Urethral Strictures

8. DISEASE MANAGEMENT IN TRANSGENDER PATIENTS

8.1. Treatment of strictures in trans men

In trans men, stricture treatment depends on the time after neophallic reconstruction, stricture location, stricture length and quality of local tissues tissues [147,494].

8.1.1. Management of strictures early after neophallic reconstruction

Urethral surgery on tissues in the acute phase urethra has been stabilised. This usually takes six months [495]. Endoscopic incision for short (< 3 cm) urethral strictures has been performed, mainly at the anastomotic site, with a maximum stricture-free rate of only 16.7% when performed within six months after neophallic reconstruction [496]. Insertion of a suprapubic catheter is the first-line treatment in cases of obstructive symptoms severely affecting the patient’s QoL, recurrent UTI or retention. The alternative is perineostomy, which is a specialist procedure and should be performed by a urologist familiar with transgender urethral anatomy. The perineostomy may be closed at the time of formal urethral reconstruction [497].

8.1.2. Treatment of meatal stenosis in trans men

Intermittent urethral dilatation is an option as palliative treatment for low-grade meatal stenosis [31]. Patients with high-grade meatal stenosis, those who refuse ISD, or those who want a durable solution should be offered simple meatotomy. Patency rates are 50% and 75% for transmasculine after respectively metoidioplasty and phalloplasty [147]. The drawback is that the meatus will be in a hypospadiac position. Alternatively, a staged urethroplasty can be offered [147].

8.1.3. Treatment of strictures at the neophallic urethra

The standard treatment for these strictures is staged urethroplasty with or without graft augmentation (BMG or full thickness SG). A patency rate of 50-88% [147,495,498] has been reported after phalloplasty and up to 100% after metoidioplasty [147,495].

For complex (e.g., fully obliterated) or recurrent strictures at the neophallic urethra, a complete urethral substitution with a tubularised radial forearm free flap has been proposed with a 67% patency rate [147].

8.1.4. Treatment of strictures at the anastomosis neophallic urethra-fixed part of the urethra

Short, non-obliterative, strictures can be treated by endoscopic incision. A first endoscopic incision has a 37-45.5% patency rate, but this dropped to 0% in case of three or more attempts (median follow-up of
51 months) [495,496]. Therefore, repetitive endoscopic incisions should be discouraged unless with palliative intent.

For very short (< 1.5 cm) low-grade strictures, Heineke-Mikulicz urethroplasty is an option reporting a 58-80% after phalloplasty and up to 100% after metoidioplasty [147,495].

If the stricture is nearly or completely obliterative, options are EPA, graft augmentation urethroplasty or staged urethroplasty. Excision and primary anastomosis yields a patency rate of 46-57% after phalloplasty and 78% after metoidioplasty [147,495]. Alternatively or if EPA is not possible (stricture length >2 cm), a graft augmentation urethroplasty can be performed with a 56-100% patency rate [147,495]. In case of insufficient ventral tissue during graft urethroplasty, it is advised to support this graft by a local fasciocutaneous flap [147]. An alternative (especially after failure of the previous techniques) can be a staged approach [147,495].

8.1.5. Treatment of strictures at the fixed part of the urethra

This part of the urethra has a more reliable blood supply, and the dorsal part of the urethra is supported by the corporal bodies of the clitoris. Therefore, single-stage dorsal inlay graft urethroplasty is possible for strictures at this site, especially after metoidioplasty, with up to 100% patency rate [495]. Staged repair with or without a dorsal graft is an alternative for these rare strictures [495].

8.1.6. Definitive perineostomy in trans men

Definitive perineostomy should be offered to patients with refractory strictures or to those with strictures who do not wish to have complex reconstructive surgery [147,495].

8.2. Peri-operative care after treatment of strictures in trans men

Anecdotally, after endoscopic incision and urethroplasty, the urethral catheter is maintained for two to three weeks [496,499]. Peri-catheter urethrography is advised before catheter removal as it might be challenging to reinsert the urethral catheter in case of urinary extravasation [499].

8.3. Strictures in trans women

It is acceptable to start with dilation of a short and non-obliterative stricture in trans women although no long term data about the effectiveness are available [31]. If this is not possible or if it fails, a short (< 1 cm) meatal stricture can be treated by Y-V meatoplasty with an 85% stricture-free rate [500]. Somewhat longer (1-2 cm) meatal strictures can be treated by a neovaginal advancement flap (inverted U or “7-flap”) with no recurrence observed after 37 months median follow-up [501].