Metoidioplasty

Basics

Metoidioplasty is one of the variants of phalloplasty in transmen. It presents reconstruction of the penis from hormonally hypertrophied clitoris, with the main goal to give the patient “male looking genitalia” and possibility to void in standing position.

Metoidioplasty with urethral lengthening can be performed simultaneously with hysterectomy, bilateral oophorectomy and bilateral mastectomy, as a one-stage gender confirmaton surgery, with satisfactory results. This is the latest one stage variant of gender affirmation surgery from Belgrade Center for Genital and Reconstructive Surgery®.

Transmen should be treated hormonally for a period of one-year minimum prior to surgery. Clitoris is preoperatively enlarged using dihydrotestosterone as a topical gel locally, applied twice a day during three months preoperatively, combined with the use of vacuum device.

Advantages of metoidioplasty are: simple, one-stage procedure with good cosmetic outcome, completely preserved erogenous sensation and erection, and voiding in standing position. Ultimately, good psychosexual outcome and improved quality of life are achieved. Also, any type of phalloplasty can be performed later, in case that person is not satisfied with metoidioplasty and wishes a larger neophallus. The main disadvantage is a small penis, incapable for penetrative intercourse in majority of cases.

SEE PHOTO GALLERY

Operative technique

The current operative technique comprises the following steps: vaginectomy, creation of the neophallus (maximal straightening and lengthening of the clitoris), urethral lengthening by combining buccal mucosa graft and genital flaps, and scrotoplasty with insertion of testicular implants. Vaginectomy is performed by total removal of vaginal mucosa (colpocleisis), except the part of anterior vaginal wall that will be used afterwards for urethral lengthening. Internal female genital organs can be removed in the same stage (hysterectomy – removal of uterus, oophorectomy – removal of ovaries) using vaginal or laparoscopic approach. It is very important to prevent any transabdominal approach in order to preserve anterior abdominal wall for possible abdominal phalloplasty in the future.

A self-adherent dressing is used for the neophallus. Suprapubic urinary drainage is placed in all cases for 3-4 weeks. The urethral stent is removed 7-9 days after surgery. Vacuum device is recommended for six months period in order to prevent postoperative shortening of the neophallus.

Advantages

Removal of the vagina. One of the main advantages of the technique is simultaneous removal of vaginal mucosa. The flap originated from anterior vaginal wall is very useful in lengthening of female urethra. At this spot, voiding pressure is the strongest and always presents the risk of fistula formation postoperatively. Joining the clitoral bulbs over the lengthened urethra and additional covering with remaining surrounding tissue is considered to be a key to successful fistula prevention.

Lengthening and straightening. Clitoris can be lengthened and straightened by division of its ligaments dorsally and short urethral plate ventrally. During this dissection, care should be taken to prevent injury of both neurovascular bundle and urethral spongiosal tissue.

Urethral reconstruction. To avoid complications described after tubularized urethroplasty, we use combined buccal mucosa graft and genital skin flaps. The application of free buccal mucosa grafts for urethral reconstruction is becoming increasingly popular in certain clinical settings. They are tough, resilient, easy to harvest and handle, and leave no visible donor site. Their histological composition makes them good grafting material. Covering of the graft can be performed with longitudinal dorsal clitoral skin flap button-holed ventrally, or flap harvested from inner surface of the labia minora. In both, good vascularized tissue completely covers all suture lines preventing fistula formation in majority of cases.

Penile shaft reconstruction. Normal appearance of the external genitalia is achieved by creation of the penoscrotal angle as a male. Penile body is covered with remaining clitoral and labia minora skin. Labia majora are joined in midline to form the scrotum, in which testicular implants can be placed.

ONE STAGE REPAIR. All of our patients are managed with a single operation. Minor complications, mostly related to urethroplasty, occur in less than 10% of cases, and are solved by simple procedure. Additional cosmetic corrections are always possible as a minor procedure. Most patients are satisfied with the final outcome of metoidioplasty, since male genitalia appearance is achieved as well as voiding in standing position. Last but not least, neophallus is functionally though not fully adequate, as it is too small to allow sexual intercourse in most of patients. Additional augmentation phalloplasty is possible, according to patient’s preferences.

NEW VARIANTS

Modifications of the technique have developed due to recent advances in anatomy and new requests from transmen.

Besides full (Belgrade) metoidioplasty, new variants include: metoidioplasty without vaginectomy, metoidioplasty without urethral lengthening, metoidioplasty without testicular implants, metoidioplasty after phalloplasty (SEE PHOTO GALLERY). All WPATH Standards of care must be fulfilled prior to surgery.

Recommendations and key points

• Metoidioplasty, as a one-stage gender confirmation procedure, presents a good and safe option for transmen who want to avoid complex and multistaged phalloplasty

• The main goals of metoidioplasty are good cosmetic, voiding while standing with preservation and/or enhancement of sexual function

• Advanced urethroplasty using a combined buccal mucosa graft and labia minora flap offers a good result with low complication rate

• The length of the neophallus may not be adequate for penetration during sexual intercourse

• Most transmen are satisfied with the final outcome of metoidioplasty as a consequence of achieving male appearing genitalia with the ability to void while standing in addition to preservation of sexual function

• Metoidioplasty can always be followed by any type of phalloplasty, in transmen who require larger phallus.