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 in London by Nim A. Christopher and David J. Ralph, the Big Ben Method was later adopted and modified at Oregon Health & Science University.[13][2] In the OHSU sequence, the phallus and pars pendulans urethra are created first; pars fixa urethroplasty, vaginectomy or colpoclesis, scrotoplasty, and urethral anastomosis follow after flap healing.[1][2][3]
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 proponents' rationale is practical: each operation is less crowded, the flap is vascularized and healed before the high-risk urethral connection is made, and complications are compartmentalized.[2][3][5] In this proposed rationale, a first-stage flap problem can be addressed before fixed urethral reconstruction, while a later fistula or stricture arises after flap healing.[2][3][5]
Indications
| 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 |
| Concern about urethral stricture | Staging has a proposed tissue-healing rationale, but a comparative reduction in stricture risk is unproven. The single-surgeon OHSU series reported an overall urethral stricture rate of 8% among 71 stage-2 patients, without a concurrent comparison group.[1][3] |
| Multidisciplinary center | Strong fit; plastic surgery, urology, and gynecology components can be sequenced cleanly |
| Uncertainty about completing urethral lengthening | The patient can assess the phalloplasty result and healing before deciding whether to undergo the stage-2 urethral connection; OHSU stage 1 has already created a phallic urethra and proximal extension.[2] |
| 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.[2][3] RFFF is the best-described flap in the Big Ben literature.[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 | In the OHSU technique, the flap includes a 4–4.5 cm proximal urethral extension. It is marsupialized beside the clitoral shaft in nonhair-bearing vulvar skin; ipsilateral labia minora are excised to flatten the surface between native and neo-urethra. The urethras are not yet connected.[2] |
| Flap transfer and inset | Complete microsurgical transfer, shaft inset, and donor-site closure. In the published OHSU sequence, glansplasty is performed at stage 2.[2] |
| 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 |
Stage 2: Urethral Lengthening
Stage 2 completes the fixed urethral segment and connects it to the already-healed phallic urethra. In the published OHSU sequence, stage 2 includes vaginectomy or colpoclesis, pars fixa urethroplasty and its connection to the phallic urethra, clitoral transposition, scrotoplasty, perineoplasty, and glansplasty.[2][3]
| Component | Operative Role |
|---|---|
| Pars fixa urethra | Bridges the native meatus to the phallic urethra using local genital tissue; the published OHSU stage-2 technique designs a U-shaped urethroplasty 23–25 mm wide.[2] |
| 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 | In the OHSU transperineal approach, vaginal mucosa is excised except for distal anterior-wall mucosa reserved for a meatus-based urethral flap; the paravaginal space is closed and cystoscopy checks ureteral patency and lower urinary tract involvement. Multilayer labial and perineal closure addresses dead space and reinforces the urethroplasty. No mucoceles were reported in the retrospective Big Ben cohort.[2][3][14] |
| 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 staged junction. In the published OHSU protocol, a 16 Fr catheter is passed through the penis into the bladder, with penile drainage for 5 days and suprapubic drainage for 4 weeks.[2] |
Outcomes
A 2025 single-surgeon OHSU retrospective series reported 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% | Veerman et al. reported 44/63 (70%) voiding from the phallus tip after treatment in a cohort including phalloplasty and metoidioplasty; Garaffa et al. reported 83/84 (99%) standing tip voiding after revision among RFFF patients with urethral continuity in a 115-patient London cohort[7]; Waterschoot et al. identify Garaffa's series as using the Big Ben method[15]; Hu et al. pooled standing voiding at 91.5% across phalloplasty studies[3][6][7][8] |
| Overall urologic complication rate | 27% | The cited comparator outcomes differ: Veerman et al. reported stricture in 35/55 (63%) phalloplasty patients in a mixed-technique cohort, while Hu et al. pooled the composite of fistula or stenosis at 48.9% across phalloplasty techniques[3][6][8] |
| Stricture rate | 8% (of 71 who proceeded to stage 2) | Hu et al. found a higher stricture/stenosis rate with prelaminated flaps than with tube-in-tube reconstruction; Veerman et al. reported stricture in 35/55 (63%) phalloplasty patients across RFFF, ALT, and SCIP techniques[3][6][8] |
| Fistula rate | 16.4% (authors' reported rate) | Veerman et al. reported fistula in 15/55 (27%) phalloplasty patients; Hu et al. pooled fistula or stenosis at 48.9%, a distinct composite endpoint[3][6][8] |
| Conversion to perineal urethrostomy | 4% of 73 first-stage patients[3] | Variable; depends on repair philosophy and threshold for abandoning standing voiding |
| Mucoceles | None reported among the 71 patients who proceeded to stage 2[3] | Mucocele risk is tied to retained vaginal mucosa and dead space |
| Would undergo surgery again | 96% of survey responders (response rate 67%) | Zack et al. reviewed sexual-function outcomes, a different endpoint from willingness to undergo surgery again among OHSU survey responders.[3][9] |
The OHSU series observed stricture in 8% of 71 stage-2 patients after at least six months of follow-up.[3] Direct head-to-head trials are lacking, follow-up definitions vary, and outcomes are tightly coupled to surgeon experience, volume, flap choice and repair algorithm.
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 (proposed rationale) |
| Complication compartmentalization | Flap problems can be addressed before the urethral junction is built; whether this reduces complication severity compared with other sequences remains untested.[3][5] |
| 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 assess the phalloplasty result and healing before deciding whether to complete the native-to-phallic urethral connection; stage 1 has already created the phallic urethra.[2] |
| Potential stricture reduction | The 2025 OHSU retrospective series reported strictures in 8% of the 71 patients who proceeded to stage 2; comparisons with other cohorts are indirect[3] |
Disadvantages and Caution Zones
| Issue | Counseling Point |
|---|---|
| Two major operations minimum | Total treatment time, travel, recovery, cost, and time away from work increase |
| Interval native-meatus voiding and retained anatomy | Standing micturition is unavailable until stage 2 heals and the urethral channel is functional; retained genital anatomy between stages may prolong dysphoria for some patients.[13] |
| 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; the labia minora flap series (n = 16) reported fistula in 25% and stricture in 37.5%[12] |
Operative Pearls
- Name the target clearly: stage 1 creates a phallus with a phallic urethra; stage 2 creates standing micturition.
- Counsel about urethral complications after staging. The high-volume OHSU series reported fewer strictures than other series, without a direct comparison.
- 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.
- 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. Zack J, Goldstein B, Okamuro K, 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
13. Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. "Phalloplasty: techniques and outcomes." Transl Androl Urol. 2019;8(3):254-265. doi:10.21037/tau.2019.05.05
14. Hougen HY, Shoureshi PS, Sajadi KP. "Gender-affirming Vaginectomy-Transperineal Approach." Urology. 2020;144:263-265. doi:10.1016/j.urology.2020.05.084
15. Waterschoot M, Hoebeke P, Verla W, et al. "Staged Phalloplasty by Metoidioplasty First Does Not Appear to Lower Complication Rates." Transgend Health. 2024;9(5):427-435. doi:10.1089/trgh.2022.0186