In recent years, phalloplasty has made remarkable progress thanks to research and the accumulated experience of specialized teams in gender-affirming surgery. One of the historical challenges of this technique has been urethral reconstruction, a frequent source of postoperative complications. At IM GENDER, we have implemented a key innovation: completing urethroplasty in a second surgical stage, which helps reduce risks and improve both recovery and the overall experience of trans patients. In this article, we explain what urethroplasty is and how it is performed.
Phalloplasty is one of the most complex procedures in gender-affirming surgery. Its goal is to construct a penis that is both aesthetic and functional, using the patient’s own tissue. In addition to creating the shape of the neophallus, the technique seeks to restore urinary function and, in some cases, sexual function.
It is a surgery that can be performed using different techniques and in several stages, depending on each individual’s characteristics and goals. Among the most delicate aspects of phalloplasty is urethral reconstruction, which is necessary to allow the patient to urinate while standing.
What Is Urethroplasty?
Urethroplasty is a type of surgery that connects or extends the urethra of the newly constructed phallus, creating a functional urinary channel for trans men and non-binary individuals assigned female at birth.
This procedure is part of phalloplasty, as it ensures that the genitalia are functional and allow urination. At IM GENDER, it is performed in two stages of the phalloplasty process, with the main goal of achieving better outcomes and ensuring maximum safety and precision.
To understand urethroplasty, it is important to first know a bit about genital affirmation surgery in trans men.
Techniques Used in Phalloplasty
There are several surgical approaches to performing phalloplasty, and the choice depends on medical factors and the patient’s preferences. Among the most common techniques are:
- Radial Forearm Free Flap (RFFF): Uses skin and tissue from the forearm, offering good sensitivity and aesthetic results.
- Anterolateral Thigh Flap (ALT): An alternative that avoids visible arm scars and provides adequate volume, though with less sensitivity.
- Abdominal or Other Donor Site Flaps: In certain cases, skin from the abdomen or other areas is used, adapting the technique to the patient’s needs.
Each of these options has advantages and limitations, and requires an individualized assessment by the surgical team.
Surgical Stages
Phalloplasty is rarely performed in a single procedure; it generally requires several stages to achieve optimal results. In the first surgery, the neophallus is constructed. After a few months, once the patient has recovered, testicular implants are placed. Finally, a penile prosthesis is inserted—if erectile function is desired—and aesthetic refinements such as micropigmentation of the neophallus are performed to achieve a more natural appearance.
At IM GENDER, urethroplasty—or urethral reconstruction—is still carried out in the first stage, but it remains non-functional at that time. In other words, it does not yet serve a urinary purpose. The urethral connection is completed in a second surgical stage, which helps prevent complications, as we explain below.
Urethral Complications
Traditionally, urethroplasty—the surgery that extends the urethra to the tip of the neophallus—was performed during the first stage of phalloplasty, and the urethra was made functional immediately. However, this approach has proven challenging, as the tissues used to form the urethra have limited tolerance for urine acidity and constant flow before they have fully healed, which increases the risk of strictures (narrowing) and fistulas (abnormal connections).
Additionally, the inflammation caused by phalloplasty could lead to vascular issues due to urethral compression, affecting the patient’s recovery.
Although making the urethra functional from the first surgery allowed trans men to urinate through the penis immediately, it also increased the likelihood of strictures, fistulas, and complications that could significantly impact both short-term recovery and long-term quality of life.
Functional Urethroplasty at IM GENDER
At IM GENDER, after years of experience and hundreds of surgeries, we have developed an innovation to minimize these risks: delaying urethral functionality until a second stage.
For over a year and a half, we have applied an approach in which the urethra is not connected during the first phalloplasty surgery, but instead during a second surgical stage, when tissues are better adapted for a secondary procedure. This second operation usually coincides with the placement of testicular implants.
During the first few months after the initial surgery, the patient urinates through a temporary stoma located below the scrotum. Once the inflammation and healing phases have passed, the urethra and stoma are connected, allowing urination through the tip of the penis in much safer conditions.
Benefits of Delayed Urethral Connection
This change in the surgical protocol provides significant advantages:
- Lower risk of urethral complications. The urethra is not exposed to early postoperative inflammation, and the skin used for reconstruction has already healed before being exposed to urine acidity, reducing the risk of strictures and fistulas.
- Safer recovery. Since the urethra is not functional during the first stage, the postoperative period—already complex by nature—comes with fewer risks of urine leakage, infection, or early revisions, and greater overall comfort.
- Better biological environment for the urethra. When inflammation and swelling have subsided, tissues are more stable, better vascularized, and less tense, increasing the surgery’s success rate.
- Improved patient experience. Hospital stays and recovery are more manageable, with fewer concerns during the postoperative phase.
Greater long-term stability. While the risk never disappears entirely, clinical evidence shows fewer urethral-related problems and therefore better long-term outcomes.
Innovation as a Commitment to Trans Patients
The decision to introduce delayed urethral reconnection stems from extensive experience and IM GENDER’s commitment to continuous improvement and patient well-being. Our priority is to provide safer, more effective surgeries with better outcomes—reducing risks and improving the quality of life for trans people.
This advancement is part of our ongoing research and development program, through which our medical team continually shares findings at international conferences and updates protocols based on scientific evidence.
Advances in Phalloplasty and Urethroplasty for Better Results
Phalloplasty remains one of the most demanding procedures in gender-affirming surgery, but technical advances are improving outcomes and reducing complications. The introduction of urethral connection in a second stage represents a major step forward in achieving more effective surgery with better results for patients.
At IM GENDER, we continue working to ensure that each person finds the best surgical option, supported by a pioneering team with a long track record in trans surgery.
Want to learn how advances in phalloplasty and urethroplasty improve outcomes?
Schedule a consultation with IM GENDER, and we’ll answer all your questions.
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