Urethral lengthening

Urethral lengthening is the part of bottom surgery that extends the urethra so it opens at the tip of the new phallus instead of at the base. Urethral lengthening is what makes standing to pee possible, and it is optional in both metoidioplasty and phalloplasty.

Urethral lengthening is the construction of a new urethra from your existing opening to the tip of the new phallus, so that urine leaves from the tip and you can stand to pee. It is also called UL, urethroplasty or urethral reconstruction; this site uses urethral lengthening or UL.

Where does urethral lengthening happen?

Urethral lengthening is offered as a version of metoidioplasty and as a stage of phalloplasty. In metoidioplasty it separates the simple release from "full meta". In phalloplasty it is a stage that can be built with the phallus or left out entirely.

How is urethral lengthening done?

Urethral lengthening builds a tube from your existing urethral opening, along the underside of the phallus, to a new opening at the tip. The lining for the lower section comes from the inner labia and the entrance of the vaginal canal. In phalloplasty the shaft section comes from the flap's own skin or from a graft, sometimes buccal mucosa, the lining of the inside of the cheek. The tissue is rolled around a catheter into a tube, joined to the original urethra at the base and covered with a second layer of skin.

Urethral lengthening nearly always requires a vaginectomy, and usually a hysterectomy before it. The join at the base needs solid tissue underneath it, and the closed vaginal tissue provides that support.

How common are complications after urethral lengthening?

Urethral lengthening is the part of bottom surgery most likely to go wrong. The two complications are fistula, a hole that lets urine out along the shaft, and stricture, a narrowing that slows the stream. Published series for meta with UL put the combined fistula-and-stricture rate somewhere between one in ten and one in three. Phalloplasty urethras are longer and built from moved tissue, and they do worse, roughly a quarter to a half depending on the flap, whether the join was staged and how the surgeon counts.

Most fistulas and strictures are fixable, and the fix is another operation, typically six months on once the tissue has softened. Living with a leak while waiting for the repair is the part people find most wearing.

What does urethral lengthening mean for the plan?

Urethral lengthening adds a catheter for two to four weeks after meta and three to four weeks after phalloplasty, hours on the table and the vaginectomy requirement. A fistula repair is the most likely unbudgeted cost, and quotes differ on whether one is included.

Skipping urethral lengthening keeps the phallus, its sensation and its erections, and you sit to pee from an opening at the base. It removes most of the complication risk, shortens the catheter period to days and drops the vaginectomy requirement. A simple release can be converted to UL later; a vaginectomy cannot be undone.

Standing to pee after urethral lengthening is rarely the clean stream of a cis penis; spraying, or standing in public and sitting at home, still counts as a good outcome.

What should I ask the surgeon about urethral lengthening?

Ask for the fistula rate and the stricture rate separately, for your operation and your flap, and what they look like after a first repair. Ask where the join is made and whether it is done in one stage or two. Ask whether a repair is in the quote. Before any of that, spend a week noticing how much sitting to pee bothers you; that decides whether the riskiest part of bottom surgery is worth it to you. The full treatment of each operation is on meta with UL and phalloplasty UL.

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