Urethral lengthening is a surgical procedure that extends the urethra, the tube through which urine exits the body. This procedure is commonly performed as part of gender-affirming surgeries, such as phalloplasty or metoidioplasty, for transgender men and non-binary individuals. Its primary goal is to enable urination through the tip of a newly constructed penis, addressing both functional and anatomical considerations. The recovery process requires careful management, and potential complications are a recognized aspect of this specialized surgery.
Understanding Urethral Lengthening
Urethral lengthening extends the urethra to allow urination from the tip of a surgically constructed phallus. This procedure is a common component of gender-affirming surgeries like phalloplasty and metoidioplasty, aiming to create a urinary channel for standing urination.
Beyond the functional aspect, urethral lengthening offers significant psychological benefits. Achieving the ability to urinate while standing and having a urethra that aligns with one’s gender identity can alleviate gender dysphoria and enhance overall quality of life. This procedure contributes positively to self-esteem and daily living experiences by fostering a greater sense of bodily congruence.
Surgical Techniques and Considerations
Urethral lengthening is often a multi-stage surgical process, involving the creation of a new urethral segment and its connection to the existing urethra. Surgeons utilize various tissue grafts to construct this new segment. Common donor sites include the buccal mucosa (lining of the cheek), vaginal tissue, or skin grafts from other body areas. Buccal mucosa grafts are often favored by some surgeons due to their robust epithelium, resistance to infection, and ease of transfer, often used for dorsal urethral plate formation.
Another approach involves mobilizing and advancing existing tissue. In metoidioplasty, neighboring tissues like the labia minora or clitoral hood are used to extend the urethra. For phalloplasty, a skin-tube urethra is created from a donor site and connected to the lengthened native urethra. The specific technique chosen depends on factors such as the patient’s anatomy, desired urethral length, and donor tissue availability.
Adequate blood supply to the newly constructed urethral segment is a consideration. Poor blood flow can lead to complications like strictures or fistulas. Surgeons connect the new urethral segment to the existing urethra, often in a two-stage process, to promote proper healing and minimize these risks. Vaginectomy, the removal of the vaginal canal, is often performed concurrently with urethral lengthening as it can provide additional vascularized tissue and has been associated with a decrease in urethral stricture and fistula formation.
Recovery and Functional Outcomes
Following urethral lengthening, patients typically have an initial hospital stay, which can range from two to six nights. Pain management is a standard part of post-operative care, with medication prescribed to alleviate discomfort, often including bladder spasms due to catheter presence. Swelling and bruising are common and generally improve within two weeks, with full resolution potentially taking up to six months.
A suprapubic catheter is placed to divert urine away from the healing urethra, remaining for two to four weeks. In some cases, a urethral catheter may also be present. This allows the newly constructed urethra to heal without constant exposure to urine. Once catheters are removed, patients can begin to urinate through the neophallus.
The primary functional outcome desired is the ability to urinate while standing. A percentage of patients achieve this goal, with reported success rates ranging from 70% to 100% after treatment of any complications. Patients also report psychological and quality-of-life improvements once functional goals are met, reflecting a greater alignment with their gender identity. Resuming light activities, such as walking, is encouraged shortly after surgery to promote circulation, while strenuous activities are avoided for at least four to eight weeks, and sexual activity for three to four months or longer.
Addressing Potential Complications
Urethral lengthening, while transformative, carries a risk of potential complications. The most frequently reported issues are urethral strictures and urethrocutaneous fistulas. A urethral stricture is a narrowing of the urethra caused by scar tissue, which can impede urine flow, leading to symptoms like a weak stream or difficulty emptying the bladder. These strictures can occur at various points along the reconstructed urethra, including the meatus or the anastomosis between the native and neourethra. Strictures have been reported in 13.7% to 63% of cases, often developing within approximately three months post-surgery.
Urethrocutaneous fistulas are abnormal openings that form between the urethra and the skin, allowing urine to leak from somewhere other than the tip of the penis. These can occur anywhere along the new urethral tube, but are most common at the junction of the native and new urethra. Fistula rates vary, ranging from 8% to 68% depending on the surgical technique. Possible causes for both strictures and fistulas include inadequate blood supply to the tissue, infection, wound healing issues, or increased pressure within the urethra due to an obstruction.
Many complications are managed with post-operative monitoring, and some smaller fistulas may close on their own with urinary diversion using a catheter. However, surgical revision is often necessary to address persistent strictures or fistulas, especially if they do not heal within three months. Revision surgeries for strictures often involve excising the scar tissue and, if needed, grafting new tissue, such as buccal mucosa. Addressing these complications is a recognized part of the overall surgical journey, with most patients ultimately achieving their functional goals after treatment.