American Association of Plastic Surgeons

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Urologic Outcomes After Big Ben Method Phalloplasty
Jens U. Berli, MD, Alvin Annen, MD, Isabel Cylinder, MD, Peter Ferrin, MD, carter buuck, bs, Blair Peters, MD;
Oregon Health & Science University, Portland, OR, USA

PURPOSE: Debate surrounds the staging for urethral creation in phalloplasty. Data on single-stage, metoidioplasty-first, Big Ben method, and other grafted urethral reconstructions are sparse. Fistula rates are reported between 10-64% and stricture between 14-57%.1 In particular strictures can lead to prolonged urinary diversion. This study evaluates the Big Ben Method, in potentially reducing strictures due to a shorter perineal urethral segment with a non-circumferential suture line.
METHODS: Database review of Big Ben Method phalloplasty procedures by a single surgeon from September 2016 to August 2023. Inclusion criteria: patients with at least 6 months post-stage 2 follow-up or those unable to proceed with urethral lengthening due to complications. Primary outcomes: flap loss, fistula, stricture, suprapubic diversion duration, and patient-reported urinary outcomes.
RESULTS: 73 patients underwent the Big Ben procedure (Radial Forearm 82%, ALT 15%, ALT+ulnar forearm 3%). Partial flap loss in 12 patients (16%); 3/25% involved the urethral segment. Total flap loss 0%. Two patients (3%) required conversion to a shaft-only phalloplasty before stage 2, while 0% needed perineal urethrostomy post-stage 2. Fistulas developed in 16% post-stage 2, strictures in 7%, and the average suprapubic diversion was 35 days (median IQR 13).
CONCLUSION:
The Big Ben phalloplasty method offers promising outcomes, notably in reducing stricture rates. Average suprapubic diversion should be considered an indirect measure of complication severity and be included in future phalloplasty outcome studies.

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