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Metoidioplasty Surgery

What is Metoidioplasty?

Content warning: the content below uses some anatomy/biological terms where it is important to be precise

This is a surgical procedure which creates a neo-phallus (small penis) from existing genital tissue. The clitoral tissue is detached from the labia and ligaments cut to form a masculine looking phallus, whilst retaining sensitivity. If you wish to pass urine through your neo-phallus, you can also have a urethroplasty (urethral lengthening plus connection (or hook-up) to the native water passage). The combination of the metoidioplasty and urethroplasty will allow you to urinate from the tip of your neo-phallus. In some cases, this will allow you to urinate standing up, but this depends on a variety of factors.

You are able to have the metoidioplasty element on its own, which would give you the neo-phallus, but allow you to keep your existing urethral opening.

You would need to urinate sitting down in this instance. Urethral lengthening without hook-up is often offered if you don’t want to consider the full urethroplasty, with the purpose to obtain a wider girth of the neophallus; choosing this last option will allow you to potentially have the connection (hook-up) of the urethra done in a second stage. Additional urethral reconstruction may be performed using tissue from the labia minora, or less frequently using a “buccal mucosa graft” (small flap of skin from the inner cheek). The buccal mucosa graft is harvested from the inner cheek. It is possible to also have the additions of scrotal implants and/or retention of the vagina. Whilst retaining sensitivity, it is a less effective surgical approach for patients wanting a phallus comparable in size to that of a cis male, or who wish to perform a penetrative role in sexual intercourse using their phallus.

What is Laparoscopic Hysterectomy?

We offer laparoscopic surgery (a minimally invasive keyhole approach) for almost all patients having gender-affirming hysterectomy. You’ll have either a robotic-assisted or a laparoscopic hysterectomy or sometimes a vaginal hysterectomy. With the robotic or laparoscopic types of hysterectomies, your surgeon will make several small incisions (surgical cuts) on your abdomen. They’ll put a laparoscope (a long, thin surgical tool with a video camera) through one of the incisions into your abdomen. The laparoscope lets your surgeon see the inside of your abdomen.

Carbon dioxide gas will be pumped into your abdomen to make space. This gives your surgeon more room to do your surgery. Your surgeon will also put long, skinny surgical tools into the other incisions on your abdomen. With a laparoscopic hysterectomy, your surgeon directly controls the surgical tools with their hands. They can see the images from the laparoscope on a television monitor. With a robotic-assisted hysterectomy, your surgeon sits at a console and controls a robot that moves the surgical tools. The console has a special monitor where they can see the images from the laparoscope on a high-definition 3D screen. With both types of hysterectomy, your surgeon will remove your uterus, cervix and fallopian tubes through your front-hole, if possible. If you have decided on having one or both ovaries removed, your surgeon will also remove these. If your uterus or cervix (+/- ovaries) can’t be removed through your front-hole (for example if your uterus is enlarged by fibroids or you have a big ovarian cyst), your surgeon will make one of your abdominal incisions bigger and remove your uterus and cervix from there. This is uncommon. Then they’ll close your incisions with sutures (stitches). Prior to surgery, your wishes for specific bottom surgery will be discussed so the incisions do not interfere with the next steps of the operation.

Hysterecotmy & Metoidioplasy Patient Information Document

Your surgical pathway

We offer patients an individualised consultation with a Clinical Nurse Specialist (CNS) with the aim to collect a detailed holistic history of the patient, and to identify potential matters that require referral to other services (e.g. dietician, endocrinology, physiotherapy, and psychologist). An appointment with one of our lead surgeons is then arranged. This will provide an opportunity for patients to ask any questions they may have regarding their surgery. The surgical case will then be discussed at our multi-disciplinary team (MDT) meeting where the outcome will determine whether the patient is fit for surgery.

If the outcome determines that the patient is not fit for surgery this will be communicated to the patient via telephone or via a virtual clinic with their surgeon. A second virtual surgical consult will take place following on from the MDT, where a clear understanding of the implications, risks, cosmetic and functional outcomes of the chosen surgical procedure will be discussed with the patient prior to their surgery date. Once a TCI (To come in) date for surgery has been provided to the patient, they can be expected to be admitted to the Surgical Admissions Lounge (SAL) on the day of surgery within the main hospital. Depending on which type of surgery the patient undergoes will depend on their length of admission and recovery, all details will be explained within our CNS and surgeon consultations.

Risks and complications

If you are accepted for surgery, your consent form will explain the potential risks and complications of your surgery. Details of this will also be discussed in your surgical consultations.

Pre-operative timeline

It is important to note that each patient’s experience will be different and the below table is a generalised overview of what to expect pre operatively. Please discuss any questions or queries you may have with your clinical nurse specialist.

Time before surgery date

6 weeks

Preparations

Stop smoking, clinical nurse specialists can guide you through this
A sexual health screen will be carried out at the one-stop clinic. If you are experiencing symptoms of sexually transmitted infections or diseases, than please visit your local sexual health services and let your clinic nurse specialist know

1 week

Preparations

Stop drinking alcohol, clinical nurse specialists can guide you through this
No aspirin or any blood thinning medication
No nonsteroidal anti-flammatory drugs such as ibuprofen, diclofenac or naproxen.
No herbal supplements e.g. St Johns Wort
No fish oil

3 days

Preparations

Pack a bag for surgery, a suggested list will be provided to you in your patient leaflet
Wash and change bed sheets if you do not have the help for this after surgery
Stock cupboards and fridge/freezer with high-fibre food such as whole grains, fruits, vegetables etc.
If you have any diarrhoea or vomiting, feeling unwell with a temperature or flu like symptoms at this point please contact the team as soon as possible. It may be safer to postpone and reschedule your surgery date for when you are feeling better.

1 day

Preparations

Remove any nail varnish

Watch the video

COVID-19 Information

Please note we continue to ask that all people entering the hospital wear a face mask and regularly wash their hands.

For further updates on our COVID-19 patient guidance , please visit COVID-19 information — Chelsea and Westminster Hospital NHS Foundation Trust (chelwest.nhs.uk)

After surgery & recovery (Metoidioplasty)

It is important to note that each patient’s experience will be different and the below table is a generalised overview of what to expect post operatively. Please discuss any questions or queries you may have with your clinical nurse specialist.

Time before surgery date

Day 1

What might you expect?

Dressings in place covering wounds
Catheter in place
There will be some pain and discomfort, you will be provided with pain relief medication
You may feel a bit sore moving in and out of bed but the physiotherapist will help you mobilise
There may be slight redness, bleeding and discharge for a few weeks after the procedure

What is safe to do?

Eat and drink normally to give your body nutrition and hydration
Dressing must be kept clean and dry
Can wash around the area of the dressings
If you have had a buccal graft taken, mouthwash will be provided for you
Physiotherapy team will provide their input and advice

Fit to Work?

Day 2

What might you expect?

Discharged from hospital depending on recovery
Upon discharge you will be provided with medications such as pain relief and antibiotics. A discharge summary will also be sent to your GP
Information and guidance will be given to you on how to care for your catheter. You will be provided with an aftercare leaflet which will provide the contact details for the team

What is safe to do?

Discharged with Dressing, must be kept clean and dry
Keep area around the catheter clean and dry. Wash hands before touching catheter or changing catheter bag.
Can wash around the area of the dressings

Fit to Work?

Day 7 to 10

What might you expect?

You will have a follow up appointment with your clinical nurse specialist
Catheter will be removed
Stent and dressings will be removed
Light dressings will be supplied to you

What is safe to do?

Able to shower, no baths until internal stitched have dissolved

Fit to Work?

2 – 4 Weeks

What might you expext?

You will have a virtual follow up appointment with your clinical nurse specialist. You will be able to discuss your progress during this appointment.

What is safe to do?

Making a plan for going back to work possibly on reduced hours, if your job is not very physical and or manual labour.

Fit to Work?

Not just yet

4 – 6 Weeks

What might you expect?

Wound should be mostly healed.

What is safe to do?

Able to engage in sexual activity after 4 weeks if you feel ready to
Making a plan for going back to work possibly on reduced hours for all types of work.

Fit to Work?

Yes, If you do not feel ready to go back to work please discuss this with your GP or employer about the reasons for this

6 weeks +

How might I feel?

Surgical wound will be mostly healed
A face-to-face or virtual appointment will be scheduled with your surgeon

What is safe to do?

Driving
Heavy lifting or excessive exercise safe to do after 2 months

Fit to Work?

Yes, If you do not feel ready to go back to work please discuss this with your GP or employer about the reasons for this

Arriving at the hospital and your stay

Supporting trans people who need additional help when coming into hospital:

Patient passport