Surgical Outcomes and Proposal for a Treatment Algorithm of Urethral Strictures in Transgender Men.

de Rooij, Freek P W; Peters, Femke R M; Ronkes, Brechje L; van der Sluis, Wouter B; Al-Tamimi, Muhammed; van Moorselaar, R Jeroen A; Bouman, Mark-Bram; Pigot, Garry L S

OBJECTIVES To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. SUBJECTS AND METHODS A single center, retrospective cohort study was conducted with transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS At last follow-up (median of 61 (IQR 25-202) months), 50/72 (69%) were able to void while standing (after one (60%), two (20%), three (6%), four (8%), five (4%), or seven (2%) procedures), 10/72 (14%) awaited further treatment, 2/72 (3%) sat to void in despite of good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 (57%) after phalloplasty, 22/29 (76%) after metoidioplasty). Highest success rates in short urethral strictures were seen after Heineke-Mikulicz procedure (6/7, 86%), and in longer or more complicated urethral strictures after two-stage with graft (4/6, 67%), two-stage without graft (10/12, 83%), pedicled flap (11/15, 73%), and single-stage graft (7/7, 100%) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION Highest success rates were observed after Heineke-Mikulicz procedure in short urethral strictures, and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, the majority of transgender men were able to void while standing, though in some multiple surgical procedures were necessary to accomplish this.