A primary surgical goal for many patients is standing to urinate. This requires urethral lengthening (UL). The opening to the native urethra is positioned in the perineum. Neighboring tissue is used to extend the urethral opening to the tip of the existing phallus. For patients interested in metoidioplasty with urethral lengthening, neighboring tissue is used to reconstruct the urethra. For patients interested in phalloplasty, a skin-tube urethra is created and connected to the lengthened urethra. After urethral lengthening, a suprapubic tube is left in place for 2-4 weeks (avg 3 weeks) and is removed once voiding thru the tip of the phallus. This tube goes from the lower abdomen skin to the bladder and diverts urine away from the urethra, allowing it to heal.
For patients who are not interested in standing to urinate (i.e. they want a phallus and have no or little dysphoria around being able to stand to urinate), urethral lengthening is not required. This can decrease the risk of postoperative complications, as the most common complications after urethral lengthening for metoidioplasty or phalloplasty are urethral stricture (narrowing of the opening causing difficulty with urinating, including weak urinary stream, straining to urinate, and not being able to empty the bladder) and fistula (abnormal connection between the urethra and outside skin, causing urine to exit thru the phallus and somewhere else, i.e. scrotum, perineum). This occurs, in general, in 10-20% of patients. A handful of patients choose not to have urethral lengthening and they have no urethral complications. In these patients, they urinate thru their original urethra, which is located in the perineum. For patients who opt for scrotoplasty without UL, the urethra is behind the scrotum.