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Vagina-Preserving Metoidioplasty

Vagina-preserving metoidioplasty is a variant of standard metoidioplasty in which the vaginal canal is intentionally left intact while the hormonally hypertrophied clitoris is released and elongated to create a neophallus.[1][2][3] Designed for transmasculine and nonbinary individuals who desire masculinised external genitalia and/or standing urination while retaining the ability for receptive vaginal intercourse.[4][5]

Unlike standard ("full") metoidioplasty — which typically includes vaginectomy, urethral lengthening (UL), and scrotoplasty as a single-stage procedure — vagina-preserving metoidioplasty omits the vaginectomy and may or may not include UL and scrotoplasty, depending on patient goals.[1][6]

This is the dedicated atlas page. For the broader variant-GGAS framework, see Non-Binary / Nullification Gender-Affirming Surgery. For the related vagina-preserving phalloplasty options, see Shaft-Only Phalloplasty with Vaginal Preservation and Phallus-Preserving Vaginoplasty. For the vaginectomy component (omitted here), see Vaginectomy / Colpectomy.

Concept and Spectrum​

Standard metoidioplasty (Belgrade / Djordjevic) is a one-stage procedure creating a neophallus from the testosterone-enlarged clitoris, lengthening the urethra to the tip of the neophallus, constructing a scrotum from the labia majora with testicular implants, and removing the vagina.[7] Vagina-preserving metoidioplasty exists along a spectrum:

VariantClitoral releaseULScrotoplastyVaginectomyStanding urination
Simple metoidioplasty (clitoral release only)✓———No
Meta + UL, no vaginectomy✓✓optional—Yes (target)
Meta + scrotoplasty, no vaginectomy✓optional✓—Variable
Full meta without vaginectomy✓✓✓—Yes (target)
Standard (full) meta (Belgrade)✓✓✓✓Yes (target)

Indications​

  • Nonbinary identity — desire both neophallus and vagina.[4][3]
  • Desire for receptive vaginal intercourse.[4]
  • Avoidance of vaginectomy morbidity — vaginectomy carries 10% major perioperative + 12% major postoperative complication rates (Nikkels 2019 n = 143).[19]
  • Absence of vaginal dysphoria.
  • Desire for standing urination — achievable with UL even without vaginectomy, but at substantially higher complication cost (see below).

Preoperative Requirements​

Testosterone therapy is essential before metoidioplasty. ≥ 1 yr of testosterone is recommended to maximise clitoral hypertrophy, which directly determines neophallus size.[8][9] Target levels in the physiologic male range (300–1,000 ng/dL).[9][1]

Bordas 2021 (largest published series, n = 813): mean neophallus length after metoidioplasty 5.6 cm (range 4.8–10.2 cm).[10]

Surgical Technique​

Core steps parallel standard metoidioplasty with the critical omission of vaginectomy.[11][8][6][7]

Step 1 — Clitoral release and lengthening​

  1. Degloving — clitoral skin (prepuce / hood) separated from the clitoral body, exposing the corpora.
  2. Division of the suspensory ligament — superficial suspensory ligament divided to allow the clitoral body to project further anteriorly and inferiorly, maximising phallic length.[8]
  3. Division of the urethral plate — short urethral plate (ventral chordee-like structure) tethering the clitoris divided, allowing further straightening and lengthening.[11][7]

Step 2 — Urethral lengthening (optional)​

If standing urination is desired, the urethra must be extended from its native position to the tip of the neophallus.[11][12][6]

  • Belgrade technique — urethral defect bridged with buccal mucosa graft (harvested from inner cheek); anterior vaginal wall (AVW) flap mobilised and combined with labia minora flaps to construct the ventral neourethra, tubularised over a catheter.[8][7]
  • Ring flap technique (Demzik 2021) — bilateral anteriorly based labia minora and vestibular flaps create the neourethra without buccal mucosa.[13]
  • Vaginal-mucosal graft (Nakamura 2025) — novel approach using vaginal mucosal grafts for UL, avoiding buccal donor-site morbidity — requires vaginal closure and is therefore NOT applicable to vagina-preserving procedures.[12]

Critical technical challenge in vagina-preserving UL: the AVW flap — a key tissue source for urethral construction in the Belgrade technique — must be harvested carefully to avoid compromising vaginal integrity. This constrains the available tissue and is the mechanistic basis for the elevated urethral-complication rates (see below).[11][14]

Step 3 — Shaft coverage​

Neophallus covered with local skin flaps, typically from labia minora. Medial aspect of contralateral labium minus is de-epithelialised and wrapped around the urethra for ventral shaft coverage.[8]

Step 4 — Scrotoplasty (optional)​

If desired, labia majora rotated anteriorly and superiorly to create a neoscrotum using the Ghent / Hoebeke technique — see Scrotoplasty.[8] In vagina-preserving procedures, the scrotum is constructed around the preserved vaginal introitus. Testicular implants placed in staged fashion (~6 mo later) — see Testicular Implants (Gender-Affirming).[1]

Step 5 — Vaginal preservation​

Vaginal canal left completely intact. No colpocleisis or mucosal excision. Introitus accessible between or posterior to the neo-scrotal structures (if scrotoplasty performed) or in its native position (if scrotoplasty omitted).[2][3]

Comparison — Metoidioplasty Variants​

FeatureSimple meta (release only)Meta + UL, no vaginectomyFull meta (Belgrade)
Clitoral release✓✓✓
UL—✓✓
Vaginectomy——✓
Scrotoplasty— (typically)optional✓
Standing urinationNoYes (target)Yes
Vaginal preservation✓✓—
Neophallus length~4–6 cm~5–6 cm~5.6 cm mean (Bordas)
Urethral complication rateNone (no urethroplasty)Higher (see below)8.85% fistula, 1.70% stricture (Bordas)[10]
OR timeShorter~408 min~170 min Belgrade

Anchors: Lin-Brande 2021[8], Demzik 2021 ring-flap[13], Bordas 2021 n = 813 Belgrade[10], Waterschoot 2021[15].

The Critical Issue — Urethral Complications with Vaginal Preservation​

The most important clinical consideration in vagina-preserving metoidioplasty with UL is the significantly higher rate of urethral complications when the vagina is preserved. Demonstrated in both phalloplasty and metoidioplasty:

Phalloplasty data — Massie 2017 (the foundational signal)​

In 224 patients undergoing phalloplasty with UL, urethral complications occurred in:[14]

  • 27% with vaginectomy vs 67% with vaginal preservation (OR 0.18, p = 0.02)
  • Stricture OR 0.25 (p = 0.047) — decreased with vaginectomy
  • Fistula OR 0.13 (p = 0.004) — decreased with vaginectomy

Mechanism: vaginectomy provides additional vascularised vestibular tissue (bulbospongiosus flap) that can be used as an extra layer of coverage over the horizontal urethroplasty suture line, reducing fistula and stricture risk.[14]

Metoidioplasty data — Waterschoot 2021 (n = 74)​

Urethral complications of any kind occurred in 56.8% overall.[15]

  • Additional urethral lengthening (AUL) is the strongest predictor of complications:
    • OR 15.5 for all urethral complications
    • OR 24.5 for strictures
    • OR 6.07 for all fistulas
  • Concomitant vaginectomy was not a significant independent predictor in this series (study underpowered for this comparison).
  • Smoking was an independent predictor of fistula formation (OR 6.54).

Claeys 2025 SR synthesis​

Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved.[5] Complications in masculinising variant surgeries primarily arose from the extended urethra, which can be mitigated through:

  • Primary perineal urethrostomy (accepting seated voiding).
  • Omitting UL entirely (the simple-metoidioplasty path).

Fundamental trade-off​

Standing urination comes at a substantially higher complication cost in vagina-preserving procedures because the vascularised tissue that would otherwise reinforce the urethral suture line (bulbospongiosus from vaginectomy) remains committed to the vaginal wall.

Outcomes​

Satisfaction​

Bordas 2021 Belgrade n = 813 (largest metoidioplasty series):[10]

  • 79% totally satisfied, 20% mainly satisfied (99% overall satisfaction).
  • All patients reported preserved sexual arousal and good erogenous sensation of the neophallus.

Series primarily included standard metoidioplasty with vaginectomy; vagina-preserving-specific satisfaction data are extremely limited.

Sexual function​

  • Erogenous sensation — Robinson 2021 multicentre survey n = 129: metoidioplasty patients 4.8/5 vs phalloplasty 3.4/5 (p < .05).[16]
  • All Belgrade-series patients reported preserved sensation and normal postoperative erection of the neophallus.[7]
  • Successful penetrative intercourse has been reported, though limited by small neophallus size (mean 5.6 cm).[11][10]

PROs with vs without UL​

de Rooij 2021 Dutch study (n = 102; 28 metoidioplasty, 74 phalloplasty):[17]

  • No significant differences in satisfaction between those who chose UL and those who did not (appearance, voiding, QoL, masculinity, sexuality).
  • Significantly higher complications and reoperations in the UL group:
    • Mean complications 2.7 vs 1
    • Mean reoperations 1.6 vs 0.4 (both p < .05).

Sexuality after GGAS​

van de Grift 2017 longitudinal: after genital GAS, transmasculine patients were more sexually active, used their genitals more frequently during sex (31% preop → 78% postop), and reported improvements in arousability, sexual interest, and pleasure.[18]

Postoperative Care — Vagina-Preserving Metoidioplasty-Specific​

  • STI screening — for patients post-metoidioplasty without vaginectomy who have receptive vaginal sex, STI testing with physician- or patient-collected vaginal swabs.[2]
  • Urologic follow-up — ongoing with a urologist familiar with GAS, particularly for patients with UL. Urinary retention, post-void dribbling, pelvic pain with fullness, recurrent UTI → urgent referral.[2]
  • Gynecologic care — preserved vagina requires ongoing surveillance; cervical-cancer screening if the cervix is retained (no hysterectomy).[2]
  • Testosterone-related vaginal atrophy — testosterone causes atrophy that may affect comfort during receptive intercourse. Topical vaginal estrogen may be considered for symptomatic atrophy, though data in this population are limited.[1]

Simple Metoidioplasty (Without UL) — The Lowest-Risk Vagina-Preserving Option​

For patients who do not prioritise standing urination, simple metoidioplasty (clitoral release only, without UL) combined with vaginal preservation is the lowest-risk variant. Lin-Brande 2021 reported on 12 patients undergoing simple metoidioplasty vs 21 with UL — the simple-metoidioplasty group avoids all urethral complications entirely.[8]

This option provides:

  • Masculinised external genital appearance (released, prominent neophallus).
  • Preserved erogenous sensation (native clitoral innervation intact).
  • Preserved vaginal function.
  • Zero urethral-complication risk.
  • Seated voiding (native meatus position unchanged).
  • Potential for future UL or phalloplasty conversion if desired.[11][8]

Broader Context — Individually Customised Procedures​

Ascha 2024 framework (n = 16) of individually customised genital procedures — including vagina-preserving phalloplasty / metoidioplasty, phallus-preserving vaginoplasty, and genital nullification — emphasised that these procedures may better affirm the identities of gender-diverse patients while preserving desired sexual function of natal genitalia.[3]

Brown 2025 survey n = 248 — nonbinary individuals were significantly more likely to prioritise retaining a vaginal canal for receptive penetration and gender-identity affirmation; both transgender men and nonbinary individuals rated maintaining tactile and erogenous sensation as a top priority.[4] Directly supports the clinical rationale for offering vagina-preserving metoidioplasty in preoperative counselling.

Evidence Gaps​

  • Long-term urethral complication rates in vagina-preserving metoidioplasty specifically — most data extrapolated from phalloplasty series (Massie 2017) or mixed cohorts (Waterschoot 2021).
  • Optimal UL technique when the vagina is preserved — AVW-flap-tissue-source constraint is the central mechanistic challenge.
  • Long-term vaginal function and sexual satisfaction with receptive intercourse after metoidioplasty.
  • Comparative satisfaction between vagina-preserving and standard metoidioplasty in matched cohorts.
  • Impact of testosterone-induced vaginal atrophy on long-term vaginal function.
  • Rates of subsequent vaginectomy or conversion to standard metoidioplasty / phalloplasty.
  • Validated PROMs specific to this population.

References​

1. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. 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

2. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565.

3. Ascha M, Rigsby S, Shoham M, et al. Individually customized gender-affirming genital procedures: techniques and considerations. J Sex Med. 2024;21(9):827–834. doi:10.1093/jsxmed/qdae075

4. Brown LK, Butcher RL, Kinney LM, Nigriny JF, Moses RA. New insights into the goals of transgender male versus non-binary individuals considering metoidioplasty and phalloplasty gender-affirming surgery. J Sex Med. 2025;22(3):526–535. doi:10.1093/jsxmed/qdae193

5. Claeys W, Wolff DT, Zachou A, et al. Variant genital gender-affirming surgery: a systematic review. BJU Int. 2025;135(1):40–53. doi:10.1111/bju.16513

6. Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res. 2020;33(7):762–770. doi:10.1038/s41443-020-00346-y

7. Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single-stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6(5):1306–1313. doi:10.1111/j.1743-6109.2008.01065.x

8. 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

9. Safer JD, Tangpricha V. Care of transgender persons. N Engl J Med. 2019;381(25):2451–2460. doi:10.1056/NEJMcp1903650

10. 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

11. 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

12. Nakamura K, Sakurai T, Sakamoto A, Watanabe K, Ogawa R. Vaginal-mucosal graft metoidioplasty: a novel surgical technique for urethral reconstruction in transmasculine surgery. J Sex Med. 2025;22(7):1275–1279. doi:10.1093/jsxmed/qdaf125

13. Demzik A, Snyder L, Hayon S, Chen M, Figler BD. Ring flap metoidioplasty. Urology. 2021;158:243. doi:10.1016/j.urology.2021.09.014

14. Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg. 2017;140(4):551e–558e. doi:10.1097/PRS.0000000000003697

15. 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

16. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Surgical outcomes following gender-affirming penile reconstruction: patient-reported outcomes from a multi-center, international survey of 129 transmasculine patients. J Sex Med. 2021;18(4):800–811. doi:10.1016/j.jsxm.2021.01.183

17. 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

18. van de Grift TC, Pigot GLS, Boudhan S, et al. A longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen. J Sex Med. 2017;14(12):1621–1628. doi:10.1016/j.jsxm.2017.10.064

19. Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019;16(6):924–933. doi:10.1016/j.jsxm.2019.03.263