FAQs Metoidioplasty (Frequently Asked Questions) - HE1292

Acknowledgements:

The primary source of information for this decision support booklet has been derived from the patient information from OHSU. Please remember the information provided here does not replace the information you receive from your surgeon. We are constantly working to improve our resources to better suit your needs, this resource will continue to be updated.

What are the complications related to my surgery?

• It is important to remember that complications can occur with any surgery. Generally, minor wound healing problems and functional issues relating to wound site swellings are the most common. As part of your surgical informed consent, you will be presented with information regarding potential complication of your surgery. Please see the sections on wound healing in our “What Is Metoidioplasty?” information resource.
• Serious complications are uncommon. However, choosing to have surgery is choosing to accept that risk. We do everything we can minimise the risk of complications during and after surgery.
• Although all surgical procedures involve risks, our surgeon is continually working to prevent them by ensuring the ongoing maintenance and development of safe surgical practices. In your first consultation, physical and lifestyle factors that play a role in decreasing the surgical risk will be discussed with you.

Note: In the unlikely event you need to return to theatre this will be arranged for you by our team.

I have seen this word spelled in different ways, what is the correct wording?

• In English, we use the word metoidioplasty. The word meta can be used as well.

What preparations are involved in having metoidioplasty with urethral lengthening surgery?

• Hysterectomy including removal of the cervix (at least six months before the procedure) for those wanting vaginectomy as part of their metoidioplasty procedures.
• Metoidioplasty with urethral lengthening is an extraordinarily complicated procedure, involving multiple steps and surgeries. A large part of its success depends on your preparedness. This means being in the best possible physical and mental health before the surgery. Above all else, it is critical to have reasonable expectations about what is possible for your body and what your surgeon can realistically accomplish.

These conditions are essential; without them, surgery will not be able to proceed or will be postponed.

Note: that due to the high risk of complications such as vaginal entrance stenosis and urinary fistula, urethral lengthening is not an option when preserving the vaginal cavity.

How long before and after surgery will I need to stop drinking alcohol and quit smoking?

• Avoid consuming any alcohol for two weeks before and after surgery. Mixing alcohol and drugs can cause unpredictable and undesirable reactions.

Note: Access to our establishment will be prohibited to anyone who presents themselves with drugs or alcohol or who are under the influence of these substances.

Tobacco and nicotine substitutes:

We are not accepting patients who smoke (including nicotine based vapes). Substances contained in tobacco and nicotine can:

• Constrict small blood vessels and therefore negatively influence the healing of your wounds and the results of your surgery. The complications nicotine can cause include poor wound healing, delayed wound healing and graft failure.
• Cause, upon rising, nausea, vomiting and excessive coughing which increase the risk of bleeding after surgery.
• Research shows that the risk of surgery failure increases 10 times for people who smoke even one cigarette a day. All products that contain nicotine including vapes and gum, although healthier alternatives to smoking tobacco all still have the same negative effect on wound healing. (Source: OSHU Transgender Health Program and Department for Urology)
• You are encouraged to talk to your GP for nicotine cessation support.

Can I have surgery if I use recreational drugs?

• Please note that access to our hospital is prohibited to anyone presenting themselves with drugs or alcohol or who are under the influence of these substances.
• Drug use can impact patient safety during surgery. Any drug use should be reported to us during the planning of your surgery. Your surgeon and the anaesthesiologist must have this information to ensure that the surgery is safe.

Do I need to be on testosterone to have a metoidioplasty?

• Yes, surgeons generally require people to be on testosterone for one to two years prior to having metoidioplasty, to maximize growth of the neo-phallus before surgery. If you're planning to go off testosterone at some point after surgery, it's important to know that you could lose phallus length, including any standing to pee ability.

Do I have to stop taking my testosterone before or after surgery?

• No, we do not routinely recommend stopping testosterone (T-GAHT) before your surgery. You can continue taking your testosterone according to your regular schedule.

How big of a penis can I get with metoidioplasty?

• The average length of a metoidioplasty phallus is 4.6 cm (1.8 inches).
• If a larger sized phallus is important to you, consider phalloplasty instead.

Will my clitoris be longer after metoidioplasty?

• No, but the release of the ligaments places the clitoris in a more advanced position and gives the impression it is longer.
• If you wish, you can try pumping once you have healed to try to give your phallus more length and girth.

Are there ways to enlarge a metoidioplasty penis?

• DHT cream was used by transgender men for many years to enlarge the neo-phallus before metoidioplasty, with some success. In recent years however, DHT cream has become unavailable. Our surgeon advocates Pumping to enlarge the neo-phallus before metoidioplasty. Pumping can also help to prevent traction (loss of length) after metoidioplasty.

Will I have a visible bulge in my clothes, underwear, and swimsuit?

• No. If having a visible or noticeable bulge is very important to you, we urge you to consider phalloplasty.

Will I be able to pee while standing after metoidioplasty?

• The ability to pee while standing after metoidioplasty depends on anatomy and is not always possible. The length of the penis will not typically allow urination through the zipper or the use of public urinals.
• People who are heavier can expect to not be able to pee standing up after metoidioplasty.

Will I be capable to sexual penetrate after metoidioplasty?

• Sexual penetration after metoidioplasty is rarely possible. Some people can find the right position to penetrate but aren't able to thrust or achieve deep penetration. If this is important to you, consider phalloplasty instead. For some people, phalloplasty may not be possible because of their body shape and weight.

Will I be able to have erections with metoidioplasty?

• You can have erections with meta, but there is usually not enough length for penetration.

Will I still be able to orgasm after metoidioplasty?

• Yes, the erogenous and erectile nature of the clitoris is maintained and stays fully intact, allowing for sexual pleasure. If direct erotic pleasure to your shaft and glans is important to you, metoidioplasty may be more right for you than phalloplasty.

Do I need to have any hair removal done on any sites to prepare for metoidioplasty?

• No, hair removal is not required.

Do I need to have a hysterectomy before metoidioplasty?

• Only if you're having a vaginectomy as part of your procedures being done with metoidioplasty, in which case the uterus and cervix need to be removed. (Ovaries do not have to be removed.)

Can I have urethral lengthening without having a vaginectomy?

• No, due to the high risk of complications such as vaginal entrance stenosis and urinary fistula, urethral lengthening is not an option when preserving the vaginal cavity.

Can I have testicular implants put in at the same time as the metoidioplasty and scrotoplasty?

• Our surgeon waits until the scrotum has healed before putting in testicular implants. Generally, this takes place six to nine months after the initial surgery.

How long do testicular implants last, what is their lifespan?

• The implants can be left in place for as long as there are no complications arising. If you do have a problem with one or both implants, it is important to contact us.

I’m not sure if I want scrotal implants.

• You can wait to decide if you want scrotal implants in the second stage of surgery. Many patients, especially those that are physically active find them uncomfortable.

Can I choose the size of my testicular implants?

• The size of your testicular implants will be selected by your surgeon who will advise you in order to obtain the most aesthetic results possible based on your appearance.

Controlling diabetes: Why is it important?

• People with diabetes may have greater risk of poor healing and infections, especially if their diabetes is not well controlled. Your primary care provider (GP) or endocrinologist can help you make sure that your diabetes is under control before surgery.

Why is my weight important?

• You will have the best result from surgery if you are as close as possible to your ideal body weight. Structures such as the clitoris and urethra are attached to the pubic bones. If you are obese, your new phallus will be more buried by the extra tissue, just like in cisgender men. This makes it more difficult to stand to urinate. You may not be able to see much of a difference in your phallus after surgery — or see it at all. Being severely overweight also increases your risk of complications such as breathing problems, infections, and blood clots.

How long do I need to stay near my surgeon after metoidioplasty?

• It's important to stay close to your surgeon during the initial healing period after metoidioplasty. Plan on staying in Wellington for at least another 12 days once you are discharged from hospital before returning home if you live outside of the Wellington region.

What is recovery from metoidioplasty like?

• Recovery can include moderate to severe pain; a suprapubic catheter for two to six weeks if urethral lengthening is performed; no desk work for two weeks and no strenuous activities for six weeks.

What if I want to carry a child/have my own baby after meta (metoidioplasty), can I deliver a baby vaginally?

• It is best to complete any childbearing you may wish to do before undergoing surgery. This should be discussed prior to agreeing to metoidioplasty, as it may not be possible, or your results may need to differ to accommodate your future plans.

What is a fistula?

• If you experience urine coming out from somewhere other than the urethra or SP catheter tube, this is a fistula. These often heal on their own but sometimes require surgery. Depending on the nature of the fistula, a period of at least three to six months between the original metoidioplasty surgery and a fistula repair surgery is needed to allow tissues to heal and strengthen.

What is a mons resection?

• A mons resection or monsplasty is a procedure that can be helpful for patients with excess skin and a prominent mons (area in front of the pubic bone.) An incision is made across the abdomen and the lower section is lifted to bring the scrotum and phallus out in front of the legs more.

How will I know if I should have mons resection?

• We will talk with you at your consultation about whether a mons-resection could help your phallus be more visible. The trade-off is you will have a thick scar.

We base this decision on:

• • Your body shape.
  • Whether it would make your phallus more prominent and visible.
  • For some people, it may help them to stand to urinate.
    

I have had metoidioplasty without lengthening of the urethra and I am satisfied with my results, but I would like to be able to urinate standing up. Can I come back for another procedure to lengthen my urethra?

• Unfortunately, no, it is not possible to lengthen the urethra at a later time since the tissues required for the elongation of the urethra will have been modified or removed during the first procedure.

What if I decide after surgery that I need phalloplasty? Can phalloplasty be performed on someone who has had a previous metoidioplasty?

• If you have chosen and received metoidioplasty via the gender affirming genital surgery (GAgS) service, you will not be further eligible or funded publicly for phalloplasty.
• Depending on how the surgery was done, phalloplasty may be possible for some patients who have had metoidioplasty in the past, however this will need to be self-funded.

Can I contract or transmit STIs even if I have undergone genital surgery?

• After surgery, you remain at risk of contracting or transmitting sexually transmitted or blood-borne infections. Ask your family doctor about the means of protection available.

How often will I see my surgeon following surgery?

• Following discharge from the hospital, you'll see your surgeon at least once a week, depending on how you're healing, until you are cleared to return home.

I am afraid of having pain after my surgery, will I be given medication?

• The majority of patients experience pain after surgery, and everyone handles pain from surgery differently. Its intensity differs from one person to another with the experience of pain being unique to each person. You may have an idea of your pain threshold from previous surgeries, but it can vary by surgery type. You should expect some degree of pain and discomfort for several weeks after surgery. We want you to be prepared for this pain and discomfort and know that it is a normal part of healing.
• You will be taking regular paracetamol, non-steroid anti-inflammatory and gabapentin which treats hypersensitivity. Some patients require in the first week additional medication for break through pain, this will be discussed with you prior to your discharge from the hospital.

If my recovery is difficult, can I find psychological support at your hospital?

• We do not have a mental health professional on site at our facility. It is therefore important to maintain contact with the healthcare professionals involved in your follow-up and to bring their contact details with you.

Will I have access to entertainment during my stay?

• Yes, each room has its own television and wireless internet service is offered free of charge. In order to respect other recovering patients, we ask that you bring your personal headphones with you. You can if you wish, bring music, your laptop, or iPad, a book or other entertainment.

Note: We recommend bringing comfortable, large, or loose fitting, low hassle clothes to go home in when you are discharged.

Who will I follow-up with after I am discharged from the hospital?

• After you are discharged from the hospital, you will have follow-up appointments arranged. Your first post-op appointment date and time will be given to you with your discharge paperwork. If you have any questions, please email our surgeon’s nurse. You will have been provided with these contact details.

Once I am discharged from the hospital, will the help of a nurse after my surgery be necessary?

• Normally not, because all patients who have had surgery benefit from a personalized follow-up by email or telephone to check that their convalescence, as well as the management of their health, are going well. You will also receive teaching guides that will serve as your reference after your return home.

Will I be able to drive my car after the surgery?

• In the case of genital surgeries, we advise you to wait two weeks before driving a motorized vehicle. You must be able to perform unpredictable arm movements without strain and avoid putting too much pressure on your genitals which could cause pain. When you start driving again, do it for short distances. If you have to walk a long distance, make frequent stops to rest a little.

Once I get home from surgery, what should I do if I need help?

• Once back home, you can communicate with your surgeon or the nurse, you will be provided with contact details.

Note: In the event of a medical emergency, you should go to your local hospital emergency department or call your local emergency number. The emergency physician will then be able to communicate with your surgeon so that you can be taken care of adequately and efficiently. The GAgS service team is willing to work with other health professionals who are involved in your medical follow-up.

When can I start swimming again after my surgery?

• It is possible to resume your swimming activities after 12 weeks, when your wounds related to the intervention are completely healed.

How long will my recovery take after my surgery and when can I return to work?

• In your pre surgery consultation, the impact of your occupation due to surgery and recovery will be discussed with you, so that a plan of time needed off work and gradual return to work is made.
• Once your surgery date is booked in with our surgeon’s practice, we can provide you with a medical certificate prior to your journey to Wellington.
• Anticipate having at least six weeks off work and to avoid heavy lifting andexercise during the recovery period.

When do I resume my normal activity?

• Walking: We ask that you limit your walking to 2,000 steps a day for the first four weeks. This is about one and a half kilometres or 20 minutes of walking for the whole day. After four weeks, you can begin to gradually increase the number of steps. You may notice that the more active you are, the more swelling, pain and fatigue you have. This is your body telling you to slow down. Listen to your body and don’t overdo things. You will get tired easily as your body recovers. Take time to rest and limit activities.
• Showering and bathing: We ask that you shower twice a day for the first sixweeks. Then you can resume your normal shower schedule. No baths, hot tubs,or swimming for the first three months.
• Lifting: Don’t lift anything over five kilograms for the first six weeks. Then you can slowly increase the amount of weight you lift.
• Workouts: No working out, running, or strenuous gardening etc for 16 weeks after surgery. Then you can slowly reintroduce these activities to your routine. No bicycling for four months.

Note: that the recovery time depends on the progress of your recovery and the type of work you do. The estimated duration is given for informational purposes only.