Long-Term Urologic Outcomes Using the Big Ben Method for Phalloplasty

Background: There are many ways to construct a urethra in gender-affirming phalloplasty, and comparing outcomes presents challenges because of the diversity of surgical techniques and staging methods in this low-volume procedure. A frequent criticism of phalloplasty is the high rate of urologic complications and associated impact on patient outcomes. Methods: This retrospective, single-surgeon study focuses on long-term outcomes of urethral creation using the Big Ben 2-stage method for urethral lengthening. This study was conducted in 73 patients between December of 2016 and September of 2023, who had at least 6 months' follow-up. Surgical outcomes - specifically, rates of urethral fistulas and strictures - were assessed along with patient-reported outcome measures obtained through distributed surveys. Results: Seventy-three patients underwent first-stage phalloplasty with the goal of urethral lengthening at the second-stage operation, with 96% achieving standing urination and 4% being converted to a perineal urethrostomy. The total percentage of patients experiencing a urologic complication was 27%. Of the 71 patients who did proceed with the second stage, 8% formed a stricture and 16.4% formed a urethrocutaneous fistula. One patient experiencing a stricture was converted to a perineal urethrostomy. There were no mucoceles or urethral, ureteral, or bowel injuries associated with the colpectomy/colpoclesis. Patient-reported satisfaction was high, with 96% expressing willingness to undergo the procedure again (response rate, 67%). Conclusions: The Big Ben method demonstrated potential in reducing urethral stricture rates compared with alternative approaches. It further allows mitigation of complication severity and impact on quality of life, and has a high degree of patient satisfaction and ability to achieve the goal of standing urination. It is particularly well suited for a multidisciplinary academic setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.