The Evolution of Phalloplasty for Masculinizing Gender Affirming Surgery: A Systematic Review of Surgical Techniques and Complications Over the Past 25 Years.

Abstract

Gender affirming phalloplasty is aimed at reducing the deleterious effects of gender dysphoria in the trans male population. Despite being first described in 1945, there is no gold standard for gender affirming phalloplasty. Our objective is to systematically review the phalloplasty literature regarding surgical technique, complication profiles, and temporal trends to understand the evolution of phalloplasty. A literature review was conducted using the electronic databases PubMed and Medline separately, Scopus, and Embase. Studies were included if they were original research studies published in English between January 2000 and September 2025, with more than three enrolled patients and gender affirmation as the indication for phalloplasty. Studies were split into two groups based on the year of publication (Group 1: 2000-2010; Group 2: 2011-2025) to allow comparison between older and more recent studies. Forty-five articles were deemed suitable after the literature search and screening. Overall, there were 2586 patients. 65.3% had a radial forearm free flap phalloplasty. The tube-in-a-tube technique was the preferred method of neourethral reconstruction, with 85.8% in Group 1 and 64.4% in Group 2 (p < 0.01). Group 2 demonstrated a significant increase in the use of pedicled flaps (p < 0.01) and the use of radial forearm free flap urethroplasty alone (p < 0.01). Group 2 showed an increase in sensory reconstruction (p < 0.01). Complication rates were high at 0.74 and 0.66 complications per patient in Groups 1 and 2, respectively. Urinary complications were also high; urethral fistulas in 25.7% and 36.6% of patients, and urethral strictures in 16.1% and 12.8% of patients in Groups 1 and 2, respectively. Outcomes such as urinary function, tactile sensation, erogenous sensation, and cosmesis were poorly reported. This systematic review, to our knowledge, is the first to analyze the evolution of phalloplasty over time, suggesting a shift from traditional free-flap techniques toward more diverse reconstructive approaches, including pedicled and perforator-based options. However, inconsistent outcome reporting limits meaningful comparison between techniques. Standardized, high-quality evidence is required to guide optimal surgical practice.