Metoidioplasty in Norway: A 13-year Experience from a National Center (2024)

Abstract

INTRODUCTION

Genital surgery is often considered the final step in surgical gender-affirming treatment. In the Nordic countries and the United Kingdom, we have seen an increase in people seeking gender-affirming treatment. The increase is mainly seen among those assigned as female at birth, or female-to-male (FtM) patients.¹ The choice to undergo gender-affirming genital surgery has a great impact on that person’s life.

For the FtM patient, there are mainly 2 surgical options when it comes to constructing genitals with a traditional male appearance. These include phalloplasty, from the Greek word phallos, which means to inflate or swell, and metoidioplasty, from the Greek words meta, which means toward, and oidion, which means male genitalia.^2–5

The metoidioplasty technique uses the enlargement effect that testosterone has on the clitoral tissue to construct a small neophallus.^6,7 This was first described by Durfee and Rowland⁸ and was further developed by several other surgeons from the first half of the 1990s.^7,9–13 It has since gained popularity and is an option for patients who do not want a large donor defect and who prefer a 1-stage procedure. The size varies between 4 and 7 cm, and it is reported that most patients are able to void standing up after the procedure.^2,14,15 Another advantage with this approach is keeping the clitoral tissue, and in this way, the possibility of erectile and erogenous function is preserved.⁴ The procedure has been performed at the Oslo University Hospital (OUH), Norway’s national center for gender incongruence, since 2007. There are several challenges in gender-affirming genital surgery for the FtM patient. The main challenge is how to lengthen the urethra and preserve a well-functioning urinary system at the same time.² The frequency of urologic complications related to the metoidioplasty procedure is reported differently in the current literature and ranges from 8.9% to 35%.^10,16–20 For many FtM patients, undergoing this kind of surgery is an important step to living and feeling as their perceived gender. Still, the number of patients who wish to undergo genital-affirming surgery remains at a low level.²¹ This patient group has not previously been examined in Norway, and there is a need for a systematic evaluation of the technique. The aim of this study was therefore to assess the surgical outcomes of all patients operated on with metoidioplasty from when the technique was introduced in Norway in 2007 to 2020, with a focus on complications and urologic outcomes.

MATERIALS AND METHODS

This study included all 84 patients who underwent metoidioplasty at OUH from January 1, 2007, to December 31, 2020, as identified by the Local Quality Register of Gender Incongruence. OUH has the only national center for gender incongruence in Norway. Variables were extracted from the Quality Register, which was designed based on an earlier retrospective chart review of all consecutive patients. The contraindications to undergoing genital surgery were active smoking, body mass index (BMI) more than 30 kg/m², modest or no growth of the clitoris, or ongoing psychiatric disease requiring active treatment.

The gender incongruence diagnosis is set by a team of experts according to the World Professional Association for Transgender Health Standards of Care for the Health of Transgender and Gender-Diverse People, version 8.²² In Norway, this treatment is offered by the public health system.²³ All patients had undergone laparoscopic hysterectomy with bilateral oophorectomy in advance. All decisions to undergo this procedure were based on individual evaluations, and exceptions from the contradictions were made over the course of time. Three different surgeons performed these operations during this time period.

RESULTS

In this national center cohort, 84 patients underwent metoidioplasty from 2007 to 2020. The median age at the time of surgery was 27.5 (range 19–59) years. Before the procedure, the patients had used hormonal treatment for an average of 4.6 years, and 97.6% of the patients had undergone chest contouring surgery.

The metoidioplasty procedure lasted on average 4.3 hours (2 hours 30 minutes to 5 hours 42 minutes), and the median time before discharge was 9 (range 6–22) days. One patient had a complicated postoperative course, which was not related to the primary surgery, that prolonged the stay to 49 days. This patient was considered an outlier and was not included in the analysis of hospitalization length. A total of 71 (84.5%) patients completed the surgery as a planned 1-stage procedure. Six of the patients had the testis implant procedure at a later stage, and the remaining 7 patients were either waiting for surgery to insert the testis prothesis or did not wish to have a testis implant at all. All patients used testosterone preoperatively. The average BMI was 23.8 (16.3–31.4) kg/m². Thirty-six patients (42.9%) completed the surgery without any complications or need of revision procedures, and 5 of the patients (6%) stated that they wanted a subsequent phalloplasty procedure after the metoidioplasty. For a further description of patient and perioperative characteristics, see (Table 1).

DISCUSSION

This study presents the surgical results from a national center of 84 patients who underwent metoidioplasty. There were many cases of complications and revision procedures related to the urinary tract.

Completing the procedure as a 1-stage procedure without further corrections or the need for revision procedures occurred in 43 of the patients (51.2%) (Table 3). Other studies have reported higher single-stage procedure rates, ranging from 77.3% in the study by Perovic and Djordjevic et al²⁵ to 91.2% in the study by Djordjevic and Bizic.¹¹ When considering the planned delayed procedures from our study, 13 patients did not have the testicle prothesis insertion as part of the primary surgery. In light of this, completion in a 1-stage procedure was 84.5% (n = 71) (Table 1).

The level of complications related to the urinary tract in our sample was high, at 35.7%, when looking at the strictures and the urethral fistulas together. Djordjevic et al⁶ from the Belgrade center reported a 12% level of urologic complications in a sample consisting of 938 FtM patients. A retrospective study by Hage and van Turnhout²⁶ reported that fistulas occurred in 37% of the 70 patients and that a urethral stricture occurred in 35%. Lumen et al²⁷ reported that of 74 transmen who had undergone metoidioplasty, 26 (35.1%) had complications related to the urethra that needed surgical management. When it comes to comparing the different techniques regarding urologic complications, systematic review and meta-analysis by Jolly et al from 2021 found that the Belgrade technique may have the lowest frequency of urethral strictures and fistulas.^27,28 The Belgrade technique, with the use of either buccal mucosa graft or labial skin graft for the urethroplasty, shows a lower occurrence of strictures and fistulas.^6,11,28 The results from our study are somewhere on the high end on this scale, and we found that strictures occurred more frequently than fistulas. Our center has used the metoidioplasty technique as described by Hage with minor alterations. All our patients received urethral lengthening with only a partial removal of the vaginal lining with the closure of the wound surface on the anterior vaginal wall. The number of patients with fistulas in our sample is at 13.1% and strictures were at 22.6%. The anterior vaginal flap is well vascularized at its base, but at the distal end, it may be that the perfusion is poorer, and it acts more like a skin transplant. It is here, where the anastomosis to the inner labial leaf is made, that the most problems concerning fistulas and strictures arise.¹⁹ With this technique, there is still a possibility to perform vaginal intercourse, but this may be challenging due to the small opening. In a systematic review of urethral outcomes after genital gender-affirming surgery by Ortengren et al,²⁹ they find an average of 21% of fistulas and 25% of strictures occurring in patients who have had a vaginectomy procedure simultaneously or before metoidioplasty. Al-Tamimi et al³⁰ found that a simultaneous or prior vaginectomy procedure has shown reduced risk of developing fistulas in a cohort of 294 transgender men from a single center in the Netherlands. Removing the epithelium lining and closing the vaginal canal may give more structural support surrounding the urethral lengthening, and one could theorize that this has a positive effect to reduce urethral fistulas.

When comparing the management of urologic complications, other studies such as Nikolavsky et al³¹ and de Rooij et al³² described a more targeted algorithm than what we have practiced in Norway. Nikolavsky et al³¹ recommended only 2 dilatation procedures before a surgical intervention, whereas de Rooij et al³² claimed that urethral dilatation should not be performed because this has been shown to be unsuccessful in the treatment of strictures. One could claim that we have taken a somewhat liberal attitude to performing a diagnostic cystoscopy and a dilatation procedure instead of a surgical intervention when the patient experienced a voiding problem. We found that a small subset of patients needed more than 6 procedures with cystoscopy and dilatations, and in hindsight, these patients may have benefited from a different surgical approach. There is, however, a knowledge gap concerning the normal voiding patterns after this procedure. De Rooij et al³² proposed using a uroflow Qmax cutoff at less than 15 mL/s when deciding to undergo surgical intervention or not. It is possible that a relatively low uroflowmetry should have been considered normal and that we should have delayed both endoscopic and surgical interventions. We have not routinely taught the patients how to perform urethral blocking postoperatively if the urine flow is reduced. It is possible that the implementation of self-catheterization in selected patients and a shift toward earlier surgical intervention could prevent the relatively high number of procedures needed to treat strictures.

The number of patients needing secondary procedures was relatively high at 41 (48.8%) patients. The proportion of patients undergoing a liposuction procedure after metoidioplasty in this sample was almost 20%. We found an average BMI of 23.8 kg/m², which is in the normal weight category. When performing univariable logistic regression, we found that an increasing BMI had a significant P value for the risk of complications and secondary procedures. Some will argue that the BMI cutoff of 30 kg/m² is a strict limit. On the other hand, one could claim that BMI is a poor measurement of the distribution of body fat, and the individual assessment of the fat distribution in the genital area is probably a better way to select the patients. Even though we found an increased risk related to increased BMI, a different study design to examine the isolated effect of weight on complication risks is necessary. Complications and secondary corrective procedures related to the testicular prothesis occurred in 32 (38.1%) patients. Hage and van Turnhout²⁶ also reported frequent events related to the testicular prothesis, at around 50% of the 70 patients in that study. Pigot et al³³ retrospectively looked into their scrotoplasty procedures from 1992 to 2018 and found a total explantation percentage of 20.8. Over the years, they have shifted from a concomitant insertion to a delayed staged prothesis insertion.³³

There is no gold standard in regard to creating a neophallus in the FtM transgender patient. Over the course of time, different approaches have been developed.³⁴ In the light of the findings of this study, future patients should be interviewed more thoroughly to disclose the actual desire to void standing up and the need for testicular prothesis to develop a more individualized surgical plan. A technique without urethral lengthening is an option for those without a strong desire to void standing up.¹⁰ The vast number of different techniques might be an expression of the imperfection of the technique, but one could also claim that it reflects the multitude of desires of the patients. Comparing results can therefore be challenging.

The strength of this study is the relatively large group of patients with none lost to follow-up. There are apparent limitations due to the retrospective design. In addition, we only have data available concerning the postoperative follow-up from our national center. The design would have benefited from the implementation of a validated patient-reported outcome measure with the evaluation from the patient concerning quality of life, voiding patterns, and satisfaction related to the surgical result. As found by Oles et al¹⁷ and Barone et al,³⁵ there are only a few validated patient-reported outcome measures for this patient group that are used more than 1 or 2 times, and Kamran et al³⁶ emphasized the importance of an evidence-based implementation of PROMs. We are a low-volume center, where the genital-affirming treatment for transgender men is not that common. Future studies from our center aim to include more public involvement than this retrospective study.

CONCLUSIONS

Metoidioplasty is a surgical procedure with relatively high levels of urologic complications. This study provides information and evidence that can be used in decision-making both for the patient and the surgeon. However, there is an urgent need for future research with a focus on quality of life and long-term follow-up.

DECLARATION OF HELSINKI

The study conformed to the Declaration of Helsinki.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENTS

The authors thank Are Hugo Pripp for his support with the statistical analyses, and Kari C. Toverud, certified medical illustrator, for the original illustrations. All illustrations are copyrighted by Kari C. Toverud. The authors also thank photographer Elen Sonja Klouman for help with patient photographs.

Footnotes

REFERENCES