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.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

“…Modifications to the metoidioplasty have been described to decrease rates of stricture and fistula. Meltzer and Esmonde described their experience with ring metoidioplasty, reporting a 6% stricture and 1% fistula occurrence rate in their series of 91 patients with a resultant success of 88% (80 patients) defined as patients endorsing standing to void with an adequate stream (21). In this series, the fistulae spontaneously resolved without intervention.…”

“…All five patients with strictures required surgical intervention: two with BMG urethroplasty and three with single urethrotomy followed by self-intermittent dilation. No longer-term follow-up of these patients has yet been reported (21). Another series of retrospective ring metoidioplasty outcomes demonstrated an incidence of 13% (n=7) of urethrocutaneous fistula and a stricture rate of 8% (n=4) in a 51 patient cohort (17).…”

“…Several metoidioplasty techniques have been described (5,(17)(18)(19)(20)(21). At our center, most patients undergo a modified Belgrade-style metoidioplasty with urethral lengthening (17,18).…”

“…As an alternative to metoidioplasty with graft urethroplasty, surgeons may reconstruct the urethra utilizing the epithelium of the bilateral inner labia which are tubularized to create the ventral and dorsal urethra ("ring metoidioplasty") (19,20). Modifications to the ring metoidioplasty have been described to avoid use of vaginal flaps and decrease urethral complications (21).…”

Genital Gender Affirming Surgery

“…While this can be performed at the time of metoidioplasty, performing monsplasty at a separate setting (before or after metoidioplasty) may avoid disruption of penile and scrotal vasculature/lymphatics and avoid excessive tension on the penis at the time of index metoidioplasty. 8,13…”