Scrotal Reconstruction in Transgender Men Undergoing Genital Gender Affirming Surgery Without Urethral Lenghtening: A Stepwise Approach

BACKGROUND: Scrotal (re)construction, scrotoplasty, is performed as part of gender affirming surgery in transgender men. Objective: To describe, step-by-step, our scrotal reconstruction technique in transgender men undergoing genital gender affirming surgery without urethral lengthening. Material and Methods: A 29-year-old transgender men underwent scrotal reconstruction and phalloplasty without urethral lengthening. For this purpose, the traditional scrotal reconstruction technique in patients that undergo urethral lengthening was modified. The patient is placed in lithotomy position. A pedicled horseshoe-shaped pubic flap, clitoral hood, and U-shaped labia majora flaps are used for scrotal reconstruction. The inner part of the labia minora (this is used to reconstruct the fixed part of the neourethra) is resected. The cranially pedicled U-shaped labia majora flaps are rotated 90 degrees medially to bring the neo-scrotum in front of the legs. Pedicled labia majora fat pads are released bilaterally and relocated in the neo-scrotum to achieve bulkiness. The meatus and vaginal orifice are diverted underneath the scrotum and a perineostomy is performed. Results: We present our scrotoplasty technique as a step-by-step video guide. The technique results in the reconstruction of a perineostomy at the perineal scrotal transition, an augmented neo-scrotum, minimal visible scars, and proper neo-perineal length. Conclusion: Scrotal reconstruction using a horseshoe-shaped pedicled pubic flap, labia majora fat pads, and 2 cranially pedicled U-shaped labia majora flaps results in a neo-scrotum that resembles the biological scrotum closely in terms of bulkiness, size, shape, tactile sensation, and anatomical position.