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

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• Urethral lengthening (UL)

• Vaginectomy

• Scrotoplasty/perineal reconstruction

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The most common combination of surgeries includes metoidioplasty with UL, vaginectomy, scrotoplasty, perineal reconstruction, and associated procedures (skin graft harvest, suprapubic tube insertion, and others). However, some patients do not need or want UL, and some do not need or want vaginectomy. Others may not want a pouchlike scrotum. We recognize that surgical goals vary from patient to patient and there are resultant combinations that better meet a patient's individualized surgical goals. A consultation with the surgeon is required to discuss the advantages and disadvantages of each unique combination. 

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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)

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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:

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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.
• Perioperative assistance (friends, family, or hired clinical help).
• No hanging mons/pannus​ (lower abdomen adipose and skin).
• The ideal anatomy for meta: favorable tissue growth in 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. 

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PROCEDURE OVERVIEW:

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General information:

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

• Duration of surgery: 5 hours

• Hospital stay: none; this is generally an outpatient procedure

  • Patients will occasionally 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 penis.

• Chordee release: the ventral tether is freed to prevent the penis from being pulled downward. 

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

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

• 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.

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

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