Radial Artery Free Flap Urethroplasty

Introduction: Urethroplasty is essential for transmasculine individuals who desire the ability to perform standing micturition. Currently, a variety of techniques are employed, including staged phalloplasty with urethroplasty performed in a subsequent surgery.1 This staged approach allows for gradual tissue healing, which may reduce the risk of complications such as wound breakdown, urethral fistulae, and infections. Some patients may not desire a functional urethra during initial consultation, or develop complications from their initial phalloplasty. Staged urethroplasty may incorporate a radial artery free flap, buccal mucosa graft, and labia minora flap.2–4 In this video, we demonstrate our technique for radial artery free flap urethroplasty (RAU) in an individual with an existing neophallus. Materials and Methods: The following footage is from a transmasculine individual who had undergone abdominal phalloplasty 6 months prior. Outcomes of other patients who underwent RAU between January 2022 and May 2023 were reviewed. Preoperatively, the patient underwent permanent hair removal, and an Allen's test was performed on the donor extremity to ensure perfusion of the one hand after occlusion of the radial artery. The flap is designed to be 4 cm wide to allow for an tubularized urethra adequate for a 16F catheter, and length 3 cm longer than the existing neophallus to allow for a tension-free anastomosis. Two teams may work simultaneously, one harvesting and tubularizing the radial artery free flap, while the other prepares the existing neophallus. An external oblique fasciotomy is made to access the recipient artery, and a groin incision is used to access the recipient veins. The neophallus is detubularized and debulked as necessary to achieve a tension-free closure. Flap transfer is performed with a surgical microscope, anastomosing the radial artery with the deep inferior epigastric artery and cephalic vein with the greater saphenous system. The ilioinguinal nerve is coapted to the lateral antebrachial cutaneous nerve with the aid of an off-the-shelf nerve allograft. A microdoppler is used to assess perfusion prior to neophallus tubularization and wound closure. In the donor arm, the brachioradialis and flexor carpi radialis muscles are advanced over the proximal ends of the donor arteries, and the wound is covered with a split thickness skin graft. A negative pressure wound dressing is then applied. The ventral abdominal wall defect is closed and reinforced with resorbable polydiaxone mesh. Results: The patient had an uneventful recovery and was discharged on postoperative day 5. Flushing of the neourethra with normal saline instilled via a small bore catheter into the meatus may be done to help remove debris starting 1 to 2 weeks postoperatively. Three patients have undergone RAU thus far, with follow-up periods of 11, 7, and 2 months. No reoperations or instances of flap failure have occurred. Two patients subsequently underwent neourethral anastomosis, scrotoplasty, glansplasty, and abdominal wound revision after a minimum of 5 months and are currently voiding orthotopically. Conclusions: RAU appears to be an effective option for transmasculine patients with an existing neophallus without a neourethra, or for those with significant complications from a prior urethroplasty. This staged approach may reduce complications related to wound breakdown, flap failure, and infection. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music Source: Recording of Partita in B-flat major, Hob.XVI:2 (Moderato) by Joseph Haydn, publisher Paris: Ivan Ilić, available under Creative Commons Attribution 3.0 from https://imslp.org. The authors have no relevant disclosures. Runtime of video: 5 mins 33 secs