Simple Metoidioplasty Without Urethral Lengthening
Simple metoidioplasty creates a sensate neophallus from the hormonally hypertrophied clitoris while deliberately leaving the urethra in its native position. The trade is explicit: the patient gives up standing micturition in exchange for a much lower urethral complication burden than metoidioplasty or phalloplasty with urethral lengthening (UL).[1][2]
This is the atlas page for the no-UL metoidioplasty pathway. For the broader cohort-level decision framework, see Masculinizing Gender-Affirming Surgery; for the clinical overview of masculinizing procedures, see Masculinizing Procedures.
Indications
Simple metoidioplasty is best suited for patients who prioritize erogenous sensation, lower morbidity, and preservation of future phalloplasty options over standing micturition or penetrative rigidity.[1][3]
| Patient Priority | Fit for Simple Metoidioplasty |
|---|---|
| Preserved erogenous sensation | Excellent fit; native clitoral neurovascular supply is preserved |
| Lower urethral morbidity | Excellent fit; UL is omitted |
| Standing micturition | Poor fit; native meatus remains proximal / perineal |
| Penetrative intercourse | Poor fit; neophallus length and rigidity are usually insufficient |
| Future flexibility | Good fit; subsequent phalloplasty remains feasible |
| Desire to avoid staged urethral reconstruction | Excellent fit |
The decision should be framed around goals rather than hierarchy. No-UL metoidioplasty is not an incomplete metoidioplasty; it is a different reconstructive endpoint.
Contraindications and Caution Zones
Absolute contraindications are uncommon, but misaligned expectations are the main preventable failure mode. Patients who strongly prioritize standing micturition need a UL pathway, with counseling about the associated fistula and stricture risk.[2][4]
| Scenario | Counseling Point |
|---|---|
| Standing micturition is a primary goal | Simple metoidioplasty does not move the meatus to the neophallus tip |
| Penetrative intercourse is a primary goal | Phalloplasty plus delayed erectile prosthesis is the more goal-concordant pathway |
| Limited clitoral hypertrophy after testosterone | Neophallus size will be limited; testosterone duration and response matter |
| Active smoking | Strongly counsel cessation, especially if any staged UL is being considered later; smoking independently predicts fistula formation after metoidioplasty with UL[2] |
| Retained vaginal canal | Continue anatomy-based pelvic / STI screening and counsel on postvoid dribbling, infections, and pelvic symptoms[5] |
Preoperative Planning
Preoperative work centers on goal mapping, testosterone-related clitoral growth, and deciding which adjacent procedures belong in the same stage. WPATH SOC8 criteria govern readiness for genital gender-affirming surgery, while ACOG and AAFP emphasize ongoing anatomy-based preventive care after surgery.[6][7][5]
| Planning Domain | Practical Point |
|---|---|
| Hormone history | Most protocols wait at least 12 months of testosterone to maximize clitoral hypertrophy before metoidioplasty[4] |
| Voiding goal | Confirm that voiding from the native proximal meatus is acceptable |
| Adjunct procedures | Vaginectomy, scrotoplasty, hysterectomy / BSO, mons reduction, and testicular implants may be staged or combined depending on anatomy and center practice |
| Future phalloplasty | Document that no-UL metoidioplasty does not burn the phalloplasty bridge; it can be a first-stage endpoint or a final operation[3] |
| Tobacco / nicotine | Stop before genital reconstruction; risk becomes especially relevant if later UL is pursued[2] |
Technique
The operation releases and straightens the hormonally enlarged clitoris, then covers the shaft with local genital skin while leaving the urethra untouched. Published descriptions vary by center, but the core reconstructive steps are consistent.[4][8][9]
| Step | Technical Goal |
|---|---|
| Exposure and marking | Mark clitoral hood, labia minora flaps, labia majora scrotoplasty flaps if planned, and any mons / vaginectomy incisions |
| Clitoral degloving | Deglove the clitoris to expose tethering structures and maximize shaft mobility |
| Suspensory-ligament release | Divide superficial suspensory attachments to improve apparent length and projection |
| Ventral chordee correction | Release ventral tethering to straighten the neophallus without compromising neurovascular supply |
| Shaft skin coverage | Use labia minora / local genital flaps to cover the ventral and lateral shaft |
| Native urethra preserved | Leave the urethral meatus in its original proximal position; no pars fixa or phallic urethral construction is performed |
| Adjunct reconstruction | Perform scrotoplasty, vaginectomy, hysterectomy / BSO, or mons work if included in the stage |
Because the urethra is not lengthened, the operation avoids the pars fixa and phallic urethral anastomoses that drive most fistula and stricture morbidity in full metoidioplasty.
Outcomes
Pigot et al. reported the largest dedicated no-UL cohort: 68 patients with median follow-up 24 months. Surgical complications occurred in 13%, urologic complications in 12%, and storage / voiding function did not significantly change after surgery.[1]
| Outcome | No-UL Metoidioplasty Result |
|---|---|
| Cohort size | 68 patients |
| Median follow-up | 24 months |
| Surgical complications | 9 / 68 (13%) |
| Urologic complications | 8 / 68 (12%) |
| Storage symptoms | No significant postoperative change |
| Voiding symptoms | No significant postoperative change |
| Urinary-symptom quality of life | Median score in the "pleased" range |
Patient-reported outcomes in the Pigot cohort showed the expected split: urinary morbidity was low, but standing voiding was not the endpoint. Among 40 respondents, 80% reported increased self-esteem, 80% would undergo surgery again, and 70% would recommend the operation to others.[1]
| Satisfaction Domain | Result |
|---|---|
| Sexual functioning satisfactory / very satisfactory | 45% |
| Voiding satisfactory / very satisfactory | 53% |
| Penis appearance satisfactory / very satisfactory | 63% |
| Neoscrotum appearance satisfactory / very satisfactory | 65% |
| Increased self-esteem | 80% |
| Would undergo surgery again | 80% |
| Would recommend to others | 70% |
No-UL Versus UL Metoidioplasty
UL changes the reconstructive target from a sensate released clitoris to a voiding neophallus, and that shift carries the urethral risk. Waterschoot et al. found UL to be an independent risk factor for urethral complications after metoidioplasty, with odds ratios of 15.5 for any urethral complication, 24.5 for stricture, and 6.07 for fistula.[2]
| Domain | Without UL | With UL |
|---|---|---|
| Voiding endpoint | Native proximal / perineal meatus | Neomeatus at or near neophallus tip |
| Standing micturition | Generally not possible | Usually the goal and often achievable |
| Urethral complication exposure | Low | Substantially higher |
| Stricture risk | Avoids new pars fixa / phallic urethra | Driven by reconstructed urethral segments |
| Reoperation burden | Lower | Higher |
| Sensation | Preserves native clitoral sensation | Also preserves clitoral sensation, but with added urethral reconstruction |
De Rooij et al. found markedly fewer complications and reoperations without UL, while patient-reported satisfaction domains were not significantly different between the UL and no-UL groups. Satisfaction with neophallus appearance and voiding were the strongest positive predictors of overall satisfaction, regardless of whether UL was performed.[10]
Postoperative Care and Follow-Up
Early care is dominated by wound care, edema control, drain / catheter protocols if adjunct procedures were performed, and monitoring for hematoma, wound separation, urinary retention, postvoid dribbling, infection, or pelvic pain. Because the urethra has not been reconstructed, evaluation of urinary symptoms should focus on the native urethra, retained vaginal cavity if present, pelvic-floor dysfunction, and any prior lower-tract disease rather than assuming a neourethral stricture.[1][5]
Patients who retain vaginal anatomy need anatomy-based preventive care, including STI screening when indicated. Patients who later request standing micturition or penetrative function can be counseled about staged UL or phalloplasty; published updates note that a minority of metoidioplasty patients ultimately pursue phalloplasty later.[5][11]
Operative Pearls
- Name the operation by its endpoint: sensate phallic release without urethral reconstruction.
- Confirm preoperatively that the patient understands voiding will remain proximal / perineal.
- Preserve the clitoral neurovascular bundle; sensation is the main functional advantage.
- Treat chordee correction as a length-gaining maneuver, but do not overpromise size.
- Keep future phalloplasty feasible by minimizing avoidable scarring in flap-planning territories.
- If scrotoplasty is performed, counsel separately on implant timing and staged prosthesis risk.
References
1. Pigot GLS, Al-Tamimi M, Nieuwenhuijzen JA, et al. Genital gender-affirming surgery without urethral lengthening in transgender men-a clinical follow-up study on the surgical and urological outcomes and patient satisfaction. J Sex Med. 2020;17(12):2478-2487. doi:10.1016/j.jsxm.2020.08.004
2. Waterschoot M, Hoebeke P, Verla W, et al. Urethral complications after metoidioplasty for genital gender affirming surgery. J Sex Med. 2021;18(7):1271-1279. doi:10.1016/j.jsxm.2020.06.023
3. Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases. Front Endocrinol. 2021;12:760284. doi:10.3389/fendo.2021.760284
4. Kocjancic E, Acar O, Talamini S, Schechter L. Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening. Int J Impot Res. 2022;34(2):120-127. doi:10.1038/s41443-020-0259-z
5. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560-565.
6. Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. doi:10.1080/26895269.2022.2100644
7. American College of Obstetricians and Gynecologists. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75-e88. doi:10.1097/AOG.0000000000004294
8. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394-400. doi:10.1001/jamasurg.2016.5549
9. Lin-Brande M, Clennon E, Sajadi KP, et al. Metoidioplasty with urethral lengthening: a stepwise approach. Urology. 2021;147:319-322. doi:10.1016/j.urology.2020.09.013
10. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-reported outcomes after genital gender-affirming surgery with versus without urethral lengthening in transgender men. J Sex Med. 2021;18(5):974-981. doi:10.1016/j.jsxm.2021.03.002
11. Stojanovic B, Djordjevic ML. Updates on metoidioplasty. Neurourol Urodyn. 2023;42(5):956-962. doi:10.1002/nau.25102