location: Transition > Bottom Surgery > Choosing a Doctor
After having the consultations with both Dr. Miro and Dr. Meltzer, I did some of my own research and attempted to compare/contrast the pros and cons of both doctors.
This is my personal reaction to and opinion about my consultations with two surgeons who perform metoidioplasty. It is not meant to be a criticism of either doctor, it is simply an attempt to outline my considerations and decision process in order to show why I have chosen to have bottom surgery with the Belgrade team (Dr. Miro). The following information is in no way meant to be a substitute for others having personal consultations with Dr. Miro or Dr. Meltzer.
The most striking difference between Dr. Miro and Dr. Meltzer was their bedside manner. When we were approached by Miro, he raised his arms in the air and had a giant smile on his face. He insisted on buying our drinks from Barnes and Noble, because he said, "when you are in Baltimore, and when you come to Belgrade, you are my guests!" In contrast, Dr. Meltzer did not even introduce himself to me or my partner (his practice manager ended up doing it), walked completely in front of us, and did not make any conversation with us the entire way up to his hotel room. The conversation with Dr. Meltzer was very business-like, compared to the conversation with Miro that felt very warm and welcoming to questions, yet still professional and confident.
While this may not signify anything about their respective surgical skills, it definitely says something about the personal investment of the surgeon in their patients' well-being. In addition, Miro said he believed in "from airport to airport" mentality, meaning he will take care of everything while you in Belgrade. He said he routinely organizes to have dinner at the apartment in Belgrade with his patients after surgery. Based on each doctor's bedside manner, I would feel much more comfortable and secure with my immediate aftercare in Miro's hands, or at least under his directive.
Primary Surgical Experience
Dr. Miro is a urologist who performs primarily penile surgeries, as opposed to Dr. Meltzer who is exclusively a plastic surgeon. Since he operates on children, Dr. Miro is accustomed to working on smaller-scale structures and is (obviously) extremely concerned with both not only aesthetic result, but also functionality of the neophallus. Sure, it'd be nice to come out of surgery with a nice-looking penis, but if it doesn't work, it won't do me any good. This point, combined with the fact that, personally, I am more impressed with Dr. Miro's aesthetic results, makes this a very difficult point to argue.
Dr. Miro and the Belgrade team uses buccal mucosa for the dorsal part of the new urethra and dorsal clitoral skin to form the ventral part of the new urethra. In contrast, Dr. Meltzer's team uses vaginal mucosa, urethral plate, and the labia minora to form the new urethra.
The most recent articles in urology journals claim buccal mucosa is the "gold standard" for urethroplasy, due to it being easily harvestable, resilient to infections, accustomed to a wet environment, hairless, and having a thick epithelium. Since vaginal mucosa also has all of these properties, I tried to find articles that compared the use of vaginal and buccal mucosa in urethroplasties. However, I found it difficult to find medical literature comparing the use of these two tissues for urethroplasty, probably because most urethroplasties are performed on males with hypospadias and they do not have vaginal mucosa as an option as a reconstruction material. Of the ones I found, articles on urethroplasty in females were mostly focusing on post-traumatic injuries to the urethra and correction of complications from previous pelvic surgeries. I did find multiple articles that concluded that buccal mucosa was a "suitable alternative" for vaginal or bladder mucosa when repairing urethral strictures in females, as well as an article that described using buccal mucosa to correct urethral strictures in female-to-male transsexuals (see Articles section).
Ultimately, I think it is difficult to conclude which is better for female-to-male urethroplasty, vaginal mucosa or buccal mucosa, due to the very small sample size of the current studies that directly compare the use of both materials. In fact, the absolute lowest complication rate (according to one article) was found when using the urethral plate, which both doctors incorporate in the new urethra. I think a benefit of using buccal mucosa is that the vast majority of current research on urethroplasty and urethra strictures is in procedures using buccal mucosa; therefore, in the event of a complication after surgery, it will be much easier to find currently-suggested methods of treatment and correction. The only potential benefit I could see to using vaginal mucosa as opposed to buccal mucosa for urethroplasty is that vaginal mucosa may self-lubricate during arousal. Dr. Meltzer said this can happen and act as a "pre-ejaculate," though there is no guarantee this function will return after the vaginal mucosa is used as a graft.
While I have not found any studies on the scientific validity of this, I think I would feel better with complete ablation of vaginal mucosa, simply due to the unknown long-term effect of cross-sex hormone (testosterone) use on this tissue type. Men-born-male do not have the same vaginal mucosa so we cannot assume how vaginal mucosa will react to testosterone over time; in fact, we do know that even short term use of testosterone causes vaginal dryness, certainly not something I would want in my urethra. Vaginal mucosa is not used in urethroplasties in males, so just because it is present in female-to-male transsexuals does not mean it is a superior urethroplasty material. At the same time, this is also not to say that it is an inferior material for urethroplasty. However, I think I would feel more comfortable sticking with what has been researched for almost 2 decades (buccal mucosal grafts) and completely removing the vaginal mucosa.
It is difficult for me to believe that Dr. Meltzer has only had 2 fistulas, 2-3 strictures, and 2 diverticula as complications from his (or rather his urologist's) urethroplasties. The fact that he boasted about having the "lowest complication rate around," without having any kind of facts, figures, or even remote guesses when directly questioned about it, was not reassuring. This leads me to wonder if 1. these numbers are grossly underestimated, 2. he has not performed nearly the number of urethroplasties as metoidioplasties in general, and/or 3. he doesn't truly know how many urethral complications have occurred in his patients. Of all of the options, my guess would most likely be that he simply is not aware of how many or what kind of urethral complications have occurred; I know if I had metoidioplasty with urethral lengthening with him, and I felt I needed a doctor for a urethral complication, I would have the option of going to a local urologist, the urologist who did the urethroplasty (Mitchell Kaye, MD), or Dr. Meltzer himself. Dr. Meltzer, as a plastic surgeon and not even the one who performed the urethroplasty, would be last on this list for me. Dr. Meltzer said that he absolutely would not want his patients to self-dilate, and that if he thought this was needed, he would be the one to do it.
In contrast, Dr. Miro said they have had a 20% complication rate, as determined by a study on their own patients (see Articles section). In addition, I found multiple articles that exhibited a similar complication rate using buccal mucosa for urethral reconstruction, signifying the Belgrade's team is competent in their surgical procedure as well as post-operative care of the new urethra. Also in contrast with Dr. Meltzer's opinions, much of the medical literature actually advises the use of self-dilation procedures for the patients in order to prevent or correct urethral strictures (see Articles section).
While researching self-dilation techniques, I did not find any articles that suggested self-dilation to be injurious to the new urethra, which was Dr. Meltzer's claim for wanting to perform the dilation himself as opposed to having the patient do it at home. In fact, I found multiple articles that incorporated self-dilation as part of post-operative follow-up (mostly after stricture repair, as that is the content of most of the articles published). Dr. Miro gives you a small dilator and antibacterial lubrication jelly and suggests you dilate for 3 months following surgery in order to help prevent strictures; the literature I encountered also seemed to support his method of post-operative care.
Multiple Stages vs. One Stage
The Belgrade team does metoidioplasty, vaginectomy, urethroplasty, scrotoplasty, and testicular implant placement in one stage; Dr. Meltzer performs metoidioplasty, vaginectomy, and urethroplasty in Stage 1, then scrotoplasty and placement of testicular implants or expanders in Stage 2. Obviously, it would be ideal to have it all done in one stage, but I had heard some arguments for doing it in multiple stages to minimize trauma on the body and allow healing between major surgeries. On the other hand, I had heard that doing it in multiple stages may actually complicate things - after every surgery, scar tissue forms, and multiple surgeries may increase scar tissue formation and delay healing. Dr. Meltzer made the statement that the increase in scar tissue formation over the multiple surgeries actually augments the blood supply to the area. I'm not sure how this could be, unless he meant that it serves to redirect blood flow to the area that was just being surgically altered.
Based on talking to both doctors, and after doing my own research, I really couldn't find anything that supported the idea that a one stage procedure is harmful or that a multiple stage procedure is beneficial. In summary, I came up with the following "facts":
Based on these ideas, I'm not convinced that a multiple stage procedure is necessary, or even beneficial in any way. In fact, exposing myself to anesthesia more than once on a voluntary basis, especially when I have not found any significant reason to do so, is simply not necessary.
- a one stage procedure is more beneficial mentally; no one wants to wait around feeling "half-done"
- a multiple stage procedure does increase scar tissue formation
- a multiple stage procedure, especially if more than one stage is under general anesthesia, increases chances for anesthesia complications, the worst of which is death
- a multiple stage procedure in which scrotoplasty is done after metoidioplasty/urethroplasty does not show any significant decrease in chance for urethral or testicular complication (see Articles section)
While cost is not a primary concern for me when considering surgery on the genitals, it certainly is a factor to consider. Dr. Melter's entire package would be about $40,000 USD, while Dr. Miro's package would be under $20,000 USD. In addition, Dr. Miro charges only a minimal amount (to cover supply costs) for complication corrections; Dr. Meltzer does not charge a surgeon's fee for corrections, but you would have to pay for anesthesia, hospital use, travel, and local stay. Even with the added cost of flights to Serbia, I still think it would be cheaper in the long run to go with the Belgrade team. However, this is not surprising, because Dr. Meltzer's price is really having to pay for 3 doctors (plastic surgeon, urologist, and gynecologist), versus Dr. Miro's price that pays for Dr. Miro and all of his associates.
Ultimately, it's probable that both surgeons are extremely competent with superior skills and the likelihood of having a complication is similar. In the event of a complication, I would much rather have a urologist as my primary doctor than a plastic surgeon. Above and beyond credentials and the difference in methods, the main difference I found was in aftercare, follow-ups, and willingness to discuss the procedure and potential correction routes in the case of complications. Also, small differences just made me feel more comfortable with Dr. Miro - for example, Dr. Meltzer did not even know the size of testicular implants they use, because he hasn't "done a water displacement test or anything," versus Dr. Miro knowing exactly what size and volume they use. Another example was that Dr. Meltzer leaves the suprapubic catheter in for 12 days, and the Belgrade team leaves it in for 4 weeks. While 4 weeks sounds like an awfully long time, Dr. Miro himself said they have experienced much fewer complications when they left it in for 4 weeks as compared to 2-3 weeks. This, to me, indicates a strive for better results, fewer complications, and a technique modification as such. Dr. Meltzer also presented some information on his area of technique modification, but it all centered around making the neophallus larger during erection; again, aesthetic results versus functionality. I know I don't want to end up with a large penis that I can't pee out of.
While I'm sure Dr. Meltzer is a fine surgeon, I (personally) do not see any compelling reason to go to him when the Belgrade team is another option. For all of these reasons, I concluded it would be best for me to have surgery with Dr. Miro in Belgrade, Serbia. I had surgery with them in June 2007.