Originally, Dr. Toby Meltzer was not on my radar as a potential surgeon for metoidioplasty, mostly due to cost. However, Dr. Meltzer’s reported 2% complication rate stuck in my head. Inspired by my hysterectomy experience, reducing the risks of complication is my top priority.
I had the chance to see Dr. Meltzer’s presentation, FTM: GRS, at the Gender Odyssey conference last week in Seattle. These are the points that stuck out for me in his talk:
- The complication rate with urethral lengthening without Vaginectomy can be 15%-20% higher. (Dr. Webb states this is actually 40%-45% higher.) Vaginal secretions into the surgical site just don’t contribute to good healing.
- In his practice, vaginectomy takes just over an hour, has limited blood loss, and has a less than 1% complication rate. (He recalls one bladder injury.)
- Metoidioplasty with urethral lengthening takes 2 – 2.5 hrs.
- Pumping works. It enlarges corporal bodies and skin. Recommended both pre- and post-op.
- Growth can continue post-operatively.
- Atypical bacteria is found in androgenized vagina (re: weakened vaginal tissues from testosterone use.)
- Hardest part of urethral extension is getting the curve right. There are no “L” or “J” urethroplasty procedures or methods. The goal is an “L” shaped hook-up; poorly executed the result is a “J.”
- There are no long term complication risks to his knowledge. Once you’re past 6-12 months post-op, there’s no complication that could occur that couldn’t be handled by any urologist.
- Dr. Meltzer displayed photos of excellent looking metoidioplasty results from his patients.
- See further notes below about complication rate and tissues used for urethral extension.
That evening, I also had the opportunity to have an in-person consultation with Dr. Meltzer. We briefly discussed why he doesn’t use vaginal tissue for urethroplasty and how that relates to my theory that trans men are at higher risk for post-hysterectomy VVF than women are.
We also talked about scrotoplasty. When Dr. Meltzer talks about “scrotoplasty” he’s referring to the surgical procedure of moving and rotating the labia majora, then fusing them into a scrotal sac–without implants. If the patient desires implants, expanders and implants can be done at a later date. Dr. Meltzer sees no issues with waiting years for implants, or not having them at all, and he will do scrotoplasty–without expanders or implants–in combination with vaginectomy, and metoidioplasty with urethral lengthening.
Dr. Meltzer offered to do a simple visual exam to ascertain my suitability for urethral lengthening based on my dick size. I mentioned to him that I’d used DHT for three months. He said, “Well, keep doing whatever you’re doing because you’ve got great growth!” I asked him what kind of post-op length I could expect and Dr. Meltzer gently grabbed my dick between his gloved fingers and pulled it straight out. “There’s your length!”
I’m extremely impressed with Dr. Meltzer, his low complication rate, the very swanky surgical venue and the North American location. His pricing is higher than my other options, but after my hysterectomy experience, I would pay twice as much to avoid a complication.
Questions and Answers
What meta procedure do you offer for trans men?
Metoidioplasty, with or without urethral extension, and scrotoplasty.
- “Scrotoplasty” refers to the surgical procedure of moving, rotating and fusing the labia majora. Scrotoplasty may or may not include expanders and/or implants.
What is your 2008 pricing for this procedure?
- Vaginectomy: $8,073
- Metoidioplasty with scrotoplasty – no prosthesis: $9,750
- Primary urethral lengthening: $12,950
- Total: $30,773 USD.
Is an in-person consultation required prior to booking surgery?
Yes. The cost for this is $100 USD.
What kind of waiting list do you have?
It’s recommended to book your consultation 2-3 months in advance. The waiting list for a surgery date is about 6 months, but those with more flexible schedules may be able to take advantage of a short notice cancellation.
Do you perform this in one or two surgeries?
Vaginectomy, metoidioplasty, scrotoplasty (no prosthesis) and primary urethral lengthening can be done in one stage. If scrotal prosthesis is desired, expanders can be put in 6 months post operatively (Stage 2), and replaced at a later date with a permanent prosthesis (Stage 3.)
Where do you perform these procedures?
Greenbaum Surgery Center, Scottsdale, Arizona, USA.
Do you require patients to stop taking testosterone prior to surgery?
Yes, patient must stop taking testosterone 2-4 weeks before surgery and can resume normal administration post-operatively.
How long is the hospital stay?
2-4 days in hospital, then stay in the area for 14 days.
What tissue is used for the urethral extension?
Labial tissue and the urethral plate. Sometimes buccal mucosa is used (inner cheek) but it’s not preferred. Vaginal tissue (anterior vaginal wall, mucosa) is not used. Androgenized vaginal tissue is weakened and more prone to fistula. Future plans include experimentation using small intestine for urethroplasty.
How long is the suprapubic catheter left in?
This depends on the patient’s healing progress, but typically it is removed 21-28 days post-op.
What are the common complications with these procedures?
Since 2003, Dr. Meltzer has had just two patients with a [notable] complication: one with a fistula (which healed spontaneously) and one with a stricture (which was healed with a simple outpatient cystoscopy.) Note: I’ve inserted “notable” into the claim above because I’ve learned that surgeons and patients don’t necessarily have the same definition of “complication.”
How many times have you performed metoidioplasty with urethral extension?
Dr. Meltzer has performed more than 800 FTM lower surgeries. He has done metoidioplasty with urethroplasty many, many times, but I don’t know the exact number. My guess is that he has the most experience with these procedures in North America.
Learn more about Dr. Meltzer:
* UPDATES to Ethan’s consult:
- The vaginectomy now removes all vaginal mucosa.
- Dr. Meltzer no longer uses vaginal mucosa for urethroplasty.
- Dr. Meltzer’s OB/GYN Dr. Webb reports minimal blood loss with vaginectomy: 125 – 300cc. Only once did he have a patient require as much as 800cc. Many surgeons talk about 1 L of blood loss and multiple blood transfusions. Dr. Meltzer’s team has not experienced this.
- Dr. Meltzer will perform scrotoplasty at Stage 1—but without expanders or implants.
Please note: This information is provided for information purposes only and in no way should it serve as a replacement for your own research and consultations. My intent is not to find a “winner”, but to figure out which surgeon I am best suited to. We each have unique requirements and criteria, so please don’t go on my word. At the same time, there are plenty of questions that surgeons have to answer over and over, so hopefully this series will cut down on some of that repetition.
More Metoidioplasty Surgeons
Also see: Metoidioplasty Surgery Guide