Top 5 Questions to ask your surgeon about Metoidioplasty
Written by Michael H Safir, MD, Crane Center
1. Am I a good candidate for metoidioplasty?
Most patients ask this question, but I secretly believe that they already know the answer. If there has been significant growth of the shaft and head of the phallus while on testosterone and they are able to see the phallus with a mirror with the legs spread apart, they are likely a good candidate. If growth of the phallus is minimal, it may be difficult to route the urethra to the tip of the phallus, but for patients who want a simple metoidioplasty (no urethral lengthening), metoidioplasty may still be a good option.
Patients who want to provide insertional sexual intercourse may be better suited to phalloplasty. Patients who have significant concealment of their phallus from adjacent fat may become candidates if pre-metoidioplasty surgery removes fat or if they lose substantial weight.
Provide your surgeon photos aimed at your current phallus. The surgeon’s office can tell you how to take these photos.
2. What other operations do you do and what percentage of your practice is metoidioplasty?
As interest in gender affirming surgery has increased, there has been a commensurate increase in the pool of surgeons performing these procedures, each with a unique set of skills and training. It is OK to ask what percentage of your surgeon’s practice is bottom surgery for trans-males and it is OK to ask how many metoidioplasty operations the surgeon has performed. Personally, 100% of my surgeries at Crane Center are masculinizing bottom surgeries and 20% are metoidioplasty. I have performed more than 480 gender confirmation surgeries in the past 3 years.
3. What type of metoidioplasty do you do and what can I do to achieve maximum length?
Here is where it gets confusing. Hold on, it may get bumpy! Try not to get mired down in terminology – most confusing words are marketing efforts to distinguish one surgeon’s procedure from another’s. You want to know (1) how do you make the phallus larger - do you release tissue from the underneath of the phallus, on top of the phallus or both? (2) how do you lengthen the urethra – do you use minora tissue, buccal (cheek) mucosa or both? (3) how do you do the vaginectomy – do you remove the lining, cauterize it or both? (4) how do you make the scrotum – will it look like a scrotum in front of your thighs (hint, this is what you want) or will the tissue still be anchored between your thighs? (5) can you make it longer by releasing suspensory ligaments to the pubic bone – do you have experience with this procedure and can you do this without the possibility of injury to the neurovascular bundle to the head of the phallus? (6) can anything be done to “bulk up the phallus” – how is this done?
While this is not an exhaustive list, it will provide you a firm foundation to understand the way your procedure will be done and how it might differ from another surgeon’s technique.
4. Can I keep my vagina and still have metoidioplasty?
The short answer is: Yes. The long answer is that experienced metoidioplasty surgeons can offer metoidioplasty options that allow you to keep your vagina (and your uterus if you want). The most important issue to consider is whether you want to pee from your current urethral opening or if you want to pee from the tip of your new phallus (called urethral lengthening). If you opt to have urethral lengthening and you wish to retain your vagina, there is a higher risk of urethral complications (mostly urethral fistula) than if you had chosen to undergo vaginectomy (closure of the vagina).
5. Can have my hysterectomy done the same day?
Again, the short answer is: Yes. Since most of our patients travel from significant distances, we have offered synchronous metoidioplasty and hysterectomy (both procedures on the same day). The procedure begins with the hysterectomy and ends with the metoidioplasty. We advise most patients to stay overnight – patients are usually discharged early the next morning.
Dr. Michael Safir is a Diplomate of the American Board of Urology in Female Pelvic Medicine and Reconstructive Surgery. He graduated from Northwestern University in the Honors Program in Medical Education where he received his Bachelors and Medical Degrees. Dr. Safir completed his urology residency at Northwestern University and was awarded the Dr. Susan Perlman Award as the senior resident, among all specialties at the Northwestern Memorial Hospital, “who best exemplified academic excellence, special leadership skills and compassion for patients.” He was selected to complete two separate year-long fellowships in Male (UCSF) and Female (UCLA) Genito-urinary Reconstructive Surgery. Dr. Safir has served as Section Chief of Reconstructive Urology at New York Medical College and as a Clinical Instructor in Urology at both UCLA and UCSF. He is one of a handful of urologists in the world with individual fellowship training and experience in both male and female genital reconstruction. Dr. Safir offers Metoidioplasty and Phalloplasty at the Crane Center in San Francisco. He is a member of WPATH.