Metoidioplasty one of the variants of phalloplasty in female to male transsexuals. 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 female-to-male 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®.
The patients should be treated hormonally for a period of one-year minimum prior to urgery. 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.
The current operative technique comprises the following steps: vaginectomy, 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. (Figures 1-3)
After complete degloving, the clitoral ligaments are divided to advance the clitoris. Ventrally, the urethral plate is dissected from the clitoral bodies. Dissection includes bulbar part of the plate around the native orifice to enable its good mobility for urethral reconstruction. Since the urethral plate is always short causing the ventral clitoral curvature, it is divided at the level of the glanular corona. In this way, complete straightening and lengthening of the clitoris are achieved. (Figures 4-7)
The bulbar part of urethra is created by joining the flap harvested from anterior vaginal wall and remaining part of divided urethral plate.
Additional urethral reconstruction is performed using buccal mucosa graft and vascularized genital skin flaps. The buccal mucosa graft is harvested from the inner cheek using a standard technique. The length of the graft depends on the distance between the tip of the glans and the urethral meatus. Then, graft is fixed and quilted to the corporeal bodies starting from the advanced urethral meatus to the tip of the glans. In this way, half of the urethra covering corporal bodies is created.
Urethral covering can be achieved using either labia minora flap or dorsal clitoral skin flap. Inner part of labia minora is dissected to create a flap with appropriate dimensions without detachment from the outer labial surface. This way, excellent vascularization of the flap is enabled. Flap is joined with buccal mucosa graft over a 12 to 14-Fr stent to create neourethra without tension. Only in cases of poorly developed labia minora, a well-vascularized longitudinal island flap is harvested from dorsal clitoral skin. (Figures 8-12)
The penile body is reconstructed using the remaining clitoral and labia minora skin. The labia majora are joined in midline to create the scrotum. Silicone testicular implants (small or medium size) are inserted through the bilateral incisions placed at the top of labia majora. (Figures 13-16)
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.
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.
Recommendations and key points
• Metoidioplasty, as a one-stage gender confirmation procedure, presents a good and safe option for female-to-male transsexuals 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 patients 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
Urethral reconstruction – bulbar part
Urethral reconstruction – buccal mucosa graft
Urethral reconstruction – clitoral skin flap
Urethral reconstruction – labia minora flap
Scrotoplasty / testicular implants
Result after surgery
8 weeks after surgery
Two months after surgery
Three months after surgery
Five months after surgery
Outcome 12 months after surgery, voiding while standing
Three years after surgery
Three years after surgery
Metoidioplasty with small clitoris
Preoperative appearance – small clitoris
Good size of the neophallus is achieved
Outcome after surgery; voiding while standing
Voiding while standing
Long-term outcome after surgery.
Voiding while standing.
Outcome 4 weeks after surgery – home photo
Outcome 12 months after surgery – home photo
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