Metoidioplasty involves the creation of a neophallus out of a hormonally hypertrophied clitoris. The primary goal of metoidioplasty is allowing the patient to void while standing. In this video, we will demonstrate our metoidioplasty technique with particular emphasis on the surgical steps related to urethral reconstruction.

The patient was a 27-year-old transgender man. He was not interested in penetrative sexual intercourse and his primary aim was to stand to void. He wanted to avoid a complicated and multi-staged reconstruction which is typical of flap-based phalloplasty. Therefore, we elected to proceed with metoidioplasty. A suprapubic tube was inserted at the start of the case. The clitoris was released and lengthened by the division of its fundiform and suspensory ligaments. The urethral plate was dissected off the ventral aspect of the clitoral corpora and then divided in order to further release and lengthen the clitoris. A flap was harvested from the anterior vaginal wall to lengthen the native urethra. Remaining vaginal mucosa was treated with electrocautery, and colpocleisis was performed using spiral sutures. The vaginal wall flap was sutured to the proximal part of the divided urethral plate. The dorsal aspect of the distal neourethra was constructed by the dorsal inlay and quilting of the buccal mucosa graft (BMG) over the clitoral corpora. The medial epithelial surface of the labia minora flap (LMF) was joined to the BMG by two lateral running sutures over an 18 Fr. catheter to create the ventral aspect of the distal neourethra. The other LMF was then sutured over the proximal portion of the neourethra to create another layer of coverage. Care was taken to place extraluminal stitches during all phases of urethral reconstruction. Glansplasty, perineoplasty, and scrotoplasty concluded the procedure. Implantation of testicular prostheses was planned as a separate procedure.

The operation lasted 375 minutes and the estimated blood loss amount was 400 ml. The patient was discharged on postoperative day 5 after an unremarkable course. The urethral catheter was removed in 3 weeks after documenting urethral patency on retrograde urethrography. Suprapubic tube was removed after an additional 4 weeks, during which the patient voided through his neourethra without issue. Follow-up duration was 6 months and no complications were reported during this time period. He was able to void while standing and did not report any urinary issues at the last follow-up.

Metoidioplasty denotes neophallic reconstruction in the transgender men from the hormonally hypertrophied clitoris with the goal of voiding in standing position. Lengthening the native urethra in a longitudinal fashion with the use of an anterior vaginal wall flap and neourethral tubularization using a combination of BMG and LMF represent a potentially applicable way to achieve this goal.