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 present challenges due to the diversity of surgical techniques and staging methods in this low volume procedure. A frequent criticism of phalloplasty are the high rates 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 Method two-stage method for urethral lengthening, in 73 patients between December 2016 and September 2023 who had at least 6 months follow up. Surgical outcomes, specifically rates of urethral fistulas and strictures, were assessed alongside patient-reported outcome measures obtained through distributed surveys. Results: 73 patients underwent 1 st stage phalloplasty with the goal of UL at the 2 nd stage operation, with 96% achieving standing urination and 4% being converted to a perineal urethrostomy. Total percentage of patients experiencing a urologic complication rate was 27%. Of the 71 patients who did proceed with 2 nd stage 8% formed a stricture, 16.4% a urethro-cutaneous 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 to alternative approaches. It further allows to mitigate complication severity and impact on QOL and has a high degree of patient satisfaction and ability to achieve the goal of standing urination. It is particularly well suited for a multi-disciplinary academic setting.