BACKGROUND: Selection of recipient vessels in phalloplasty is challenging due to the absence of adequate vessels in the immediate proximity. There is no consensus on the appropriate vessel selection. We hypothesized that recipient vessel selection in phalloplasty is associated with differences in complications and flap survival. METHODS: A literature search following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines across Ovid MEDLINE/PubMed, Embase, and CENTRAL databases identified 46 articles. Collected data included demographics, surgical details, donor and recipient vessels, use of interpositional grafts, number of venous anastomoses, and outcomes. Statistical analysis followed the random-effects model. RESULTS: One thousand nine hundred and seventy six phalloplasty cases were identified. The deep inferior epigastric artery (DIEA) was used in 1413 cases (71.5%) and the femoral artery (FA) was used in 563 cases (28.5%). Pooled proportions of arterial and venous thrombosis were 2.0% and 2.2%, respectively. The use of an interpositional vein graft or arteriovenous loop with the FA was associated with a significantly higher arterial thrombosis rate (16.0%) compared to direct anastomosis to the FA (0.1%, p < 0.001) and to the DIEA (1.2%, p < 0.001). In the absence of vascular thrombosis, partial flap necrosis occurred significantly less often with direct anastomosis to the FA (0.6%) than with the DIEA (6.2%, p = 0.016). CONCLUSIONS: The choice of recipient vessels is an important consideration in phalloplasty flap survival. The DIEA is associated with a low thrombosis rate. However, the significantly higher proportion of thrombosis observed with the FA may be attributable to the use of an interpositional vein graft or arteriovenous loop. Despite lower thrombosis rates, the use of the DIEA was associated with a higher proportion of partial flap necrosis when vessels were patent.