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location:  Transition  >  Bottom Surgery  >  Consultations  >  Consult with Dr. Miro The following information is what I gathered from a metoidioplasty consultation with Dr. Miro in Baltimore, MD on January 13, 2007. My intention with this write-up is to simply present what I learned from speaking with him and is in no way meant to be a substitute for others having personal consultations with Dr. Miro. Doctor Miroslav Djordjevic Doctor Miro is a pediatric urologist at University Children's Hospital in Belgrade, Serbia. He is also an Assistant Professor of Surgery at Belgrade University Medical School. He is a member of the European Society of Pediatric Urology, European Association of Urology, International Urological Association, American Academy of Pediatrics (Section of Urology), American Urological Association, American Academy of Phalloplasty Surgeons, and the Harry Benjamin International Gender Dysphoria Association. With Dr. Sava Perovic, he has authored more than 30 peer-reviewed articles. History The Belgrade, Serbia team began performing metoidioplasty about 10 years ago. They used Dr. Donald Laub's metoidioplasty technique as their baseline and began making their own improvements. They used to perform it in the Children's Hospital, but they now use a private hospital, because they found their adult patients to be more comfortable. The team has performed over 100 metoidioplasties, and about 50 of those patients were from the United States. Miro said he performs 500-700 penile surgeries total per year. They like to plan surgery so that Miro is in the United States when you are a couple of weeks post-op so he can do a check up if necessary or address any complications. Surgery - One Stage Vaginectomy The surgery begins with removal of the vagina, complete closure of the vaginal opening, and creation of a perineum. All vaginal mucosa is removed, and their recent use of a laser-like instrument has presented them with a 0% complication rate. The vaginal muscles are retained, but they are non-functioning. Since removal of the vagina presents the highest risk for blood loss during the procedure, they prepare blood products (from the national blood center) in advance in case you need a blood transfusion. Miro assured us that the national blood center adheres to the same standards as the United States and tests their blood accordingly. If you do not use the blood, they dispose of it. However, since using the laser during the vaginal removal, they have not needed to give anyone a blood transfusion. Metoidioplasty The metoidioplasty includes the straightening and lengthening of the hormonally-enlarged clitoris. The connecting ligaments are transected to straighten, and the urethral plate (a band of mucosa that is normally between the clitoris and the urethral opening) is transected and reattached to the base of the neophallus to allow lengthening and provide rigidity. Urethroplasty Urethroplasty is performed using a buccal (inner cheek) mucosal graft, which is also used in normal male urethral construction. The buccal mucosa is used to form the dorsal (superior) part of the new urethra while dorsal clitoral skin is used to form the ventral (inferior) part of the new urethra. The labia minora can also be used to form the ventral (inferior) part of the new urethra and/or to cover the elongated neophallus, but many times there is not enough tissue to do this and they are simply removed. They like to keep you in the hospital for 3 days after surgery since a nurse will keep the buccal mucosal graft moist to help with blood vessel development. Testicular Implants The Belgrade team uses EuroSilicone (a subsidary of MediCor) testicular implants made in France, placed in the labia majora, to create the testicles. One implant is placed on each side, and the two labia majora are joined in the middle, divided by a septum to prevent contact between the implants, which would increase the chance of complications. Although the two sides are joined in the middle, a small exterior groove can usually be seen. This groove can be removed in the future to create one smooth-appearing sac, and this procedure can be done under local anesthesia. They use medium-sized implants (18cc), as any larger of an implant could cause pressure on the new urethra causing urethral complications. If you want larger implants, you can get the medium-sized implants replaced with the larger version in 3-6 months after the initial surgery. They have never had a complication due to using silicone (instead of saline) for the implants, and a capsule forms around the implants in 3-4 months. Post-op The entire procedure lasts about 5 hours. A suprapubic catheter (3.3mm in diameter) is placed during the surgery and remains for 4 weeks. There is no need to carry a urine bag; there is a clamp at the end of the catheter to keep the catheter closed. When you feel your bladder is full and need to void, you simply release the clamp and allow your bladder to empty. Then clean the end of the catheter, and replace the clamp. They have had a much lower complication rate when leaving the suprapubic catheter in for at least 4 weeks, as compared to 2-3 weeks. With the suprapubic catheter, the only thing that prevents you from urinating out of the new urethra is voluntary holding of urine (ie. you could urinate out of your new urethra from the very beginning, but they recommend waiting at least 4 weeks to allow it to heal). At the end of 4 weeks, you can begin urinating out of the new urethra. The suprapubic catheter should remain in place for the first 2-3 days while you are using the new urethra. If everything goes well using the new urethra, you can simply pull the suprapubic catheter out yourself at home, and the hole in the bladder will contractually close immediately. They recommend you take antibiotics to prevent any bladder infections. During the surgery, they also place a catheter in the new urethra to keep it open, which remains for about 7 days. It is removed 2-3 days before you are scheduled to go home, in order to give a couple days of monitoring after its removal to make sure everything is OK with the new urethra. Revisions/Complication Corrections Any additional surgery to correct complications (strictures, fistulas, testicular implant problems) are free of charge, including anesthesia and hospital costs. You would only need to pay for the plane ticket to Belgrade and wherever you decided to stay. However, if the correction can be performed by a local urologist (and most complication correction surgeries can), it may still be cheaper to get other procedures done at home, especially since health insurance may view it as a medically-necessary procedure. Cost Total cost for vaginectomy, metoidioplasty, urethroplasty, and scrotoplasty is 10,000 Euros, and the testicular implants cost an additional 780 Euros. At least 2 months before surgery, they require 10% deposit plus payment for the implants so they can order them. At the time of this writing, 10,780 Euros equals about $13,925 USD using an online currency converter. Complication Rate Overall, they have a 20% complication rate, mostly due to urethroplasty, and the vast majority of these are either a stricture or fistula. A stricture can usually be corrected (or prevented) by inserting a small dilator coated with antibiotic jelly twice per day for the first 3 months following surgery. Fistulas can usually be corrected by one additional 30 minute procedure that can performed under local anesthesia by any urologist. Stay in Belgrade Upon arrival in Belgrade, Miro or one of his assistants picks you up from the airport and brings you to the hospital to meet the team and get pre-anesthetic bloodwork done. Miro or his assistants will also provide transportation to and from the airport and hospital, as well as arrange for an English-speaking cab driver for any tourist excursions or other errands. They give you a cell phone to use while you are there with all of the phone numbers you may need to get in touch with the surgical and hospital staff. While a hotel can cost 120 Euros/night, the Belgrade team offers a private, fully-equiped apartment for 60 Euros/night. The apartment has A/C, TV, and the internet. It has two floors, and each can accommodate one patient; if you share the apartment with another person having surgery, each person pays 50 Euros/night. Other Miro recommends getting liposuction of the mons pubis, especially for heavier patients, but this should be done at a later date so as to not jeopardize the blood supply to the metoidioplasty. He also will give you a CD of photos from your surgery. Miro is more than willing to write any reports necessary to give to other doctors or workplaces. Masturbation can be resumed in 4-5 weeks post surgery. Example timeline of days and events in Belgrade: Day 1 - arrive in Belgrade, meet surgical team, pre-operative blood work Day 2 - surgery, usually performed in the afternoon since our body clocks would really feel like it was morning Day 5 - leave hospital Day 9/10 - new urethra catheter removed Day 13/14 - leave Belgrade At the consultation, Miro gave me a pump and recommended pumping for 1 minute, then releasing, for a total of 15 minutes twice a day to encourage more genital growth and skin stretching. Pumping should be continued after surgery to prevent retraction of the neophallus back into the skin. He also gave me Andractim, a DHT gel that has local testosterone effects, and recommended applying a small amount to the glans twice per day. Application of Andractim should begin at least 3 months before surgery (though sooner the better) and can be continued until surgery.