027 Robotic-Assisted Vaginectomy, Mobilization of Vaginal Mucosa for Urethral Lengthening and a Gracilis Muscle Flap for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction

Abstract

One goal of neophallus construction in female-to-male (FTM) transgender surgery is to achieve the ability for the individual to void while standing. Complications from phalloplasty include urethral stricture, urethrocutaneous fistula, meatal stenosis, and persistent vaginal cavity. Fundamental anatomic differences between the male and female urethra can account for some of these complications. The aim of this study was to describe our technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a gracilis muscle flap to recreate the bulbospongiosus muscle and bulbar urethra in FTM phalloplasty. This procedure was performed on 11 transgender men from 5/2016-6/2017. Robotic assisted laparoscopic transabdominal approach is performed to resect the posterior and lateral vaginal mucosa. An anterior vaginal flap is elevated between the bladder and the vagina down to the meatus. The urethra is lengthened to the level of the pubic symphysis, by ventral placement of an anterior vaginal mucosa flap. A gracilis muscle flap is harvested and passed through a tunnel created between the groin and the vaginal cavity and split into two halves. The inferior half is used to close the vaginal cavity and superior half used to recapitulate the bulbospongiosus muscle to support the lengthened urethra (See attached images). Phalloplasty is performed at a separate stage about 3 months after perineal reconstruction.