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Belgrade Metoidioplasty

Belgrade Metoidioplasty is one of the most widely practiced and longest-standing forms of masculinizing genital surgery for transgender men. Developed by Dr. Miroslav Djordjevic and his team at the Belgrade Center for Genitourinary Reconstructive Surgery, this approach is known for its comprehensive, single-stage design, which constructs a small phallus using the hormonally enlarged clitoris, enables standing urination, and includes scrotoplasty with testicular implants.

Because it reconstructs all external genital structures and typically includes urethral lengthening, vaginectomy, and scrotoplasty, this technique is often referred to as Full Metoidioplasty. It is considered the most complete form of metoidioplasty, offering a well-rounded outcome in terms of appearance, function, and sensation. With more than two decades of refinement and over 500 cases, it stands as a gold standard in metoidioplasty procedures.

How It Works

During surgery, the clitoral ligaments (suspensory and fundiform) are fully released to allow the clitoris to extend outward. The vaginal canal is closed, and a new urethra is constructed using a combination of buccal mucosa grafts (from inside the cheek) and labial skin flaps. This allows the urethra to pass through the neophallus, enabling urination while standing.

At the same time, the labia majora are reshaped to form a scrotum, into which testicular implants are inserted. The reconstructed penis is anchored in a way that creates a natural penoscrotal angle, and often, a vacuum device is recommended postoperatively to support healing and enhance projection.

Expected Results

Patients undergoing the Belgrade method can expect a neophallus length of 4 to 10 centimeters, with an average of about 5.7 cm. Because the clitoral nerve supply is preserved, most patients maintain erogenous sensation and are able to achieve spontaneous erections and orgasm. Importantly, the vast majority of patients who undergo urethral lengthening with this technique are able to urinate while standing, which is a central goal for many.

The Belgrade method creates a bifid scrotum using a midline union of the labia majora, often resulting in a more visibly separated appearance than techniques like V-Y advancement scrotoplasty. While this maintains a natural division consistent with cis male anatomy, some patients may find the result more distinctly “split” than expected. Testicular implants are placed in each half, giving the scrotum definition and fullness.

View a photo of the appearance of the scrotum immediately following Belgrade Metoidioplasty surgery. Note: This is a graphic operating room photo.

The result is a complete set of male-appearing external genitalia, including a visible penis and scrotum, often with a natural contour enhanced by the implants. While the neophallus is generally not long enough for penetrative intercourse, satisfaction with appearance and function is typically high.

Risks and Complications

Like any major surgery, Belgrade Metoidioplasty carries risks. The most common are related to urethral lengthening, with urethral fistulas occurring in 7–15% of cases and strictures in approximately 2–3%. Additional risks include infection, hematoma, and complications with testicular implants, such as rejection or shifting. Some patients may require revisions or secondary procedures to address aesthetic concerns or minor complications. However, overall satisfaction and success rates are high with careful patient selection and when performed by experienced surgeons.

Complementary Procedures

Because the Belgrade Metoidioplasty is a comprehensive, single-stage technique, most complementary procedures are integrated into the initial surgery. These may include:

• Hysterectomy and vaginectomy
• Scrotoplasty with testicular implants
• Urethral lengthening with buccal grafts
• Aesthetic refinements

In the standard Belgrade approach, testicular implants are placed during the initial surgery, making it a true one-stage procedure when no complications or additional steps are required. However, in certain cases, implant placement may be delayed by 6-9 months. This decision can depend on factors such as tissue availability, risk of infection, or concern about wound tension.

Who Is This Procedure Right For?

Belgrade Metoidioplasty is well-suited to transgender men who want a complete male genital reconstruction in a single surgery, including the ability to urinate while standing and a fully formed scrotum. It is ideal for patients who value aesthetics, function, and a straightforward timeline, and who prefer to avoid the multi-stage complexity and donor site scarring associated with phalloplasty.

However, this method is not the ideal choice for individuals whose primary goal is achieving a larger phallus capable of penetrative sex. It is also important that candidates are comfortable with the risk of urethral complications, which remain the most common issue requiring revision. Those with a higher BMI or significant mons pubis fat pad may not be ideal candidates, as excessive adipose tissue in the pubic region can limit visible phallic length and affect the ability to urinate while standing.

Recovery

Recovery typically involves a hospital stay of 5 to 7 days, during which patients are monitored for bleeding, infection, and graft success. A catheter is worn for 10 to 14 days to allow the newly constructed urethra to heal. Most patients can return to non-strenuous activities within 4 to 6 weeks, although full healing may take several months.

A vacuum erection device may be introduced a few weeks after surgery to support phallic length and reduce scar contraction. Sexual activity can usually be resumed after about 8 to 12 weeks, depending on individual healing.

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The Belgrade Metoidioplasty technique has become the foundation for most comprehensive, or "full," metoidioplasty procedures performed today. Its single-stage approach has set a new standard in gender-affirming genital surgery. Many surgeons around the world now perform variations of this method, often incorporating their own modifications or refinements based on patient anatomy, surgical philosophy, or advances in technique.

Belgrade Metoidioplasty offers a well-balanced combination of aesthetic appearance, standing urination, and sensation preservation. For patients who want a single, transformative surgery with reliable long-term results, and who are comfortable with the size limitations, the Belgrade technique continues to be a highly trusted choice.

 

References

1. Stojanovic, B., Djordjevic, M. L. (2023). Updates on metoidioplasty. Neurourology and Urodynamics, 42(5), 956–962. doi.org/10.1002/nau.25102
2. Djordjevic ML, Bizic M, Stanojevic D, et al. (2019). Metoidioplasty: techniques and outcomes. Translational Andrology and Urology. doi.org/10.21037/tau.2019.06.12
3. Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, Perovic SV. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009 May;6(5):1306-13. doi: 10.1111/j.1743-6109.2008.01065.x. Epub 2009 Oct 27. PMID: 19175859.

Last updated: 05/28/25