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Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening

International Journal of Impotence Research volume 34, pages 120–127 (2022)Cite this article

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Abstract

Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors’ preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.

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Fig. 1: Intraoperative planning.
Fig. 2: Clitoral release.
Fig. 3: Transecting the native urethral plate.
Fig. 4: Vaginal wall flap harvest.
Fig. 5: Grafting the dorsal neourethral plate with buccal mucosal tissue.
Fig. 6: Preparation of left labial flap.
Fig. 7: Preparation of right labial flap.
Fig. 8: Immediate postoperative appearance.

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Authors and Affiliations

  1. University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA

    Ervin Kocjancic, Omer Acar & Susan Talamini

  2. Weiss Memorial Hospital, Center for Gender Confirmation Surgery, Division of Plastic and Reconstructive Surgery, Chicago, IL, USA

    Loren Schechter

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  1. Ervin Kocjancic
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  2. Omer Acar
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Correspondence to Omer Acar.

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Kocjancic, E., Acar, O., Talamini, S. et al. Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening. Int J Impot Res 34, 120–127 (2022). https://doi.org/10.1038/s41443-020-0259-z

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