RECONSTRUCTIVE UROLOGY

Urethral lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap
Djordjevic ML, Bizic M, Stanojevic D, Bumbasirevic M, Kojovic V, Majstorovic M, Acimovic M, Pandey S, Perovic SV
Belgrade Center for Genital Reconstruction, University of Belgrade, Serbia
Urology. 2009; 74: 349-53

• Objectives: To develop a technique for urethral reconstruction using a combined labia minora flap and buccal mucosa graft. Urethral lengthening is the most difficult part in female transsexuals and poses many challenges.
  Methods: From April 2005 to February 2008, 38 patients (aged 19-53 years) underwent single-stage metoidioplasty. The technique starts with clitoral lengthening and straightening by division of both clitoral ligaments dorsally and the short urethral plate ventrally. The buccal mucosa graft is quilted to the ventral side of the corpora cavernosa between the native orifice and the tip of the glans. The labia minora flap is dissected from its inner surface to form the ventral aspect of the neourethra. All suture lines are covered by the well-vascularized subcutaneous tissue originating from the labia minora. The labia majora are joined in the midline and 2 silicone testicular implants are inserted to create the scrotum. The neophallus is covered with the remaining clitoral and labial skin.
  Results: The median follow-up was 22 months (range 11-42). The median neophallic length was 5.6 cm (range 4-9.2). The total length of the neourethra was 9.4-14.2 cm (median 10.8). Voiding while standing was reported by all 38 patients, and temporary dribbling and spraying were noted by 12. Two fistulas and one urethral erosion resulted from the testicular implant and required secondary revision.
  Conclusions: A combined buccal mucosa graft and labia minora flap present a good choice for urethral reconstruction in female-to-male transsexuals, with minimal postoperative complications.

• Editorial Comment
  Belgrade has established itself as one of the premier centers for urologic reconstruction. Specifically, they have pushed advances in female-to-male sex reassignment surgery. In this article, accompanied by several instructive photographs, they describe the technique and results of the metoidoplasty with urethral lengthening using buccal mucosa. This technique represents a departure from the radial forearm free flap technique. Instead, they rely on pre-operative clitoral lengthening with a combination of androgens and a vacuum pump. The enlarged clitoris is freed from its ligamentous attachments and the urethral plate is divided to achieve adequate length. This leaves a urethral defect of several centimeters, which is then bridged with a dorsal buccal graft, and a ventral onlay of labia minor flap.
  From a reconstructive standpoint, this is really a sensible and beautiful operation. It employs techniques familiar to the urethral reconstructionist. Many of the men are able to obtain erections postoperatively, although none was sufficient for penetration. All were able to void in the standing position. Hopefully this variation of the metoidoplasty can offer a relief from the complications of urethral construction associated with previous female-to-male transsexual procedures. We look forward to hearing long-term results.

Dr. Sean P. Elliott
Department of Urology Surgery
University of Minnesota
Minneapolis, Minnesota, USA
E-mail: selliott@umn.ed