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location:  Transition  >  Frequently Asked Questions (FAQ)  >  Transitioning Process  >  Bottom Surgery Questions 1. How did you know which bottom surgery was best for you? 2. Where does the tissue for a phalloplasty come from? 3. Is it ever too late to get bottom surgery? 4. Where did you find out about the Serbian surgeon Miroslav Djordjevic? 5. Can you urinate normally (through your phallus and without pain)? 6. Did you lose sensation after your bottom surgery? / Can you orgasm after your bottom surgery? 7. Do you get an erection? / Can you have penetrative sex now? 8. How did you find a reputable local doctor or surgeon to take care of you post-operatively after your bottom surgery? 9. How can I contact the surgeon who did your bottom surgery (Dr. Miroslav Djordjevic)? 10. Did Dr. Sava Perovic and Dr. Miroslav Djordjevic used to work together? / How do I contact Dr. Sava Perovic? 11. Why don’t you post photos of your bottom surgery results when you’ve posted photos of virtually every other aspect of your transition? 12. Since you’ve had bottom surgery, can you get a woman pregnant? 13. What types of catheters did you have after your bottom surgery? 14. What is a VCUG, and why did you have so many of them? 15. How much length did you gain from having bottom surgery? 16. Did you pump and/or use DHT (dihydrotestosterone) cream before or after surgery (and did it help)? 17. Are you satisfied with your bottom surgery results? / Because of your complications, if you had to do it again, would you choose not to have urethral lengthening and vaginectomy? 18. After all of your complications, would you recommend the Belgrade, Serbia team (headed by Dr. Miroslav Djordjevic)? 19. Was having surgery in another country up to par with having surgery in the United States? 20. How long were you off work/out of school for bottom surgery? 21. Is a vaginectomy (removal of the vagina) required during bottom surgery? 1. How did you know which bottom surgery was best for you? I weighed the pros and cons of the two main types of bottom surgery: metoidoplasty and phalloplasty. With metoidioplasty, you can end up with an erotically-sensate phallus that can become erect naturally, but the average size is 2-3 inches so penetration can be more difficult. Since it is small, urethral lengthening with metoidioplasty is much easier. With phalloplasty, the resulting phallus is generally much larger at 5-7 inches, making penetration more of a possibility, but having erotic sensation is not guaranteed since the phallus is created by a skin graft from the arm, back, or abdomen. Since it is much larger, urethral lengthening with phalloplasty is more difficult. Erection with a phalloplasty is generally created by a pump implant in the phallus that must be pumped before penetration. Erotic sensation and urination abilities were much more important to me than penetrating my partner so I chose to have metoidioplasty with urethral lengthening instead of phalloplasty. 2. Where does the tissue for a phalloplasty come from? The most common phalloplasty procedure, the Radial Forearm Free Flap Phalloplasty, uses tissue from the forearm. Two other less-common phalloplasty procedures use tissue from the shoulder/deltoid area or the abdomen. The Abdominal Flap Phalloplasty, where skin from the abdomen is used and never fully separated from the body (hence retaining blood supply and nerve innervation for surface sensation) is becoming more popular. 3. Is it ever too late to get bottom surgery? Not to my knowledge, besides the normal contraindications for any type of surgery. 4. Where did you find out about the Serbian surgeon Miroslav Djordjevic? I knew someone personally who went to him (when he worked with Dr. Sava Perovic) and had a very good experience and results. Since then, I have read on the Yahoo Group FTMmetoidioplasty about multiple other people having the same procedure with these surgeons who seem to be very satisfied. 5. Can you urinate normally (through your phallus and without pain)? Yes. Now that my fistulas have been fixed, I can successfully urinate standing up and at a urinal. 6. Did you lose sensation after your bottom surgery? / Can you orgasm after your bottom surgery? I did not lose any sensation after my metoidioplasty. Orgasming after surgery is actually much more intense and pleasurable, because I can finally fully relate to that part of my body now. 7. Do you get an erection? / Can you have penetrative sex now? The phallus I have from my metoidioplasty is very small, similar to an infant-sized penis. Although small, it does react to sexual stimulation and excitement and gets larger with erection – large enough for slight penetration. 8. How did you find a reputable local doctor or surgeon to take care of you post-operatively after your bottom surgery? My metoidioplasty surgeon (Dr. Miroslav Djordjevic) suggested I find a pediatric urologist (as opposed to an adult urologist), because a pediatric urologist would have more experience with working on phalluses similar in size to what I would end up with as well as being familiar with the complications possible (strictures and fistulas are common complications of urological surgery, which is most often performed in children with congenital urological abnormalities). I noticed on my surgeon’s Curriculum Vitae that he had worked briefly about 10 years before with someone at a hospital near where I lived. I then emailed that person at the hospital and explained my situation and plans – and asked if they would be willing to take me on a patient. Their reply was that he could not help me. I asked him for suggestions on who might be willing to help me, and he told me to ask one of his colleagues in his same department. I emailed this other pediatric urologist, again explained my situation, and asked if he would take me as a patient – and he said yes. I think the key to my success in finding a pediatric urologist for my post-op care is not that my surgeon had previously worked with someone in my area – I think it is that I explained my plan to have surgery upfront and did not give up when the first person said “no.” You may run into multiple doctors who are unwilling to help before finding one who will, but the perseverance is well worth it. 9. How can I contact the surgeon who did your bottom surgery (Dr. Miroslav Djordjevic)? His website at http://www.metoidioplasty.com has his contact information as well as photos of some of his results. 10. Did Dr. Sava Perovic and Dr. Miroslav Djordjevic used to work together? / How do I contact Dr. Sava Perovic? Yes, Perovic and Djordjevic used to work together in Belgrade, Serbia. For reasons unknown to me, they no longer work together, but both still perform metoidiplasty separately. Dr. Miroslav Djordjevic’s website is http://www.metoidioplasty.com and Dr. Sava Perovic’s website is http://www.savaperovic.com. 11. Why don’t you post photos of your bottom surgery results when you’ve posted photos of virtually every other aspect of your transition? Would you want photos of your genitals flying around cyberspace on a public domain? I don’t either. You can see very similar results to mine on my surgeon's website. Maybe one of his case studies is actually me, you never know. 12. Since you’ve had bottom surgery, can you get a woman pregnant? No. There are currently no surgeries that will allow a female-born person to make sperm (which are needed to create pregnancy). 13. What types of catheters did you have after your bottom surgery? I had two types of catheter tubing after my metoidioplasty: a stint and a suprapubic catheter. The stint was just a piece of plastic catheter-like tubing that went from just past the bladder to the tip of the penis. The purpose of the stint was to keep the new urethra open to help prevent strictures, and it was removed at 9 days post-op. The suprapubic catheter was a plastic catheter that was inserted into the bladder through the skin right above the pubic bone while under anesthesia. At night, the suprapubic catheter can be connected to a bag so you don’t have to get up and urinate at night. During the day, the free end of the suprapubic catheter can be clamped off (and not connected to a bag) so you can go about your business; then, when you feel like you need to urinate, go to the bathroom and unclamp the end of the suprapubic catheter over a toilet to empty your bladder. Typical Foley/urethral catheters that are inserted into the bladder through the penis can not be clamped off like a suprapubic catheter, because they need to continually drain urine (and thus the need for a urine bag all the time when using Foley/urethral catheters). Having a suprapubic catheter (versus a Foley catheter) makes it more convenient and avoids the need for dragging a catheter bag around all day. Here is an image that compares the two types of catheters. 14. What is a VCUG, and why did you have so many of them? VCUG stands for voiding cysto-urethrogram. The purpose of a VCUG is to visualize the urinary tract to look for abnormalities such as fistulas or strictures. During the procedure, radiodense dye is instilled into the bladder through an existing suprapubic catheter or via in-office catheterization through the penis. After the dye is instilled into the bladder, a series of x-rays are taken while you urinate. The radiodense dye shows up on the x-rays as white while the body structures (urethra, bladder, muscles, etc.) show up as various shades of grey. By looking at the flow of the white dye through the urinary tract, the doctors can make speculations or diagnoses of urethral abnormalities. I ended up having so many VCUGs, because my doctors were tracking the progress of my fistula. Eventually, when the fistula was completely healed closed, the radiodense dye was seen flowing only through the urethra, as would be normally expected. 15. How much length did you gain from having bottom surgery? None, in fact I probably lost about an inch in length (though gained about 300% in girth). Before surgery, the hormonally-enlarged clitoris was about 2 inches long; after surgery, the phallus is just over an inch in length (flaccid). Loss in length is common after metoiodplasty and is attributed to moving the phallus up further toward the pubis to put it in a more naturally-male position. 16. Did you pump and/or use DHT (dihydrotestosterone) cream before or after surgery (and did it help)? I got a pump and DHT cream from my surgeon about 6 months before my metoidioplasty. I didn’t use them for very long, maybe 2 weeks total, mostly due to being very busy in school and laziness. For those 2 weeks, I did notice a change (ie. more phallus length), but it went back to normal as soon as I stopping pumping. Some people will swear pumping makes a difference, some will say it doesn’t help at all. I suspect it makes at least some temporary difference, especially if you pump the recommended twice per day; that way it is virtually always slightly enlarged. Personally, I have my doubts about the possibility for permanent changes (changes that stick around after pumping is permanently stopped). I can see how pumping after surgery would be helpful to stretch out scar tissue, but I was unable to pump post-operatively due to my fistula complications. 17. Are you satisfied with your bottom surgery results? / Because of your complications, if you had to do it again, would you choose not to have urethral lengthening and vaginectomy? If I had to do it all over again, I would not change my surgeon or procedure choice; I would however be more prepared for an over two-year recovery. Urethroplasty (urethral lengthening) and vaginectomy (removal of the vagina) were prerequisites for my surgeon choice, thus vastly narrowing down my options. Overall, I am happy with my bottom surgery results. 18. After all of your complications, would you recommend the Belgrade, Serbia team (headed by Dr. Miroslav Djordjevic)? Yes. Due to the limited number of surgeons in the world who even perform the “full package” (metoidioplasty, scrotoplasty with testicular implants, urethroplasty, and vaginectomy), I believe Dr. Miroslav Djordjevic’s Belgrade team is a good option for those who want to attempt it in one stage. If you are willing to do it in multiple-stages, there are other doctors that can be considered (including, but not limited to, Dr. Toby Meltzer, Dr. Harold Reed, and Dr. Pierre Brassard). Dr. Sava Perovic also does a one-stage metoidioplasty, scrotoplasty with testicular implants, urethroplasty, and vaginectomy. At this point in time, I personally do not believe that doing it in multiple stages has any major advantages over doing it in one-stage, at least in terms of the risk of complications. Plenty of people have done it in one stage with absolutely no complications and many have had complications after doing it in multiple stages (and vice versa). I was willing to take the risk in having the one-stage procedure – maybe I would be one of the lucky ones to not have any complications! Alas, I did have complications, turning it into a multi-stage procedure; however, since they were considered “complications” and not “elective procedures,” my medical insurance deemed them necessary and has covered the additional surgeries. 19. Was having surgery in another country up to par with having surgery in the United States? It was definitely very different. Small things that I wasn’t used to could be sometimes challenging to deal with. For example, smoking in the clinic waiting room was allowed when I went to Belgrade, Serbia, and somehow the cigarette smoke made its way into my bathroom (however, this was not the case in the other FTM patient’s room). It didn’t seem like they had access to as powerful pain medications; I was given what was essentially injectable Advil in Serbia versus when I had my revision (which was less invasive than the original surgery) in the United States they gave me morphine. I did see the inside of the Serbian operating room, and they definitely had all of the same up-to-date fancy medical equipment I have seen in United States operating rooms. I also felt like the care given to me directly from my Serbian surgeon was much more personalized than in the US (where you see your surgeon for maybe only three minutes per day and the nurses mostly take care of you). It was nice to have one of the surgeons come visit us at the apartment every day while in Belgrade. 20. How long were you off work/out of school for bottom surgery? I had my original bottom surgery procedure during the summer when I was out of school and not working. I did start working (a sitting-down job) about 4 weeks after the original surgery, and by then my only main problem was that I still walked somewhat like a wide-legged cowboy. I probably could have started working a sit-down job or gone back to school at 3 weeks post-op, but definitely not earlier. 21. Is a vaginectomy (removal of the vagina) required during bottom surgery? No, not necessarily. Most surgeons who perform urethral lengthening do require a vaginectomy, because the surgical procedure for urethroplasty makes it necessary. There are some surgeons who will do a metoidioplasty or phalloplasty without urethral lengthening (and thus without vaginectomy).