Big Ben Method for Phalloplasty
The Big Ben Method is a two-stage, phalloplasty-first approach to urethral lengthening in masculinizing gender-affirming phalloplasty. Developed at Oregon Health & Science University, it separates phallic construction from fixed urethral lengthening: the phallus and pars pendulans urethra are created first, then the pars fixa urethra, vaginectomy / colpoclesis, scrotoplasty, and urethral anastomosis are completed after the phalloplasty flap has healed.[1][2][3]
This is the atlas page for the Big Ben Method. For flap-specific donor-site and tube-in-tube details, see RFFF Phalloplasty, ALT Phalloplasty, and SCIP Phalloplasty. For cohort-level pathway selection, see Masculinizing Gender-Affirming Surgery.
Concept
The core maneuver is staging the urethral junction. In single-stage phalloplasty, the phallus, pars pendulans urethra, pars fixa urethra, vaginectomy, scrotoplasty, and urethral anastomoses are performed during the same operative episode. In the Big Ben sequence, the neophallus and phallic urethra are built first, while the connection to the native urethra is deferred until a second operation.[1][2][4]
| Strategy | Sequence | Main Tradeoff |
|---|---|---|
| Single-stage phalloplasty | Phallus + pars pendulans + pars fixa + vaginectomy + scrotoplasty at one operation | Shorter overall pathway, but maximal urethral and wound complexity in one setting |
| Metoidioplasty-first staging | Perineal masculinization and pars fixa urethroplasty first, phalloplasty later | Standing voiding may be tested before phalloplasty; phalloplasty occurs after perineal work |
| Big Ben Method | Phalloplasty with pars pendulans first, pars fixa / urethral lengthening second | Phallus declares itself before urethral connection; requires at least two major operations |
The rationale is practical rather than mystical: each operation is less crowded, the flap is vascularized and healed before the high-risk urethral connection is made, and complications are compartmentalized. A first-stage flap problem does not necessarily compromise the fixed urethral reconstruction, and a later urethral fistula or stricture does not threaten flap survival.[2][3][5]
Indications
The Big Ben Method is most useful when the patient wants standing micturition after phalloplasty, but the team prefers to separate microsurgical flap transfer from perineal urethral lengthening and vaginectomy / colpoclesis.
| Scenario | Fit for Big Ben Staging |
|---|---|
| Standing micturition desired | Strong fit if the patient accepts a staged path to urethral lengthening |
| RFFF phalloplasty with pars pendulans urethra | Common fit; the phallic urethra can be created in the flap at stage 1 |
| Need to reduce stricture risk at urethral junction | Strong conceptual fit; the 2025 OHSU series reported an 8% stricture rate[3] |
| Multidisciplinary center | Strong fit; plastic surgery, urology, and gynecology components can be sequenced cleanly |
| Uncertainty about urethral lengthening | Useful; some patients can assess the phalloplasty result before committing to UL |
| Need for fastest standing voiding | Poor fit; the patient voids through the native meatus between stages |
| Desire to minimize number of operations | Poor fit; at least two major stages are required |
Stage 1: Phalloplasty
Stage 1 creates the neophallus and, when standing micturition remains the goal, the pars pendulans or phallic urethra. RFFF is the best-described flap in the Big Ben literature, although the staging principle is not limited to one donor site.[2][3]
| Step | Technical Point |
|---|---|
| Flap selection and design | RFFF commonly uses a tube-in-tube design; ALT, SCIP-assisted, abdominal, and other donor-site pathways require separate urethral planning |
| Pars pendulans construction | The phallic urethra is incorporated into the flap, but it is not yet anastomosed to the native urethra |
| Flap transfer and inset | Complete microsurgical transfer, shaft inset, glansplasty according to local protocol, and donor-site closure |
| Urinary drainage during interval | The patient continues to void from the native urethral meatus until stage 2 |
| Interval purpose | Allow flap edema, perfusion, wounds, and donor-site issues to declare themselves before perineal urethral work |
The first stage is therefore a phalloplasty operation, not a completed urethral-lengthening operation. This distinction matters for counseling: standing micturition is not expected until after the second stage.
Stage 2: Urethral Lengthening
Stage 2 completes the fixed urethral segment and connects it to the already-healed phallic urethra. In the OHSU description, this stage includes pars fixa urethral reconstruction, vaginectomy / colpoclesis, scrotoplasty, and anastomosis between the pars fixa and pars pendulans urethra.[2][3]
| Component | Operative Role |
|---|---|
| Pars fixa urethra | Bridges the native urethral meatus to the base of the neophallus using local genital tissue |
| Anterior vaginal-wall flap | Common local-tissue substrate for the ventral / fixed urethral segment |
| Labia minora flaps | Augment local urethral coverage and help close the urethral plate / tube |
| Vaginectomy / colpoclesis | Eliminates dead space and lowers the risk of persistent vaginal cavity complications |
| Scrotoplasty | Usually completed with labia majora tissue during the perineal stage |
| Pars fixa-to-pars pendulans anastomosis | Creates the continuous channel for standing micturition; this is the high-value staged junction |
Outcomes
The largest Big Ben outcomes publication is a single-surgeon OHSU retrospective series of 73 patients treated from December 2016 through September 2023, with at least 6 months of follow-up. Seventy-one of 73 patients proceeded to stage 2.[3]
| Outcome | Big Ben OHSU Series | Context From Other Phalloplasty UL Literature |
|---|---|---|
| Standing micturition achieved | 96% | Many single-stage or mixed-stage series report roughly 70% to 91.5% standing voiding, depending on definition and follow-up[3][6][7] |
| Overall urologic complication rate | 27% | Urethral-complication rates across phalloplasty series commonly approach or exceed 40%[3][6][8] |
| Stricture rate | 8% | Published stricture rates after phalloplasty with UL commonly range from the 20% range to above 60% in high-risk series[3][6][8] |
| Fistula rate | 16.4% | Fistula rates around 25% to 33% are common in comparator literature[3][6][8] |
| Conversion to perineal urethrostomy | 4% | Variable; depends on repair philosophy and threshold for abandoning standing voiding |
| Mucoceles | 0% | Mucocele risk is tied to retained vaginal mucosa and dead space |
| Would undergo surgery again | 96% of survey responders | Satisfaction after phalloplasty is generally high despite revision burden[3][9] |
The signal is strongest for stricture reduction. The OHSU 8% stricture rate is substantially lower than many historical and contemporary phalloplasty UL series, where urethral strictures are often the most durable source of morbidity.[3][6][8] This should not be framed as proof that the Big Ben Method is universally superior: direct head-to-head trials are lacking, follow-up definitions vary, and outcomes are tightly coupled to surgeon experience, volume, flap choice, and repair algorithms.
Advantages
| Advantage | Why It Matters |
|---|---|
| Better vascular context for the junction | The pars pendulans urethra and phalloplasty flap have healed before the fixed-to-phallic urethral anastomosis |
| Complication compartmentalization | Stage-1 flap complications and stage-2 urethral complications are less likely to imperil each other |
| Cleaner team sequencing | Plastic surgery can focus on flap transfer first; urology / gynecology can focus on fixed urethra, colpoclesis, and scrotoplasty later |
| Decision flexibility | The patient can live with the phalloplasty result before committing to standing-voiding reconstruction |
| Potential stricture reduction | The 2025 OHSU series reported 8% strictures, favorable against most historical phalloplasty UL cohorts |
Disadvantages and Caution Zones
| Issue | Counseling Point |
|---|---|
| Two major operations minimum | Total treatment time, travel, recovery, cost, and time away from work increase |
| Interval seated voiding | Standing micturition is not available until stage 2 heals and the urethral channel is functional |
| Not all patients proceed | In the OHSU series, 71 of 73 proceeded to stage 2; patients may defer or decline UL after stage 1[3] |
| Still not a low-risk urethra | Fistula, stricture, prolonged suprapubic diversion, and revision remain real risks |
| Evidence is center-specific | The best data come from a high-volume OHSU single-surgeon series, not a randomized comparison |
Comparison With Other Urethral Strategies
| Approach | Best Use | Main Limitation |
|---|---|---|
| Single-stage RFFF tube-in-tube | Patient wants one major phalloplasty / UL operation and accepts high urethral-revision probability | Fistula and stricture burden remains high in many series[4][6][8] |
| Metoidioplasty-first staging | Patient wants perineal masculinization and a standing-voiding trial before phalloplasty | Phalloplasty occurs later and may not be desired by all patients after metoidioplasty[1][10] |
| Big Ben Method | Patient wants phalloplasty first and a staged urethral connection after flap healing | Requires interval native-meatus voiding and at least two major operations |
| ALT with staged skin-graft urethroplasty | ALT shaft is desired, but local urethral strategy is staged separately | Donor-site thickness and urethral graft bed remain key determinants[11] |
| Separate-flap urethra (SCIP / labia minora) | Main shaft flap is too thick or unsuitable for tube-in-tube urethra | Adds flap-specific complexity; complication rates depend on tissue quality and center experience[12] |
Operative Pearls
- Name the target clearly: stage 1 creates a phallus with a phallic urethra; stage 2 creates standing micturition.
- Do not promise that staging eliminates urethral complications; it appears to reduce strictures in a high-volume OHSU series.
- Preserve decision flexibility between stages, especially for patients unsure about urethral lengthening.
- Treat the pars fixa-to-pars pendulans junction as the central risk point; staging is designed around that anastomosis.
- Coordinate gynecology, urology, and plastic surgery before stage 1 so the stage-2 tissue plan is not an afterthought.
- Track outcomes by standing voiding, stricture, fistula, suprapubic-tube duration, conversion to perineal urethrostomy, and patient-reported satisfaction.
References
1. Berli JU, Monstrey S, Safa B, Chen M. Neourethra creation in gender phalloplasty: differences in techniques and staging. Plast Reconstr Surg. 2021;147(5):801e-811e. doi:10.1097/PRS.0000000000007898
2. Peters BR, Sajadi KP, Berli JU. Big Ben Method phalloplasty: step by step. Plast Reconstr Surg Glob Open. 2023;11(7):e5126. doi:10.1097/GOX.0000000000005126
3. Berli JU, Ferrin PC, Buuck C, Cylinder I, Putnam C, Dy GW, Peters BR, Llado-Farrulla M, Sajadi KP, Annen A. Long-term urologic outcomes using the Big Ben method for phalloplasty. Plast Reconstr Surg. 2025;156(2):279e-290e. doi:10.1097/PRS.0000000000012010
4. Chen ML, Safa B. Single-stage phalloplasty. Urol Clin North Am. 2019;46(4):567-580. doi:10.1016/j.ucl.2019.07.010
5. Danker S, Esmonde N, Berli JU. "Staging" in phalloplasty. Urol Clin North Am. 2019;46(4):581-590. doi:10.1016/j.ucl.2019.07.011
6. Veerman H, de Rooij FPW, Al-Tamimi M, et al. Functional outcomes and urological complications after genital gender affirming surgery with urethral lengthening in transgender men. J Urol. 2020;204(1):104-109. doi:10.1097/JU.0000000000000795
7. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol. 2010;57(4):715-722. doi:10.1016/j.eururo.2009.05.018
8. Hu CH, Chang CJ, Wang SW, Chang KV. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24. doi:10.1016/j.bjps.2021.08.006
9. Goldstein B, Okamuro K, Lewis P, et al. Sexual health outcomes following gender-affirming phalloplasty: a systematic review. J Sex Med. 2025;22(9):1700-1706. doi:10.1093/jsxmed/qdaf166
10. Kocjancic E, Acar O, Talamini S, Schechter L. Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening. Int J Impot Res. 2022;34(2):120-127. doi:10.1038/s41443-020-0259-z
11. Robinson I, Chao BW, Blasdel G, et al. Anterolateral thigh phalloplasty with staged skin graft urethroplasty: technique and outcomes. Urology. 2023;177:204-212. doi:10.1016/j.urology.2023.03.038
12. Al-Tamimi M, Pigot GL, Ronkes B, et al. The first experience of using the pedicled labia minora flap for urethral lengthening in transgender men undergoing anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty: a multicenter study on clinical outcomes. Urology. 2020;138:179-187. doi:10.1016/j.urology.2019.10.041