Transsexualism - Metoidioplasty

Preoperative Appearance
Despite there is a long time since its beginning, female-to-male sex reassignment surgery remain very challenging and demanding. There is still no perfect procedure for making male genitalia in female transgender patients. However, that gives us more obligations to strive for better solutions.
Metoidioplasty is the only procedure that enables creation of penoid with completely preserved protective as well as erogenous sensitivity. Simultaneously, scrotum is created from labia majora with two implanted testicular prostheses to imitate testicles. The goal of Metoidioplasty is forming of neophallus that looks like small penis and enables voiding in standing position. This is possible due to similar embryological development of male and female external genitalia. Although this way created neophallus it is not sufficiently large to enable sexual intercourse with vaginal penetration, significant number of transgender patients are satisfied with this solution (approximately 30% in our experience). Also, some of them are not willing to undergo great surgery and big scars that are coupled with total phalloplasties. Anyway, we noted that one part of them change their mind later and underwent total phalloplasty.

Indications and limitations:

The procedure is used in female transsexuals who wish one-stage SRS without having complex, multistage total phalloplasty or who want this procedure later. Clitoris has to be large enough, i.e. length over 2 cm in stretched position and without severe obesity to satisfy patient’s wish for voiding in standing position. Labia minora should be normally developed in order to use it as an onlay flap.  If mons pubis is prominent, simultaneous liposuction should be performed to allow better neophallic exposure.

Fig.1(a) Lines of incision show design of urethral plate (UPF) and labia minora flaps (LMF)
Fig.1(b) Area for deepithelezation of outer surface of labia minora is marked

Operative technique

The procedure starts with removal of internal genitalia through vaginal approach.
Vagina is completely removed starting with circumferential incision of vestibulum and its dissection from bladder anteriorly and rectum posteriorly.
After ligation of uterine vessels, follows removal of uterus, tubes and ovaries.
In some patients internal genitalia are removed laparoscopically.
Perimeatal part of anterior vaginal wall is left for 2-3 cm in depth and carefully mobilized from urethra preserving its lateral blood supply; it is used later as a ventral flap for proximal part of neourethra, analog to bulbar urethra in males (fig.1).




Fig.2 Subtotal division of suspensory clitoral ligament with preservation of the skin
Two longitudinal parallel incisions at least 2 cm apart are made along “urethral plate”, starting from native urethral meatus till subcorolal level of clitoris (fig.2)


Fig.3 Fixation of clitoral base skin to the albuginea for prevention of its retraction




















Fig.4 Proximal part of urethra is created from mobilized urethral plate and vaginal flap
Fig.5 Vaginal mucosa graft: (a) epithelial surface, (b) raw surface

























Fig.6 Gap created after division of urethral plate is grafter with vaginal mucosa (VMG).
Fig.7 Labia minora flap (LMF) is onlayed over vaginal mucosa graft (VMG) for pendular urethra reconstruction. Deepithelialized outer surface of LMF is visible


























Fig.8 Testicular prostheses are implanted through oblique lateral incisions above labia majora in order to decrease tension on suture line Appearance at the end of surgery (a,b)
Fig.9 one-year later. Ch 16 urethral catheter is easily passed through the neourethra


   
Outcome two years




































Fig.10 Vacuum device for pre and postoperative penoid stretching
Vacuum device  was recommended for at least 6 months, starting 4 weeks postoperatively in order to lengthen neophallus during healing process.

Results

Statistical results on 53 patients between 2004-2008 showed neophallus length ranged from 3.5-7cm (mean 4.5) in stretched position. Voiding in standing position was reported in all patients. Erection was preserved in all according to the interview which was also confirmed by PGE1 test. Protective and orgasmic sensitivity was demostrated in all patients Temporary spraying of urine during voiding was reported by 18 patients and resolved spontaneously in all 3-6 months after surgery. Two patients developed fistula after infection and 3 short strictures on anastomosis between vaginal and labial flaps, probably due to impaired vascularity. They were treated by small additional surgery and normal voiding is reestablished in all. Voiding uroflowmetry was in normal range (18-28 mL/sec) in all patients including patients with complications after their repair.  Two patients had testicular prosthesis protrusion which required its removal and later reimplantation.

Related Arguments:

  • Transgender
  • Sava Perovic technique
  • Metoidioplasty




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