Metoidioplasty using labial advancement flaps for urethroplasty

Abstract

Aim: A variation of the ring metoidioplasty has been performed for masculinizing transgender surgery by the senior surgeon since 2010. It does not require buccal grafts or vaginal wall flaps. An excisional vaginectomy was completed in all patients. We sought to evaluate the urologic outcomes and complications for this technique. Further, we provide a detailed technical description of the technique, including ancillary masculinizing procedures.

Methods: This is a retrospective, single surgeon chart review of all patients undergoing metoidioplasty from 2010 to 2020. Demographics, outcomes, and complications are reported. A self-reported patient questionnaire provided data on patient-perceived urologic outcomes.

Results: Ninety-one patients were included in the study, with 80 (87.9%) patients reporting ability to stand and void with a strong stream. We observed five strictures (5.5%) and one fistula (1%). Scrotoplasty with tissue expanders and testicular implants were performed in 75 (82.4%) patients, while monsplasty was performed in 54 (59%) patients.

Conclusion: Our technique has a low complication rate and patients report a strong urinary stream and the ability to stand in the large majority of cases. Ancillary masculinizing procedures are common. The limitations of metoidioplasty, in general, still persist, which are the small phallus size and variable ability to clear the zipper without lowering the pants to void.

Keywords

Metoidioplasty / urethroplasty / transgender surgery / transmasculine surgery

References

[1] Cohanzad S.Extensive metoidioplasty as a technique capable of creating a compatible analogue to a natural penis in female transsexuals..Aesthetic Plast Surg2016;40:130-8

[2] Djordjevic ML,Stanojevic D.Urethral Lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap..Urology2009;74:349-53

[3] Djordjevic ML.Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery..J Sex Med2013;10:1431-8

[4] Hage JJ.Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals..Ann Plast Surg2006;57:312-6

[5] Hage JJ,Bouman FG.The anatomic basis of the anterior vaginal flap used for neourethra construction in female-to-male transsexuals..Plast Reconstr Surg1993;92:102-8discussion 109

[6] Takamatsu A.Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals..J Plast Reconstr Aesthet Surg2009;62:318-25

[7] Selvaggi G,Ceulemans P.Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty..Plast Reconstr Surg2009;123:1710-8

[8] Djinovic RP.Metoidioplasty..Clin Plast Surg2018;45:381-6

[9] Chen ML,Poh MM.Overview of surgical techniques in gender-affirming genital surgery..Transl Androl Urol2019;8:191-208 PMCID:PMC6626317

[10] Veerman H,Al-Tamimi M.Functional outcomes and urological complications after genital gender affirming surgery with urethral lengthening in transgender men..J Urol2020;204:104-9

[11] Santucci RA.Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence..Clin Anat2018;31:187-90

[12] Morrison SD,Vyas KS,Crane CN.Phalloplasty: a review of techniques and outcomes..Plast Reconstr Surg2016;138:594-615

[13] Al-Tamimi M,Elfering L.Genital gender-affirming surgery in transgender men in the netherlands from 1989 to 2018: the evolution of surgical care..Plast Reconstr Surg2020;145:153e-61

[14] Berli JU.Discussion: genital gender-affirming surgery in transgender men in the netherlands from 1989 to 2018: the evolution of surgical care..Plast Reconstr Surg2020;145:162e-3

[15] Frey JD,Chiodo MV.A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male transgender genital reconstruction: is the “ideal” neophallus an achievable goal?.Plast Reconstr Surg Glob Open2016;4:e1131 PMCID:PMC5222645

[16] Giraldo F,Solano A,Ferrón M.Anatomic study of the superficial perineal neurovascular pedicle: implications in vulvoperineal flap design..Plast Reconstr Surg1997;99:100-8

[17] Elliott SP,McAninch JW.Long-term followup of the ventrally placed buccal mucosa onlay graft in bulbar urethral reconstruction..J Urol2003;169:1754-7

[18] Markiewicz MR,Margarone JE3rd,Chuang SK.Morbidity associated with oral mucosa harvest for urological reconstruction: an overview..J Oral Maxillofac Surg2008;66:739-44

[19] Hage JJ.Metaidoioplasty: an alternative phalloplasty technique in transsexuals..Plast Reconstr Surg1996;97:161-7

[20] Stojanovic B,Bencic M.One-stage gender-confirmation surgery as a viable surgical procedure for female-to-male transsexuals..J Sex Med2017;14:741-6

[21] Hoebeke P,Ceulemans P.Impact of sex reassignment surgery on lower urinary tract function..Eur Urol2005;47:398-402

[22] Small MP.Use of tissue expanders in genitourinary reconstructive surgery for transsexuals. Proceedings of the eleventh Harry Benjamin International Gender Dysphoria Association Symposium.1989;Cleveland, OH67