Introduction

Metoidioplasty 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 standing up. 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.

The main intended benefit is the alleviation of gender dysphoria. Other benefits versus phalloplasty are that there will be no donor site scarring generally visible (only inside cheek potentially if a buccal mucosa graft is taken). The recovery time for a metoidioplasty is shorter compared to that of a phalloplasty.

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 the addition of scrotal implants and/or retention of the vagina. While 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.

We recommend reading through this leaflet carefully, noting down any questions you may have for your initial clinical nurse specialist and consultant surgeon appointments.

Pre-surgery appointments

Gender Affirmation Surgery (GAS) Clinical Nurse Specialist

Your first appointment will be an individualised consultation with a Clinical Nurse Specialist (CNS). This appointment is for you to ask any questions, hear more about the surgery and learn about the support that we can offer you as a team throughout your care. The nurse will ask questions about your medical history, some of which may be of a sensitive nature. They will also organise any tests that you require.

The option of fertility preservation (egg collection) will be discussed with you at your first nurse appointment if you have not already had a hysterectomy, or if you have had a hysterectomy but no salpingo-oophorectomy (removal of ovaries). Fertility preservation may be within the Imperial NHS trust or at an NHS trust that offers this service locally to you. 

Your first appointment will be virtual, but future appointments will also be face-to-face. Please let us know at your initial appointment if you have difficulty attending appointments at the hospital in Chelsea.

• Information about video consultations

For your first appointment please ensure you have:

• A written list of all your current medication, medical conditions and any operations or illnesses you have had
• Information from any other hospitals or doctors that you visit
• If you receive copies of hospital doctor's letters about you and your health, please bring them with you

First face-to-face appointment with your consultant surgeon

You will have an appointment with your consultant surgeon and this is an opportunity for you to ask any questions and discuss the surgery and what it entails and understand the outcomes of this surgery. The appointment will cover:

• Desired procedure detail, how long it will take, and what you should expect from this surgery
• A review of previous surgeries
• Initial Verbal informed consent discussion regarding the procedure, risks and outcomes
• Physical examination with the option of medical photography to be done on the day
• Advice about the use of vacuum pump device

In addition to your verbal consent conversation, you will receive a digital consent form which formally documents the discussion that you will have had with your consultant. The consent form will be sent to your email or mobile phone using our digital consent system known as Concentric. If you still need some more time after the first consultation, the form will be delayed and sent after the second encounter.  This form confirms you are informed about the surgery including knowledge about the associated risks and complications of the procedure. You will need to sign this prior to your surgery.

Consent to the planned procedure will be confirmed with you again on the day of your surgery and any discussions or questions raised can be documented on your Concentric profile by the clinician.

Your consultant surgeon will discuss with you about when to stop your testosterone preoperatively.

If you have any difficulties with remotely consenting, please contact our Patient Pathway Co-ordinators. Their telephone contact details can be found on the last page of this information leaflet.

To make sure we provide you with the best possible holistic care your case will be discussed in the MDT (Multi-Disciplinary Team meeting) and the procedure can only go ahead with the agreement of the panel; sometimes further investigations/clinical steps are required before the MDT is happy for you to have the procedure.

Second surgical consultation

During this consultation (usually video or telephone based) we will discuss the outcome of the MDT, you will confirm the procedure you want to go ahead with and the consent discussion will also be retouched on. If not previously completed, the electronic consent form will be sent to you at this time. You will have all the time for reading it and signing it when you feel comfortable with the explanations.

When you attend for your consultant appointment you will also be seen by a specialist physiotherapist and your clinical nurse specialist who will be able to offer support and advice to you about your surgery.

Pre-operative assessment (usually six weeks before your operation)

You will attend a face-to-face appointment with a pre-operative nurse, who will talk through your previous and current medical history, arrange any tests such as blood tests that you need before surgery and give you information about preparing for your anaesthetic. We understand that you may need to travel a long distance to be seen in London, which is why, whenever it is appropriate, we may run the preoperative assessment during the same day of the face to face consultation, in the form of a one-stop clinic. If your pre-operative assessment has not been carried out on the day of the one-stop clinic a telephone assessment will be arranged and carried out with one of the pre-operative nurses, at least 6 weeks before your surgery.

Psychology support

Anxiety around surgery is normal and as a team we are here to support you; our clinical nurse specialists are available to answer any questions. We also have a psychologist who has specialist knowledge in trans healthcare who can support you pre or post operatively. People meet with our psychologists for all sorts of reasons including:

• To think about anxiety related to medical settings or procedures.
• Connect with their strengths and resources and plan what they might need at different times.
• To think about how they navigate surgery with the important people in their lives - for example how they share information or let them know what they need.
• To talk about experiences of transphobia and the effects this is having on them - for example, how they feel about themselves, others, or surgery.
• To think about how to understand anxiety or low mood, and how to respond to it, in relation to surgery or gender identity.

If you think it might be helpful to meet with our psychologist, just let your CNS know and they will arrange a referral.

Important points to note in the lead up to your surgery

• You will have to stop smoking for at least six weeks before your surgery date. If you require help with this, please speak to your clinical nurse specialist or access a stop smoking service near you.
• NHS stop smoking services
• BMI/Weight loss—it is recommended for your BMI (Body Mass Index) to be 30 or less for the operation to achieve the best outcome. Additionally, there can be a higher risk of surgical and anaesthetic complications if you have a BMI over 30. This is something that can be discussed at your first appointment with your Clinical Nurse Specialist. Support and advice can be offered if you need to lose weight preoperatively.
• When you are provided with your surgery date we suggest letting your workplace know. Your fit note will be provided to you after surgery and will cover the period from your surgery date to when the surgeon deems you are ready to go back to work. This is normally at least three weeks post operatively depending on your type of work.
• You should continue to take all your regular medication on the morning of your operation as well as post-operatively, unless you have specifically been told not to. This will have been discussed with you in the pre-assessment clinic or by your surgeon. Taking medication that you have been asked not to or that has not been prescribed, may result in your operation being cancelled. Please bring all your medications into the hospital with you on the day of surgery.

Prior to surgery

We will ask you to carry out a routine Sexual Health Screen. This can be carried out when you attend your face-to-face consultations. If you develop or experience any symptoms, we advise you to visit your local sexual health services and to inform us of this.

One week before surgery

• It is required that you stop drinking alcohol one week before and for three weeks after surgery, because alcohol increases chances of bleeding—if you need support with this, let your Clinical Nurse Specialist know
• NO aspirin or any blood thinning medication
• NO nonsteroidal anti-inflammatory drugs- such as Ibuprofen, Diclofenac, or Naproxen
• NO herbal supplements eg St Johns Wort
• NO fish oil
• Wash and change bed sheets, as this will be more difficult to do when you get back from the hospital
• If you have had diarrhoea or vomiting 72 hours or less, before your operation, please contact the team as soon as possible, as your procedure will need to be rescheduled. It is also important that you inform us if you are feeling unwell, have had a temperature or flu like symptoms on or on the days leading up to your planned operation. It may be safer to postpone your operation until you are well.
• Please remove any nail varnish before you come in for your operation as it can interfere with monitoring.

Suggestions of things to stock up with at home

• Paracetamol for pain relief
• Easy to eat foods or ready meals
• High-fibre fruits, vegetables, pulses, and whole grains, which will help prevent constipation after a general anaesthetic
• A thermometer
• Anti-bacterial hand wash and gel

Day before admission

• Bowel preparation—for selected cases you may be given an oral medication at your pre op assessment to take the day before your surgery to ensure your bowels are emptied prior.  Specific instructions will be given to you at your Pre-op appointment.

Suggestions of what to pack

• Clean and loose clothing such as jogging or pyjama bottoms—things that are easy to put on and take off
• A pillow for your own comfort
• Ear plugs and eye mask in case you have trouble sleeping in a hospital ward
• Reading material
• Toiletries
• Phone charger
• All medications that you are currently taking
• We recommend that you leave your jewellery at home

Day of surgery

Fasting instructions

• Morning Surgery: You can eat until midnight the night before the surgery you may drink sips of clear fluids (which includes only water, black tea, or black coffee until time of surgery)
• Afternoon Surgery: You must finish eating breakfast by 7am on the day of the surgery.

You may drink sips of clear fluids (which includes only water, black tea, or black coffee until time of surgery).

Why is fasting important?

Fasting (not eating, sips of clear fluids are allowed) is important to avoid complications with your anaesthetic during your operation.

What to expect on the day

It is important you arrive on time. Please note the time provided on your admission letter is not the time of your surgery. All patients for the morning or afternoon theatre list are asked to come in at the same time in order for us to run the list most efficiently. You may be waiting for a few hours for your surgery.

Arrival at the Surgical Admissions Lounge

When you arrive at the Surgical Admissions Lounge (SAL), you will be seen by a nurse or Healthcare Assistant (HCA) who will check your details, check your observations (pulse, blood pressure, temperature, height, and weight). You will also be provided with surgical compression stockings and a theatre gown to wear. The gown should be put on back-to-front, so it opens at the back. You may be able to leave your underwear on, until you are ready to go to theatre. Your nurse will let you know when you need to remove them before surgery.

On admission, all patients with a uterus will need to have a pregnancy test done.

Your anaesthetist and surgeon will also see you before your operation. The anaesthetist will discuss the anaesthetic plan, including providing you with information on how you can control your pain after the operation. Your surgeon will discuss the details of their plan, review the details of your consent form, and confirm you are happy to proceed. If required, they will mark the site of surgery.

When it is time for your surgery, a porter will take you from the Surgical Admissions Lounge to the Operating theatre.

Postoperative care

You will wake up from your surgery in the post-operative recovery area with one or two nurses monitoring your recovery post-surgery. Once they are happy with your status, you will be transferred to your elective surgical ward.

You will have dressings and surgical drains (although the latter will depend on the details of your operation) in situ around the wound site to help drain fluid to aid healing. These will remain in place for 1–2 days after your operation. A coban bandage will also be placed around the wound, as it is a durable, elastic wrap which will secure the dressing. It is important to note that this could look very similar to your skin. This will be stitched on which will mean that suture removal will also be undertaken at your first post op appointment.  Please take simple analgesia such as paracetamol and/or ibruprofen (if you are able to do so) before your first post op appointment.

You will also have pad/gauze and mefix dressings immediately post op that will be removed on the ward round the following morning.

If you have full urethroplasty (urethral lengthening with hook-up) you will also have two urinary catheters—a catheter is a hollow, flexible tube designed to drain urine from your bladder. You will have a urethral catheter placed through your neo phallus and a suprapubic catheter inserted into the bladder through a tract made in the stomach wall.

If you have metoidioplasty without urethral lengthening OR with urethral lengthening but without hook-up, you will only have a single catheter passing through the normal water passage, which will usually be removed within 7 days. You may also have a little circular tube (splint) that will also remain in place until the first postoperative appointment (7–10 day post-op).

You will have a cannula which is most likely to be placed in your arm or hand, which will allow us to administer fluids and pain relief intravenously. If you are in pain or discomfort, let the nursing team know as soon as possible.

You will be able to eat and drink as normal after the operation. If you have had a buccal graft taken from the inside of your mouth to create your neourethra, your mouth may feel sore. You will be provided with mouthwash, and we recommend that you use this as prescribed.

You will be seen post operatively by a physiotherapist who will help you to mobilise out of bed after your surgery and give you advice for physical activity for when your return home and about pelvic floor health.

You will receive pain medication and antibiotics to go home with, all medications will be discussed with you on discharge and advice will be given to you on when to restart your testosterone.

Visitors while in hospital

The surgical theatres unit (where the operating theatres are located) are only for staff and patients undergoing their procedure. Relatives and/or friends are not permitted in this area. This includes the recovery area.

Once patients have been discharged from the recovery area to the surgical ward, they are allowed visitors (1–2 at a time). The ward will have specific allocated visiting hours, this can be confirmed with you Clinical Nurse Specialist before admission.  Please note that the number of visitors and visiting times may vary in accordance with NHS Guidelines and the Trust’s visiting policy. The measures are put in place to protect our patients and staff when necessary. Changes or updates are available on the Trust website.

If you have special needs and require a carer to be with you; please speak to your Clinical Nurse Specialist prior to the day of surgery. A plan can be implemented before your admission to hospital.

Discharge information and aftercare

You will need to stay in hospital until your medical team decides it is safe for you to be discharged. The usual length of stay for metoidioplasty is 1–2 days.

It is required that if you live outside of London that you stay in London or within 60 minutes travel from the hospital, for at least 7–10 days after you have been discharged (more detail will be provided to you at your first CNS appointment).

You will also be able to shower, however it is important that you avoid soaking the coban bandage. Once showering, the wound area can also be gently dried by patting with a clean towel or using the cool setting on a hairdryer.

7–10 days after your operation

You will have an outpatient appointment with your Gender Affirmation Surgery Clinical Nurse Specialist who will review your general recovery. Your urethral catheter will be removed. If you chose not to have a full urethroplasty we will then make sure that you pass good amount of urine. If you chose to have a full urethroplasty, you will then use the suprapubic catheter to pass urine until its removal at day 21. At this appointment you will also be seen by the Plastics Nurse Specialists who will assess your wound healing, remove stiches and give you wound care advice for when you go home. It is also normal to have some localised swelling, mild post op bleeding and/or serous ooze from wounds. Patients are also asked to provide images of their wound healing via a safe and confidential programme known as ISLA. Pictures will also be taken by the nurses during your wound check appointment via ISLA to upload to your medical records.

21 days post-op

In case you opted for full urethroplasty (urethral lengthening plus hook up to native urethra) you will need to have your suprapubic catheter removed—this will be arranged for you by your Clinical Nurse Specialist at your local hospital or with the community team where you live or at Chelsea and Westminster Hospital.

Aftercare planning and recovery

• It is advisable to have a comfortable place to recover for 4 weeks post-surgery.
• We recommend that you have someone who can accompany you on discharge, come with you to your post-operative appointments and help with shopping, prepare meals, and make pharmacy visits.
• If you have chosen to have testicular implants inserted, you will need to be very careful in moving for the first week, limiting the amount of steps to 200 a day, and avoiding any trauma or compression to the area. Pain and bruising are expected.
• Some postoperative pain is always expected, but this should be manageable with the advices given to you at the discharge. Should this not be the case, please contact your GP or our team to discuss further options.
• It is possible to return to work once your suprapubic catheter is removed (21 days post operatively) depending on your job and the manual labour involved. Please discuss this with the team if you are unsure.
• We recommend that you do not do excessive or strenuous exercise for 2 months after your operation.
• Usually, it is recommended to wait at least 4 weeks post-surgery prior to engaging in sexual activity to allow time for the healing process.  If you have any doubts regarding this, please ask your surgeon or specialist nurse.

If there are any clinical issues, do not wait until your next appointment. Please contact your Clinical Nurse Specialist to discuss.

Contact details

Please contact our Clinical Nurse Specialist Team if you have any questions about your care or surgery. They will provide their contact number to you directly at your first attendance.

Please contact our Patient Pathway Coordinators if you any questions about appointments or date of surgery, you need information about your care and treatment in a different format (such as easy read, large print, braille, or audio) due to disability, impairment or sensory loss or you require this information leaflet in another language. The email address for contacting them is: chelwest.ccgs.admin@nhs.net

Patient Advice and Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception.

Alternatively, you can send us your comments or suggestions on one of our comment cards, available at the PALS office, or on our feedback form.

We value your opinion and invite you to provide us with feedback.

T: 020 3315 6727
E: cwpals@chelwest.nhs.uk