Discussion: Outcomes after Phalloplasty

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Mr. Remington and colleagues reviewed available literature and conduced a meta-analysis of outcomes of phalloplasties in both transmale and cismale patients.1 Using appropriate Meta-Analysis of Observational Studies in Epidemiology guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria, they were able to pool data from 50 published studies (19 on phalloplasty in transmale patients, and 31 on phalloplasty in cismale patients). Their primary variables of interest were surgical complications (urethral strictures and fistulas, flap complications), sexual function, and patient satisfaction. In accordance with previous literature, they found that, overall, urethral complications are seen in approximately one-third of patients undergoing phallic reconstruction, with transmale patients at a higher risk of stricture or fistula than cismale patients. Cismale patients also had better rates of adequate sexual function and of standing micturition, although patient satisfaction was high, over 80 percent, in both groups. They note that staged reconstruction was associated with a higher rate of complications and a lower rate of patient satisfaction than one-stage reconstruction. The authors point out some limitations of their study, including a low level of evidence in all included articles, that phallic and urethral reconstruction present different anatomical challenges in transmale and in cismale patients, and that many different techniques were used across all the studies included.
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.
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