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:

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• 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. 

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PROCEDURE OVERVIEW:

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General information:

• 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.

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