Discussion: Outcomes after Phalloplasty
My main comment is that “phalloplasty” is not the name of one operation. The authors take care to point out the heterogeneity of techniques, staging, reported outcomes, and patient populations (transmale and cismale patients, primarily) undergoing phallic reconstruction. However, they have still chosen to pool these very heterogeneous data. Although this may have some value in quoting overall complication rates to patients during informed consent discussions, to go beyond that to perform statistical comparisons on transmale versus cismale patients, one versus two stages, and so forth, seems inappropriate to me. This is especially true if we consider that the most significant variable in any study of surgical outcomes is always individual surgeon, something that pooled analyses, the current one included, never account for. Basically, if I choose to compare an apple pie baked by a professional baker with a pumpkin pie baked by a first-time amateur, I will surely conclude the outcomes are different. The myriad of different flaps/stages/approaches used and the high complication rates across all studies testify that phallic reconstruction remains an unsolved surgical challenge. To pool outcomes, especially outcomes of reconstruction in transmale versus cismale patients, into one data set does not make that much sense to me and, in fact, gives the impression of homogeneity when it does not exist.
My second comment is actually the same comment over again, but more general. We have seen an exponential proliferation of systematic reviews and meta-analyses in our literature. Much of this, I believe, is fueled by the runaway curriculum vitae inflation driving medical school, residency, and fellowship applications and also by the fact that arduous and expensive high level-of-evidence clinical studies are rarely conducted in our specialty. When focused on important questions and when designed and executed well, literature reviews can clearly provide useful information. However, it is my observation that the current avalanche of systematic reviews has created very little new knowledge. Shackled by the reality of heterogeneous data reporting in the component studies and frequently lacking a central, testable hypothesis, meta-analyses have a limited ability to give us new information relevant to surgical decision-making. That is true even when the focus is on a single, well-defined, standardized operation.