Metoidioplasty is an operation to construct a phallus sufficient for voiding standing up in a transgender man. This operation is performed after a patient who was born female or intersex has undergone psychologic assessment and has decided to take male hormone (testosterone) to phenotypically match their identified gender male. Preoperative clitoral hypertrophy is essential to the success of achieving voiding while standing. This video reflects a variant of the operation because no laminectomy was performed at the patient's request. This technique would increase the risk of proximal fistula.
Dr. Zhao: This video describes how the hypertrophied clitoris can be transformed into a male-appearing phallic organ that allows for standing to void. For those in the audience that are unfamiliar with gender-affirming surgery, there are many similarities between metoidioplasty and proximal hypospadias repair. Division of the vaginal mucosa results in release of a “chordee,” and straightening of the clitoris. This division results in a gap between the native female urethra and the distal glans that is bridged by a tubularized flap of labia minora. The neourethral reconstruction is then buttressed by a flap of de-epithelialized labia minora. Reduction of mons pubis via monsplasty helps to accentuate the appearance of a prominent phallus.
Dr. Hotaling: Here, Dr. Grotas demonstrates how a hypertrophied clitoris can be reconstructed to allow a standing void. The most important take-home point of this video is how crucial the maintenance of proper anatomic planes is in reconstructive gender confirmation surgery. This allows the reconstruction of a neo-urethra from existing tissue.
David Shi, MD, is a urology resident and Aaron Grotas, MD, is clinical assistant professor of urology at the Icahn School of Medicine at Mount Sinai, New York. Dr. Grotas is also the urologist at the Center of Transgender Medicine and Surgery at Mount Sinai. Miroslav L. Djordjevic, MD, PhD, is professor of urology and surgery at the School of Medicine, University of Belgrade, Serbia.