Dr. Richard Santucci, MD, FACS is an expert in Reconstructive Urology who has devoted his career to transgender surgery after spending 18 years as one of the nation’s most distinguished academic Reconstructive Urologists. Dr. Santucci joined the practice of Dr. Curtis Crane in January 2018, working out of the Austin location of the Crane Center for Transgender Surgery. Dr. Santucci’s deep experience with complex genitourinary surgery uniquely positions him to excel at the most technically challenging gender affirming procedures, such as Phalloplasty and Vaginoplasty.
Optimization of Second-stage Metoidioplasty
Nkiruka Odeluga, Soumya A Reddy, Michael H Safir, Curtis N Crane, Richard A. Santucci. Urology, June 2021.
Metoidioplasty generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.
Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty
Richard A Santucci, Emma R Linder, Galen S Wachtman, Curtis N Crane. Plast Reconstr Surg Glob Open, 2021 Jun 22;9(6):e3654.
Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.
Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction
Richard A Santucci, Keeley D Newsom, Galen S Wachtman, Curtis N Crane. Plast Reconstr Surg Glob Open, 2021 May 21;9(5):e3595.
Up to 19% of RFF Phalloplasty patients require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFF Phalloplasties was first reported in 1996. AVF can be reliably used for salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss.
Trends and Techniques in Gender Affirmation Surgery: Is YouTube an Effective Patient Resource?
Santucci RA, Deleon AN, Crane CN. Plast Reconstr Surg. 2021 May 1;147(5):904e.
Vaginoplasty tips and tricks. [FULL TEXT]
Li JS, Crane CN, Santucci RA. Int Braz J Urol. 2021 Mar-Apr;47(2):263-273.
In this review, we discuss how to achieve satisfactory surgical outcomes with gender-affirming Vaginoplasty, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.
What urologists need to know about male to female genital confirmation surgery (vaginoplasty): techniques, complications and how to deal with them.
Drinane JJ, Santucci R. Minerva Urol Nefrol. 2020 Apr;72(2):162-172.
Currently, there are no absolute contraindications to vaginoplasty in a patient who is of the age of majority in their country, only relative contraindications which include active smoking and morbid obesity. Important complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula.
What urologists need to know about female-to-male genital confirmation surgery (phalloplasty and metoidioplasty): techniques, complications, and how to deal with them. [FULL TEXT]
Jun MS, Crane CN, Santucci RA. Minerva Urol Nefrol. 2020 Feb;72(1):38-48.
This review will discuss the surgical elements behind metoidioplasty and phalloplasty, and the diagnosis and treatment for the most common postoperative issues.
Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery. [FULL TEXT]
Carter EE, Crane CN, Santucci RA. Plast Aesthet Res 2020;7:33.
In the setting of no established “gold standard”, this review seeks to describe the components and staging of phalloplasty, with an emphasis on established and experimental solutions to the most common and vexing problems.
The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series.
Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, van Moorselaar RJA, Mullender MG, Weigert R, Buncamper ME, Özer M, de Haseth KB, Djordjevic ML, Salgado CJ, Belanger M, Suominen S, Kolehmainen M, Santucci RA, Crane CN, Claes KEY, Monstrey S, Bouman MB. J Sex Med. 2019 Nov;16(11):1849-1859.
In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty.
Urethral stricture after phalloplasty. [FULL TEXT]
Jun MS, Santucci RA. Transl Androl Urol. 2019 Jun;8(3):266-272.
The most common complications after Phalloplasty surgery are urinary, mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures. Improvements in surgical technique have driven down complication rates over the past few decades. Despite these innovations, complication rates remain high, and transgender surgeons must be well versed in their diagnosis and treatment. Over the same time period, gender affirming surgery has seen unprecedented growth in the United States. Phalloplasty surgeons are few, and their patients often travel great distances for their index surgery. As such, locally available reconstructive urologists will be called upon to treat these complications with greater frequency and must be proficient in diagnosis and treatment to help these patients achieve a good outcome.
Cultural Considerations Regarding Glansplasty.
Nolan I, Crowe CS, Massenburg BB, Massie JP, Santucci RA, Morrison SD. Plast Reconstr Surg. 2018 Sep;142(3):427e.
A variety of flaps have been pioneered to meet the goals of Phalloplasty and many of them allow for glansplasty to approximate a corona. However, not all transmale patients may desire the appearance of a circumcised phallus after glansplasty. Although construction of foreskin is not currently an option, foregoing glansplasty is certainly possible and can more closely resemble an uncircumcised penis.
The Rise of the Neophallus: A Systematic Review of Penile Prosthetic Outcomes and Complications in Gender-Affirming Surgery.
Rooker SA, Vyas KS, DiFilippo EC, Nolan IT, Morrison SD, Santucci RA. J Sex Med. May 2019.
This is the first study to aggregate all reported penile prosthesis characteristics and outcomes in trans masculine patients. Prosthesis implantation in gender-affirming operations poses significant risk of complication, but it is still a reasonable and useful method to achieve rigidity necessary for sexual intercourse. There is a great need for a prosthesis designed to meet the specific needs of the trans masculine patient after phalloplasty.
Review: Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence [FULL TEXT]
Richard A. Santucci, Clinical Anatomy, 2018 March, 31:187–190
Radial forearm free flap phalloplasty (RFFP) is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required.