Background: Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate. Objective: To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes. Methods: We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique. Results: For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2). Conclusion: We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.
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