Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.

Background: Vessel-sparing anastomotic repair (vsAR) has been developed as a less traumatic alternative to transecting anastomotic repair (tAR) to treat isolated short bulbar urethral strictures. This vessel-sparing technique could result in improved functional outcomes without jeopardizing the excellent surgical outcome after (transecting) anastomotic repair. The purpose of this study is to directly compare vsAR and tAR for both surgical and functional outcomes. Methods: This trial is a prospective, interventional, multi-center, single-blinded, 1:1 randomized, controlled, non-inferiority, phase II trial. Sample size calculation resulted in a required sample size of 100 patients (50 patients per arm). Trial participants will be randomized by an independent third party using a computer-based random sequence generator with permuted blocks of variable size. The primary objective of this trial is to show that vsAR is non-inferior to tAR in terms of failure-free survival after 24 months of follow-up, considering a non-inferiority limit of 10%. Failure is defined as the inability to pass a 16-Fr flexible cystoscope through the reconstructed area without damaging the urethral mucosa. Secondary end-points mainly include differences in postoperative complications and changes in functional outcome parameters, which will be assessed with validated questionnaires. All participants are scheduled for follow-up at 3, 12, and 24 months postoperatively. Discussion: This trial will provide level Ib evidence about the differences in both surgical and functional outcome between vsAR and tAR, which may importantly scape the future of bulbar urethral reconstruction. Depending on the trial results, this phase II trial may generate a larger phase III trial with more statistical power and a lower alpha value. Trial registration: This trial is registered at clinicaltrials.gov (NCT03572348) and in the Belgian Clinical Trial Registry (B670201837335). The trial was registered prospectively. Registered on 28 June 2018.

Purpose: Surgical reconstruction for posterior urethral injuries associated with pelvic fractures (PFUI) is complex. Perineal posterior urethroplasty via excision and primary anastomosis (EPA) is the standard treatment. This study evaluates risk factors for stenosis recurrence after primary EPA and analyzes predictors of postoperative complications. Methods: A retrospective analysis was conducted on male patients who underwent primary posterior EPA for PFUI at Ghent University Hospital (2001–2024). The primary outcome was stenosis recurrence at 1-, 2-, and 10-year follow-up, defined as urethral narrowing causing obstructive symptoms and requiring intervention. Demographic data, prior urethral manipulation, surgical techniques, 90-day complications (Clavien-Dindo), and functional outcomes were analyzed. Univariate and multivariate coxregression analyses were performed using IBM SPSS Statistics v. 29.0.2.0. Results: Among 70 patients, 75.5% underwent transecting EPA. After a median follow-up of 130 months (IQR 78.5-178.5), stenosis recurrence occurred in 15.8% at a median of 3 months (IQR 2.0–5.0). The 1-, 2-, and 10-year recurrence-free survival rates were 85.4%, 83.8%, and 83.8%, respectively. In multivariate analysis, postoperative complications (HR = 4.85, p = 0.007) and persistent extravasation (HR = 6.36, p = 0.006) significantly increased recurrence risk. Postoperative complications (21.4%) were all low-grade and managed conservatively. Erectile function was impaired in 97.9% due to trauma, with 12.2% improving postoperatively. De novo urinary incontinence occurred in 6.6%. Conclusions: Posterior urethroplasty demonstrates a high long-term success rate in patients with PFUI. Postoperative complications and persistent urinary leakage significantly increase the risk of surgical failure, highlighting the need for rigorous follow-up. The non-transecting technique, when possible, does not negatively impact outcomes.