Trans men generally have two choices for genital surgery: metoidioplasty and phalloplasty. Phalloplasty (creation of a penis with tissue grafts) will be a topic for another day; metoidioplasty (“Meta”) is more common and less expensive. Depending on the needs of the individual, a meta can involve the following:
- Clitoral release: removing tissue and ligaments from the clitoris, allowing it to hang freely, in the correct position for a penis
- Urethral reconstruction: lengthening the urethra and surgically inserting it into the new penis (formally the clitoris)
- Vaginectomy/Scrotoplasty: removing the vagina (vaginectomy) and creating a scrotum using the labia tissue (scrotoplasty), potentially including testicular implants
- Hysterectomy (removal of the uterus and/or cervix) and oophorectomy (removal of the ovaries and/or fallopian tubes) can also be done at this time
Dr. Djordjevic and Dr. Bizic recently compared two different methods of urethral lengthening at their clinic in Serbia. Urethral lengthening is the most technically challenging aspect of a meta. Complication rates can be high; this particular study cites a rate of 22% in previous studies. Part of the challenge is finding tissue to use for the new section of urethra (male urethras are much longer than female urethras; a different of perhaps 15 cm). So where do you find it? One of the options is buccal tissue, the tissue on the inside of the cheek. Have you ever scraped something like a q-tip inside your cheek, either for looking at the cells in a microscope or for a DNA test? That’s buccal tissue. Buccal tissue has previously, and successfully, been used in urethral lengthening surgeries for the treatment of hypospadias (when a male-bodied person’s urethra doesn’t come out the tip of the penis). Buccal tissue was used in both techniques in this study. But buccal tissue isn’t quite enough. One method used tissue from the underside of the clitoris/neopenis, the other used tissue from the labia minora. But before the results, let’s look at the study’s participants and the methodology.
207 trans men, with an average of 3.7 years on hormone therapy, had metoidioplasty with one of the two methods. Before the surgery, they were instructed to use dihydrotestosterone cream and a vacuum pump for three months to increase the size of their future penis. The surgery was a single stage surgery, including all the options I listed above: urethral reconstruction, vaginectomy, scrotoplasty with testicular implants, and hysterectomy/oophorectomy.
Participants chose their surgical method, so this was not random assignment. 49 (24%) of the participants had the clitoris/neopenis method. The other 158 (76%) participants had the labia method. Follow up varied, but ranged from 12 months to nearly 10 years, averaging around 3 years. There was no different in the time the surgeries took (roughly 4 hours).
So how about the surgical results? All the participants had good sensation and were satisfied with the appearance. No sexual problems were reported, though they generally were not able to have penetrative sex. Participants who had the labial method surgery had a longer penis than participants who had the clitoral/neopenis method surgery (5.9 cm vs 5.2 cm). Likewise, participants who had the labial method surgery reported a better ability to pee while standing.
There were no major complications. Minor complications included urethral fistulas (7.7% of the participants), testicular rejection (2%), testicular displacement (6.7%) and urethral stricture (3%). All were corrected with minor procedures. Some minor complications resolved on their own (e.g., dribbling/spraying while peeing). More urethra fistulas were reported in the clitoral/neopenis method group than in the labial method group. 19 participants (9%) chose to have esthetic (appearance-based) adjustments, and 13.5% chose to later have a phalloplasty to allow for penetrative sex. Dr. Djordjevic and Dr. Bizic also note that complications happened anywhere from a few months to years after surgery. Because of the long timeframe, they recommend “permanent follow-up.”
In all, this study supports using buccal and labial tissue as a superior metoidioplasty method rather than using buccal and clitoral tissue. Trans men should consider these results, as with all surgical information, when considering metoidioplasty.