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Metoidioplasty (or meta) is the first and largest step of penis or phallus reconstruction without use of thigh or arm flaps. It is often performed with or without:

  • Urethral lengthening (UL)

  • Vaginectomy

  • Scrotoplasty/perineal reconstruction

The most common surgery is metoidioplasty with urethral lengthening, vaginectomy, scrotoplasty, perineal reconstruction, and associated procedures. However, some patients do not need or want UL, and some do not need or want vaginectomy. In these individualized cases, we can offer metoidioplasty without UL, but with everything else; or metoidioplasty without vaginectomy, but with everything else. There are other combinations that better meet a patient's surgical goals, and these will need to be discussed with your surgeons to discuss the pros and cons of each unique combination. 

Further reconstruction of the penis is sometimes required due to variations in anatomy and healing. Examples include:

  • Majora fold reduction (for metoidioplasty patients with prominent upper majora folds)

  • Monsplasty (for prominent prepubic skin leading to perineal or inferior positioning of the penis/scrotum)

  • Scrotoplasty or neoscrotal revisions

  • Penis reposition (for asymmetric scarring) 

  • Penile length reduction (for penises that are too long)

  • Penile Implants

Metoidioplasty is considered a good option for patients who want male external genitalia without the risks associated with phalloplasty. Patients wanting metoidioplasty generally accept a small penis. 


PREOP REQUIREMENTS for metoidioplasty include:

  • Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor).
  • Overall good health.
  • No smoking, nicotine use, or inhalational products (including vaping, marijuana, and 2nd hand smoke) around 3 months before and after surgery (ideally 6 months before and after surgery). This includes chewing tobacco and nicotine free inhalational products. Use of these products can cause about a 5-fold increase in complications. Use within this 3-6 month window before surgery may prompt rescheduling of the surgery to a later time when then the patient has reliably stopped smoking.
  • Perioperative assistance (friends, family, or hired clinical help).
  • No hanging mons/pannus​ (lower abdomen adipose and skin).
  • The ideal anatomy for meta: favorable native phallus response to hormone treatment, minimal surrounding tissue, plentiful minora tissue.
  • Hysterectomy is done separately and should be completed about 3 months prior to metoidioplasty for patients wanting vaginectomy. Getting hysterectomy done simultaneously, although convenient, makes it technically more difficult to perform the vaginectomy portion of the procedure and may increase risk of serious complications. 


General information:

  • Team members: reconstructive urologist, associated surgical and perioperative care staff

  • Duration of surgery: 5 hours

  • Hospital stay: none

    • patients will sometimes stay 1 night

    • rarely do patients require 2 or more days 

  • In town stay: 4 weeks on average

Reconstructive urology portion:

  • Cystoscopy, SP tube insertion: camera that looks into bladder with placement of a catheter through the lower abdomen skin.

  • Note: we use a variation of the "ring" metoidioplasty technique described by Drs. Takamatsu and Harashina.

  • Vaginectomy: removal/fulguration of the mucosa with closure of the canal.

  • Urethral lengthening: minora tissue is used to extend the urethra from where it is currently to the head of the native phallus.

  • Chordee release: the ventral tether is freed to prevent the phallus form being pulled downward. 

  • Transposition of native phallus: the phallus with urethra at the tip and all its associated nerve and blood supply is moved to a more superior location.

  • Scrotoplasty: the majora tissue is dissected free and folded into a pouch that lies more anteriorly--about 10cm away from the anus depending on patient anatomy.

  • Perineal reconstruction: the perineum is the area between the anus and the back of the scrotum. This is reconstructed with inner thigh skin and neighboring genital tissue.

  • Phallus reconstruction: the excess outer minora skin is excised and then sutured in the ventral midline to create a more cylindrical phallus.

Note: This is a generalized description of the procedures, and steps vary depending on patient anatomy, medical/surgical history, and surgical goals.

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