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Extended Metoidioplasty

Extended Metoidioplasty is a modern technique developed collaboratively by teams in the Netherlands and the United States. Extended Metoidioplasty focuses on maximizing functional and aesthetic outcomes while minimizing complications. It’s especially well-suited for transgender men and nonbinary individuals who wish to optimize length and retain erogenous sensation, and are comfortable urinating while sitting. The procedure is also notable for avoiding staged reconstruction, offering a lower-risk pathway to genital affirmation.

How It Works

During surgery, the clitoris is extensively released to maximize visible length. The suspensory ligaments are carefully dissected, and the clitoris is repositioned and anchored to the pubic tubercle for forward projection.

Scrotoplasty is performed by reshaping the labia majora, and a unique element of this technique is the use of a suprapubic adipocutaneous flap. This flap adds volume to the scrotum, mimicking the appearance of testicles without requiring silicone implants.

Rather than performing urethral lengthening, the surgeon creates a perineal urethrostomy, which moves the urethral opening behind the newly constructed scrotum. This significantly reduces the risk of complications such as fistulas and strictures. Additional labial tissue may be used to enhance the base of the phallus for improved aesthetics and bulk.

Expected Results

Patients can expect a neophallus measuring between 4 and 9 centimeters in length, with a girth of about 2 to 4 centimeters. Because the clitoral nerves are preserved, sensory and erectile function remain intact, and many patients are able to achieve orgasm and spontaneous erections. Some patients report being able to engage in penetrative sexual activity, depending on the size achieved and personal anatomy. However, because urethral lengthening is not performed, urination remains seated, and standing to pee is generally not possible without the use of an external device. The final appearance includes a natural-looking penis and scrotum, with a moderate degree of projection and a soft tissue contour similar to testicles, even though implants are not used.

Risks and Complications

This technique has a relatively low complication rate, largely because it avoids urethral lengthening. That said, minor risks such as wound dehiscence, hematoma, and local infection have been reported in a small number of patients.

Complementary Procedures

Patients may opt to have a vaginectomy performed alongside this procedure or in a later stage. Other optional refinements include labial skin adjustments and aesthetic contouring. Because this procedure is structurally conservative, it leaves open the possibility for future phalloplasty for those who later decide they want a larger phallus or full urethral reconstruction.

Who Is This Procedure Right For?

Extended Metoidioplasty is an excellent option for transgender men and nonbinary individuals who want a larger and more prominent phallus than traditional Metoidioplasty (such as the Belgrade method) typically provides. It’s particularly suited for those who wish to maintain erogenous sensation and spontaneous erections, avoid urethral complications, and achieve a natural, masculine appearance.

This procedure is not recommended for individuals whose primary goal is standing urination, or those who seek a phallus large enough for reliable penetrative intercourse in all positions.

Recovery

Patients typically spend 2 to 3 days in the hospital after surgery. A Foley catheter remains in place for 1 to 2 days, and the neophallus is supported with light bandaging to reduce swelling. Most people can return to non-strenuous activities within 2 to 4 weeks. Sexual activity is generally resumed after 6 to 8 weeks, following medical clearance. No post-operative devices such as pumps or traction systems are required for this technique.

Surgeons Who Offer Extended Metoidioplasty

Access to Extended Metoidioplasty is currently limited, as only a small number of surgeons offer the procedure. Patients interested in this technique may need to travel internationally or join waitlists, as availability remains restricted to a few centers with expertise in advanced genital reconstruction.

This technique is currently performed by:

• Dr. Shane Morrison - University of Washington, Seattle, USA
• Dr. Salam Kassis and Dr. Patrick Assi - Vanderbilt University, Nashville, USA
• Dr. Müjde Özer - Amsterdam University Medical Center, Netherlands

 

References

• Morrison SD, et al. (2022). Technical Refinements to Extended Metoidioplasty without Urethral Lengthening: Surgical Technique. PRS Global Open. doi.org/10.1097/GOX.0000000000004101

 

Last updated: 05/28/25