Single-stage dorsal-inlay augmented metoidioplasty: technique, complications, and patient-reported outcomes

Metoidioplasty is a genital gender-affirming surgery that preserves native sensation and erectile capability but remains technically demanding, particularly regarding urethral lengthening. We evaluated perioperative and functional outcomes of a single-stage modified metoidioplasty using dorsal labia minora graft augmentation, ventral anterior vaginal advancement flap reconstruction, and bilateral rotational scrotoplasty incorporating bilateral Martius fat pads. 23 transgender men underwent surgery at a tertiary referral center between 2017 and 2025. Median age was 38 (33-46) years and median follow-up was 36 (24-48) months. Median operative time was 165 (147.5-175) min and hospital stay was 2 (1.5-2.5) days. Early and late complications were observed in 13.0% of patients each. Cumulatively, urethral fistula and urethral stenosis occurred in 17.4 and 8.7% of patients, respectively. 2 (8.7%) fistulas resolved spontaneously, while 17.4% of patients required surgical revision. Patient-reported satisfaction was high, with 95.7% of patients satisfied with surgery and 91.3% reporting satisfaction with micturition and quality-of-life improvement using a non-validated binary questionnaire. This buccal mucosa graft-sparing, tissue-preserving approach appears feasible and safe, with urethral complication rates within the spectrum of outcomes reported in the literature, while potentially simplifying specific reconstructive steps and avoiding donor-site morbidity. Larger prospective comparative studies are warranted.