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Page 4 of 8 Bizic et al. Plast Aesthet Res 2020;7:43 I http://dx.doi.org/10.20517/2347-9264.2020.80

Figure 1. Preoperative appearance. Hypertrophied clitoris under hormonal therapy. Foley catheter inserted into the bladder

introitus, attached ventrally to the clitoral body, and tubularized, thus creating the neophallic urethra. Final
urethroplasty is performed by joining the tubularized ring flap and the flap from the anterior vaginal wall in
an oblique fashion, while the remaining labial and clitoral skin is used for neophallus shaft reconstruction
[27]
using multiple Z-plasties to avoid ventral scar contracture . Complication rates occurring after ring
metoidioplasty vary from 3%-5% for urethral strictures to 10%-26% for urethral fisulae. Ring metoidioplasty
is performed as a one-stage procedure, except the scrotoplasty, which is always performed as an additional
[25]
procedure in one or two stages .

Complete metoidioplasty (Belgrade metoidioplasty) is based on the experience in dealing with the most
severe forms of hypospadias and disorders of sex development in children [24,28] . The latest modification of
the original technique involves simultaneous removal of internal female organs, vaginectomy (colpocleisis),
complete clitoral lengthening and straightening with the urethroplasty to the tip of the glans, and
scrotoplasty with bilateral testicular implants insertion as a one-stage procedure. The current technique
relies on the embryological and anatomical homology between the clitoris and penis, confirming the
clitoris as a smaller version of the penis with impaired urethral development [2,14] [Figure 1]. The procedure
involves laparoscopically-assisted hysterectomy with bilateral salpingo-oophorectomy, if not performed
prior to metoidioplasty, and complete vaginal mucosa removal by colpocleisis, with male-like perineoplasty,
except for one small portion close to the native urethral meatus. Further, clitoral degloving is performed
by a circular incision between the inner and outer layers of the clitoral prepuce downwards to the urethral
plate and continued with complete dissection of the superficial and deep portions of the suspensory
ligament. Additional straightening and lengthening are obtained by urethral plate dissection to correct
ventral chordee [Figure 2]. Urethroplasty is performed using all available hairless skin and/or mucosal
grafts over the urethral stent size 12-14Fr so that standing micturition would be possible, and a suprapubic
urinary catheter is introduced to the bladder for urine derivation [5,26,29,30] [Figure 3A and B]. Scrotoplasty is
performed by joining two labia minora flaps in the midline and inserting two silicone prostheses [Figure 4].
Postoperative care includes administration of broad-spectrum antibiotics and anticholinergic drugs
while the suprapubic catheter is in place. Vacuum pump use, in combination with phosphodiesterase
Type-5 inhibitors, for a period of six months postoperatively, is advised to prevent retraction of the