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 phallus.
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 may be done at the same time if not done prior. However, we strongly recommend getting hysterectomy done separately and 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.
Team members: reconstructive urologist, occasional gynecologist (for hysterectomy), associated surgical and perioperative care staff
Duration of surgery: 4-6 hours
Hospital stay: less than 1 day (outpatient); patients will sometimes stay 1 night; rarely do patients require 2 or more days
In town stay: 3-4 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.
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.