Metoidioplasty and EXPLORING YOUR SURGICAL OPTIONS Objectives

• REVIEW your surgical options

• UNDERSTAND the objectives of genital

• LEARN about prevention and treatment of possible complications Decision-Making Considerations for Genital

Appearance • Length • Width • Donor Site Scar (phallo)

Complications/Risks Function • Urethral Lengthening • Stand to pee • Graft (phallo) • Sexual • Flap (phallo) • Fertility • Implants • Unresolved dysphoria Genital Surgeries PHALLOPLASTY o Surgery that reshapes and o Surgery that creates a new releases the existing phallus phallus from other tissue (donor site) Associated Surgeries o Urethral reconstruction o Removal of uterus, ovaries, and/or vaginal canal () o Fertility preservation considerations – Ob/Gyn referral available, if interested o Creating a scrotal sac +/- implants o Penile implants (phalloplasty only) Urethral Reconstruction o The is the tube that carries urine from the bladder to the outside of the body o Genital surgeries can include lengthening the urethra o from natal position to base of phallus o through the phallus Associated Surgeries Fallopian tube Vaginectomy o removal and closure of Ovary o Removal of the uterus Uterus Salpingo- o Removal of fallopian tubes and ovaries Fertility and Hormone Considerations o Consultation with an Ob/Gyn for discussion If urethral lengthening: Associated Surgeries o Hysterectomy can be done separately, or combined with metoidioplasty or 1st stage of phalloplasty o In patients seeking urethral lengthening, vaginectomy is required Then vaginectomy and hysterectomy required: o If vaginectomy is planned, hysterectomy is required o Oopherectomy is not required for any genital surgeries Metoidioplasty Overview Metoidioplasty Defined Goal Use existing genital tissue to create a more o cylindrical shaft appearance for the phallus

Technique Phallus () is released from surrounding o ligaments and skin

Phallus is reshaped to make it more prominent; o phallus maintains current length and width

o Preserve current sensation and nerves (no nerves are cut) Metoidioplasty: Testosterone and phallus length o Testosterone causes a variable amount of phallus (clitoris) growth o Maximum growth is usually achieved within 1-2 year after starting testosterone o Maximum growth from testosterone is usually 1-3 centimeters, but this is variable o Overall length of phallus after meta is determined by testosterone effect not by surgery Metoidioplasty Options: Meta without Urethral Lengthening

What is meta without urethral lengthening? o Current phallus is released and shaped into a shaft o No routing of the urethra through phallus o Can include , vaginectomy, and hysterectomy nd o Testicular implants placed in 2 outpatient surgery scheduled at least 3 months after initial surgery Metoidioplasty Options: Meta with Urethral Lengthening

What is meta with urethral lengthening? o Current phallus is released and shaped into a shaft and urethra routed through phallus o Can include scrotoplasty, vaginectomy, and hysterectomy nd o Testicular implants placed in 2 outpatient surgery scheduled 3 months after initial surgery Metoidioplasty Considerations

META WITHOUT URETHRAL LENGTHENING META WITH URETHRAL LENGTHENING o Least time in the operating room o Less time in operating room than of genital surgery options phalloplasty o Shortest recovery time of genital o Urethral surgery increases surgery options chances of urinary complications No change in urination (ie, o o Standing to urinate is a goal, standing to urinate is not a goal) more likely if BMI is normal and phallus protrudes beyond surrounding tissue Phalloplasty Overview Phalloplasty Staging Phalloplasty is a series of surgeries o The number of surgeries depends on surgical goals and donor site, with the possibility of more surgeries if complications arise o Total surgery timeline depends on recovery process; can be up to 1-3 years before all surgeries are complete o Important to consider time off work required, multiple hospital stays, financial needs Sample Surgical Staging Pathway Radial Forearm Flap (Double Tube) with Urethral Lengthening

Stage 1 (Plastic Surgeons, Gynecologist, Urogynecologist) 1) Vaginectomy / hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) (Approximately 6 weeks after Stage 1 + 2) 3) +/- Scrotoplasty Post-Op Check (Urologist) 4) Local Urethral Lengthening 1) VCUG (urinary xray) 5) Suprapubic Catheter 2) Removal of Suprapubic Catheter (Wait at least 3 months for healing) (May be repeated) Stage 2 1) Phallus construction (flap) with new urethra tube inside 2) Glansplasty 3) Suprapubic Catheter

Stage 3 (Urologist) 1) Penile Implants 2) Scrotal Implants (Wait at least 9-12 months until implants) 3) +/- Glansplasty Sample Surgical Staging Pathway Anterior Lateral Thigh Flap (Single Tube) with Urethral Lengthening

Stage 1 (Approximately 6 weeks after Stage 1 + 5) 1) Vaginectomy / hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) Post-Op Check (Urologist) 3) +/- Scrotoplasty 1) VCUG (urinary xray) 4) Local Urethral Lengthening (Suprapubic Catheter) 2) Removal of Suprapubic Catheter (May need to be repeated) Stage 2 Phallus construction (flap) as single tube

Stage 3-4-5 (Wait at least 3 months for healing in Tubularization of Flap between each stage 1-5)

Stage 5-6 1) Urinary hook up 2) Suprapubic Catheter 3) Glansplasty

Stage 6-7 (Urologist) 1) Penile Implants (Wait at least 9-12 months for healing until implants) 2) Scrotal Implants Sample Surgical Staging Pathway Radial Forearm Flap or Anterior Lateral Thigh Flap (single tube) WITHOUT Full Urethral Lengthening

Stage 1 (Approximately 6 weeks after Stage 1 + 2) 1) Vaginectomy / Hysterectomy / +/- salpingo-oophorectomy 2) Glans/shaft release (similar to meta) Post-Op Check (Urologist) 3) +/- Scrotoplasty 1) VCUG (urinary xray) 4) Local Urethral Lengthening 2) Removal of Suprapubic Catheter 5) Suprapubic Catheter

Stage 2 1) Phallus construction (flap) as single tube 2) Urethra placed at base of phallus (or scrotum if present)

Stage 3 (Urologist) 1) Penile Implants 2) Scrotal Implants Wait at least 9-12 months

Phalloplasty without Urethral Lengthening Considerations: o Urinate from base of phallus or under scrotum; standing to urinate not possible o Fewer urinary complications Radial Forearm (RFA) Phalloplasty Flap removed from forearm Superficial Inner tube l Deep

Thickness of Penis (Diameter) = -4 x flap thickness Drs. Lin and Safa, 2020 oBlood vessel test to ensure forearm is eligible donor site RFF Surgery Summary o Creating the flap from the forearm o Resurfacing the forearm with skin graft from the thigh o Transplanting the forearm flap to the groin o connecting vessels, nerves, and urethra RFF Healing Three healing sites: oForearm (Donor Site) o Skin graft covers part of forearm where flap came from oSkin graft donor site (usually upper thigh) o Heals over several months oPhallus o Expect swelling and bruising after surgery Forearm: Healing and Rehabilitation o Initial Skin Graft Healing o Wound vac for 1 week o Daily dressing changes o Splint for 1 month o Minimizing Edema o Postoperative swelling (edema) occurs as a result of the surgical flap harvest and reduction in drainage of the hand o Compression and Hand therapy to restore hand function o Final Cosmetic Result o Step off at juncture of skin graft is thinner than surrounding forearm Forearm: Healing and Rehabilitation Skin Graft Donor Site: Healing

st o 1 Phase: Daily dressing change (4-6 weeks) nd o 2 Phase: Apply moisturizer and sunscreen 1st Phase: Hospital Recovery and Monitoring 5-7 days

• Bedrest • Frequent blood vessel checks of flap

2nd Phase: Recovery at home First few months

Phallus Healing • Limited mobilization • Elevation of phallus for first few months • Suprapubic Catheter in for about 2 months • Monitoring for urine leak and skin healing

3rd Phase: Monitor for Additional Revision After 3 months

• Persistent urine leak • Glansplasty – initial or revision RFF Phalloplasty Results

Glansplasty images from Journal of Sexual Medicine – Sommeling et al. RFF Images Copyrighted by Buncke Clinic Thigh Phalloplasty

PEDICLED ANTEROLATERAL THIGH FLAP Thigh Phalloplasty: Pedicled ALT Flap Thigh Phalloplasty: Pedicled ALT Flap

1cm thick flap

Single tube (no internal urethra) ALT Surgery Summary o Creating the flap from the thigh o Resurfacing the thigh with skin graft from the other thigh o Tunneling the thigh flap to the groin o connecting nerves and urethra (vessel stay attached) ALT Healing Three healing sites: o Thigh (Donor Site) o Skin graft covers part of thigh where flap came from o Skin graft donor site (usually upper thigh) o Heals over several months o Phallus oExpect swelling and bruising after surgery Thigh Flap Donor Site: Healing & Rehabilitation o Initial Flap Donor Site Healing o Wound vac for 1 week o Daily dressing changes o Minimizing Edema o Postoperative swelling (edema) occurs as a result of the surgical flap harvest and reduction in drainage of the leg o Compression and elevation to restore leg function o Final Cosmetic Result o Step off at juncture of skin graft is thinner than surrounding thigh Skin Graft Donor Site: Healing

st o 1 Phase: Daily dressing change (4-6 weeks) nd o 2 Phase: Apply moisturizer and sunscreen 1st Phase: Hospital Recovery and Monitoring 5-7 days

• Bedrest • Frequent blood vessel checks of flap

2nd Phase: Recovery at home ALT Phallus First few months Healing • Limited mobilization • Elevation of phallus for first few months

3rd Phase: Additional stages for urinary reconstruction 4-6 months after initial surgery

• Glansplasty • Rolling up of flap to create urethra ALT Phalloplasty Results

Images Copyrighted by Buncke Clinic RFF and ALT Results Compared

Images Copyrighted by Buncke Clinic Sensation after Phalloplasty o Goal is to have protective sensation and erogenous sensation o Sensation at base of phallus o Glans / clitoris positioned inside phallus o One sensory nerve from glans / clitoris is maintained o Sensation in the shaft of the phallus o One sensory nerve is connected to sensory nerve from flap for sensation to the phallus o 1-2 years for nerves to regrow down length of phallus o It’s common to have areas of numbness and incomplete sensation o Until there is adequate protective sensation phallus skin is at risk of injury so important to monitor regularly for swelling and color changes Associated Surgeries Scrotoplasty and Implants (Surgical Option with Meta or Phallo) Scrotoplasty o Creation of a scrotal sac using skin from the

Testicular Implants o Implants usually placed in final stage of surgery when all surgical healing is complete o Implants are typically saline filled (Phalloplasty Only)

There are two penile implant options

Semi Rigid Rod Inflatable Implant Post-Operative Monitoring (Meta/Phallo Both) General Surgical Complications

o Infection o Delayed Skin Healing o Abnormal Swelling / Bleeding or Hematoma o Thick Scars Urinary Considerations: Bladder Spasms o This frequently occurs when there is a catheter in place. o The symptoms often mimic those of a urinary tract infection: lower pelvic pain and spasms, frequency and urgency. o If you are having these symptoms, you may need anti-spasm medication and a urine test. Urinary Complications: Stricture o Scar that develops in the urethra. o Narrows the urethra and blocks urine flow. o Inability to urinate requires immediate medical attention o Often requires additional surgery to repair Urinary Complications: Fistula oWhen urine exits through a second opening other than the end of the urethra oMay heal by itself; if not healed within 3 months additional surgery required to close the opening Phalloplasty Healing o Portions of phallus skin may not heal well and may require revision o skin grafted sites may take longer to heal than expected Surgical Complications with Implants o Scrotal/Penile extrusion o Implant pushes out of scrotal sac or through tip of phallus o Infection o If implant becomes infected it usually requires immediate surgery to remove it o Pain o Implant can sometimes be positioned in such a way that causes pelvic pain (by poking or jabbing into the pelvis during sex) or it can sometimes sit on a nerve causing pain. o Insufficient firmness / insufficient softness o Degradation o Device can malfunction or wear out over time requiring replacement after 5-10yrs o Displacement of implant o Testicular implants sometimes ride too high in the new-scrotal pouch. Optimizing recovery after surgery  Stop nicotine products prior to surgery  Healthy nutrition and body movement/exercise before surgery  Follow all discharge instructions  Attend all follow up appointments  Be in touch with surgeon if you have any concerns about healing  Keep the surgical area clean and dry  Listen to your body and check in with surgeon before resuming activities FAQ/Questions What if I have metoidioplasty and later want to have phalloplasty? o Yes. The first stage phalloplasty is very similar to metoidioplasty with urethral lengthening. If metoidioplasty is completed without urethral lengthening there may not be enough tissue to do a urethral lengthening later. What’s the best way for a person to have a successful urethral lengthening with phalloplasty? o RFF with a double tube. It is difficult and may not be possible with and ALT donor site. How much of my forearm length can be used for phalloplasty? o About half the length of the forearm.