Metoidioplasty


Basics

Metoidioplasty is 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.

Operative technique

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)

Figure 1                   Figure 2                   Figure 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)

Figure 4                   Figure 5                    Figure 6                   Figure 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)

Figure 8                   Figure 9                 Figure 10           Figure 11         Figure 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)

Figure 13                     Figure 14                   Figure 15                  Figure 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.

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.

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




Related articles

 

1. Bizic MR, Stojanovic B, Djordjevic ML. Genital reconstruction for the transgendered individual. J Pediatr Urol 2017;13:446-52.

2. Stojanovic B, Bizic M, Bencic M, Kojovic V, Majstorovic M, Jeftovic M, Stanojevic D, Djordjevic ML. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-6.

3. Stojanovic B, Djordjevic M. Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenfers. Clin Anat. 2015; 28(3):368-75.

4. Djordjevic ML, Salgado CJ, Bizic M, Kuehhas FE. Gender dysphoria: the role of sex reassignment surgery. ScientificWorldJournal. 2014;2014:645109.

5. Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013 May;10(5):1431-8.

6. MiroslavDjordjevic, MD, DusanStanojevic, MD, Marta Bizic, MD, Vladimir Kojovic, MD, Alexandar Milosevic, MD. Urethral reconstruction in metoidioplasty: comparison of three different methods. 2011 WPATH Symposium, Atlanta, GA, USA

7. Bizic M, Majstorovic M, Kojovic V, Stanojevic D, Korac G, Stojanovic B, Djordjevic M, One stage metoidioplasty in female to male transgender patients: the role of genital flaps for urethral reconstruction,EurUrol, Suppl 2010; 9 (2): 107 (249)

8. Bizic M, Majstorovic M, Kojovic V, Korac G, Djordjevic M, Metoidioplasty: sex reassignment surgery in female transsexuals, 21st Video Urology Congress, Egypt, 2010, p20, (II-9)

9. Djordjevic ML, Bizic M, Stanojevic D, Bumbasirevic M, Kojovic V, Majstorovic M, Acimovic M, Pandey S, Perovic S. Urethral lengthening in metoidioplasty (female to male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap. Urology, 2009 Aug;74(2):349-53

10. Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, Perovic SV. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade Experience. J Sex Med., 2009, 6(5):1306-1313.

11. Djordjevic M, Stanojevic D, Bizic M, Majstorovic M, Kojovic V, Martins F, Pandey S. Metoidioplasty as a one-stage gender reassignment surgery in female-to-male transsexuals. Urology, 2009;74(4, suppl 1) S164

12. Kojovic V, Bizic M, Majstorovic M, Kojic S, Stanojevic D, Korac G, Djordjevic M. Combined total phalloplasty and metoidioplasty as a single stage procedure in female to male gender reassignment surgery. EurUrolSuppl, 2009;8(8):648

13. Kojovic V, Djordjevic M, Stanojevic D, Bizic M, Majstorovic M, Pandey S. Single stage metoidioplasty (female to male surgery): the role of genital flaps for urethral reconstruction. Urology, 2009;74(4, suppl 1) S37

14. Vujovic S, Popovic S, Sbutega-Milosevic G, Djordjevic M, Gooren L. Transsexualism in Serbia: a twenty-year follow-up study. J Sex Med., 2009, 6(4):1018-1023.

15. Djordjevic M, Stanojevic D, Bizic M, Majstorovic M, Kojovic V, Pandey S, The purpose of genital flaps in urethral reconstruction in single stage metoidioplasty, 19th World Congress for Sexual Health, Goeteborg, Sweden,2009, p195-196 (PO- 1332)

16. Djordevic M, Stanojevic D, Bizic M, Majstorovic M, Kojovic V. Metoidioplasty: sex reassignment surgery in female transsexuals. J Sex Med 2008;1-149:80

17. Djordjevic M, Perovic S, Reed H. Combined buccal mucosa graft and local flap for urethral reconstruction in female transsexuals. J Urol, 2007; 177(4): 59 (abs. 175)

18. Djordjevic M, Perovic S, Korac G, Bizic M, Majstorovic M. Buccal mucosa graft combined with genital flaps for urethral lengthening in female transsexuals. Urology, 2007; 70(suppl. 3a):166(abs.MP22.01)

19. Perovic S, Djordjevic M. Metoidioplasty: a variant of phalloplasty in female transsexuals. J Urol, 2001; (suppl. 5): 165


Surgical procedure

 

Watch the one-stage metoidioplasty performed by professor Djordjevic

 

Preoperative appearance

 


 

Clitoral lengthening

 

 

 


 

Urethral reconstruction - bulbar part

 


 

Urethral reconstruction - buccal mucosa graft

 

 


 

Urethral reconstruction - clitoral skin flap

 

 

 


 

Urethral reconstruction - labia minora flap

 

 


 

Scrotoplasty / testicular implants

 


 

Final aspects

 


 

Results

 

 

 



 

CASE 1

Result after surgery

 

 


 

CASE 2

8 weeks after surgery

 

 

 


 

CASE 3

Two months after surgery

 


 

 


 

CASE 4

Three months after surgery



 

CASE 5

Five months after surgery

 

 

 


 

CASE 6

Outcome 12 months after surgery, voiding while standing

 


 

CASE 7

Three years after surgery

 

 

 


 

 

CASE 8

Three years after surgery

 

 

 


 

 

CASE 9

Metoidioplasty with small clitoris


Preoperative appearance - small clitoris

 


Good size of the neophallus is achieved

 

Good outcome


 

CASE 10

Outcome after surgery; voiding while standing

 

 



 

 

CASE 11

Voiding while standing

Long-term outcome after surgery.

 

Voiding while standing.


 

 

CASE 12

Outcome 4 weeks after surgery - home photo

 


 

 

 

CASE 13

Outcome 12 months after surgery - home photo


 


 

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