a trend toward lower complications in
first-stage phalloplasty procedures. The complications reported in NSQIP within 30
days, however, do not encompass the urethral complications that might arise following
phalloplasty and which are a major concern for gender-affirming surgeons and their
patients. This might explain the relatively lower incidence of postoperative complications
in our study population. Hence, according to our results, staging does not significantly
impact the odds of 30-day complications following phalloplasty, but this remains unclear
for complications arising beyond that 30-day window. These complications were studied
by Huayllani et al who demonstrated significantly higher complication rates in two-stage
phalloplasties.[18] Similar findings were reported by Remington et al when specifically comparing staging
of urethroplasty, where staged procedures had higher rates of flap and urethral complications.[13] Although there is a paucity of evidence to support staging versus no staging in
phalloplasty, our results show no significant difference in 30-day complications,
including flap failure causing unplanned reoperation, between the two techniques.
ALT was the most common flap type used in our study population, though in half of
the patients, flap choice was not specified. We hypothesize that the unspecified flaps
in NSQIP used in phalloplasty procedure are actually RFFF. The RFFF is typically the
most common flap choice, which has been reported to be used in 75% of 1,731 procedures,
due to the reliable vascular pedicle, pliability of the flap, well-established functional
and esthetic satisfaction, and preservation of erogenous and tactile sensation.[14]
[17]
[33] Challenges for this flap include donor-site morbidity, atrophy of the neophallus,
requirement of prosthesis, and requirement for microsurgical technique and equipment.[7]
[9]
[16]
[41] The ALT flap offers improved color match, an easily concealed donor-site scar, preserves
sensation, and can be a pedicled or free flap.[7]
[17] Although the pedicled ALT does not require extensive microsurgical techniques, the
bulky subcutaneous layer might explain the significantly higher overall urethral complication
rate of 32.8% versus a 24.2% in the RFFF cohort.[17]
Future research is needed to demonstrate the effect of perioperative variations to
improve efficiency for phalloplasty specifically. Advancing technology, increasing
number of experienced surgeons operating, and preoperative imaging to guide flap design
may help drive efficiency.[34]
[36]
[41]
[42] Preoperative counseling should include the risk of 30-day postoperative complications
and urge the importance of smoking cessation to reduce minor complications. Adherence
to smoking cessation recommendations can be further confirmed with urine cotinine
testing the morning of surgery.[43]
This study has several limitations associated with a retrospective review of a national
database. The nongranularity of the CPT codes for TGNB procedures and gender-affirming
phalloplasty in the NSQIP database precluded precise construction of our cohort or
differentiating single from double tube phalloplasty. Additionally, NSQIP does not
report sexual orientation and gender identity demographic information. To mitigate
this limitation, we followed robust inclusion/exclusion criteria using proxy identifiers
of ICD-9 and ICD-10 codes of gender dysphoria for proper patient selection and a meticulous
search of principal and concurrent CPT codes for proper patient categorization into
masculinizing genital surgery and phalloplasty stages. The urethral lengthening component
of phalloplasty is a large driver of long-term complications, for example, urethral
strictures, which might not be captured within the 30 days window of NSQIP. Other
outcomes not captured by NSQIP include sexual functioning, late wound complications,
and reoperations occurring after 30 days. There was heterogeneity of the included
patients by concomitant surgery, unknown type of primary flap, and unknown data about
surgical team makeup or experience. However, care teams will still benefit from the
knowledge of risk factors of immediate phalloplasty complications in the immediate
postoperative period thus improving preoperative patient counseling. While the institutions
participating in the ACS NSQIP data collection are not necessarily a representative
sample of the population undergoing phalloplasty, the multi-institutional nature of
the database increases generalizability of the results. Our study is the first to
use the NSQIP database to analyze surgical outcomes following phalloplasty and categorize
patients according to phalloplasty stages. Previous research regrading phalloplasty
outcomes had not used the NSQIP data or briefly discussed the procedure in aggregate
with other surgeries.
Conclusion
Multistage phalloplasty may be associated with lower 30-day complications. Reducing
operating times, smoking cessation, and strict preoperative nicotine testing may assist
in mitigating odds of complications following phalloplasty. Future prospective studies
with long-term follow-up are needed to properly assess the predictors of complications
following phalloplasty.
