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Page 4 of 12 Meltzer et al. Plast Aesthet Res 2020;7:61 I http://dx.doi.org/10.20517/2347-9264.2020.122

A B C

D E F

Figure 1. A: Standard markings for metoidioplasty technique; B: ventral chordee released and flaps elevated. Bulbospongiosus muscles
and corporal body visible on deep side; C: ventral urethral repair (V-Y configuration); D: native urethra to neourethra repair; E:
completed urethral repair over 14F catheter; F: paramedian skin closure

epithelium of the flaps is imbricated in all suturing of the neourethra. The medial edges of the flaps are
sewn together with running 4-0 Monocryl stopping when it reaches the dorsal urethra without tension
[Figure 1C]. The flaps are now sewn around the native urethra, with 3-0 interrupted Monocryl [Figure 1D].
Once completed, a 14F catheter is placed and the lateral border of the flaps are rolled over the catheter
and approximated with interrupted 3-0 Monocryl (with the knots facing away from the urethral lumen),
creating the ventral wall of the neourethra. As the suturing proceeds distal to the pars fixa, a 4-0 Monocryl
suture is used. The urethra is repaired as far distal as possible provided there is no tension on the repair
over the catheter. Depending on the size of the glans clitoris, the urethroplasty will usually terminate at or
just distal to the base of the glans.

The levator ani muscles in the vaginectomy site are now approximated in the midline snuggly with 2-0
Monocryl. Approximating the muscles provides hemostasis at the vaginectomy site and buttresses the
ventral and proximal urethra to help prevent diverticulum and fistulas. A single TLS drain (Stryker Corp.,
Kalamazoo, MI) is placed along the urethra and brought out superiorly. The remainder of the vaginectomy