# Gender-Affirming Urologic Surgery

## Introduction

Gender-affirming surgical care is a growing field within urology that involves various reconstructive procedures aimed at aligning an individual's physical anatomy with their gender identity. The World Professional Association for Transgender Health (WPATH) Standards of Care establish the eligibility and readiness criteria for these surgeries. Urologists are integral to performing both masculinizing and feminizing genital procedures, making proficiency in these surgical techniques, perioperative management, and long-term follow-up increasingly essential for urologic trainees.

## Terminology and Framework

The term "transgender" serves as an umbrella descriptor for individuals whose gender identity differs from the sex assigned to them at birth. A transgender woman, also referred to as male-to-female (MTF), is someone assigned male at birth who identifies as female. Conversely, a transgender man, or female-to-male (FTM), is assigned female at birth but identifies as male. Gender dysphoria refers to the distress experienced due to the incongruence between one's gender identity and physical sex characteristics. Gender-affirming surgery (GAS), previously known as sex reassignment surgery, encompasses a variety of procedures including genital, chest, and other surgeries tailored to affirm an individual's gender. Additionally, nonbinary individuals do not identify exclusively as male or female and may seek surgical goals that are customized to their unique identities.

## Preoperative Considerations

### WPATH Eligibility Criteria for Genital Surgery

To be eligible for genital surgery under WPATH guidelines, individuals must have persistent and well-documented gender dysphoria. They must possess the capacity to make informed decisions and provide consent for treatment. Candidates should be of the age of majority in their country or follow adolescent-specific guidelines if applicable. Any significant medical or mental health concerns must be reasonably well controlled prior to surgery. For gonadectomy, twelve months of continuous hormone therapy is generally required unless hormones are contraindicated or not desired. Similarly, twelve months of living in a gender role congruent with one's gender identity is typically required before genital surgery, although some guidelines are evolving on this point. Finally, two referral letters from qualified mental health professionals are necessary to confirm readiness.

### Preoperative Evaluation

Preoperative evaluation includes assessing hormonal status, such as estrogen and anti-androgen therapy for MTF individuals or testosterone therapy for FTM individuals. A thorough surgical anatomy assessment is conducted, reviewing any prior surgeries and evaluating genital anatomy. Psychosocial readiness must be confirmed in collaboration with a mental health team. Smoking cessation is mandatory for procedures involving flaps and grafts due to the risk of vascular compromise. Hair removal through electrolysis or laser treatment is essential for genital skin that will be used in neovaginal lining for MTF patients or urethral construction for FTM patients, as incomplete hair removal can lead to intravaginal or intraurethral hair growth. Planning for venous thromboembolism (VTE) prophylaxis is critical because estrogen therapy increases VTE risk; coordination with endocrinology regarding perioperative hormone management is advised.

## Feminizing Genital Surgery (MTF/Transfeminine)

### Vaginoplasty

The most common feminizing genital surgery worldwide is penile inversion vaginoplasty. This technique involves inverting penile and preputial skin to create the neovaginal lining. Orchiectomy and removal of erectile tissue are performed concurrently. The neoclitoris is fashioned from dorsal glans tissue while preserving the neurovascular bundle to maintain sensation. Labiaplasty is also performed, creating labia majora from scrotal skin and labia minora from remaining penile or urethral tissue. The typical neovaginal depth achieved ranges from 12 to 16 centimeters.

When penile and scrotal skin are insufficient—such as in cases of prior circumcision, a small phallus, or revision surgery—a sigmoid colon vaginoplasty may be indicated. This procedure uses a pedicled segment of the sigmoid colon to line the neovagina. Advantages include a self-lubricating mucosa and less dependence on dilation. However, it requires abdominal surgery and carries risks such as diversion colitis and excess mucous discharge.

An emerging technique is the peritoneal pull-through vaginoplasty, which uses robotic assistance to utilize pelvic peritoneum for neovaginal lining. This approach avoids bowel surgery and may provide superior epithelialization. Although evidence is still growing, intermediate-term outcomes appear promising.

<image>Surgical illustration showing the key steps of penile inversion vaginoplasty: (A) initial dissection and orchiectomy, (B) creation of the neovaginal canal between the rectum and prostate/bladder, (C) inversion of penile skin flap to line the neovaginal canal, and (D) creation of neoclitoris from dorsal glans with preserved neurovascular bundle, neourethral meatus, and labia from scrotal flaps</image>

### Complications

Neovaginal stenosis is the most common complication, occurring in 5-15% of cases. It is managed primarily with aggressive dilation and may require revision surgery if severe. Rectovaginal fistula occurs in 1-3% of patients and necessitates surgical repair. Urethral meatal stenosis may require procedures such as meatotomy or meatoplasty. Early postoperative complications also include wound dehiscence and granulation tissue formation. Clitoral necrosis is rare but can result from vascular compromise of the neurovascular bundle. Some patients experience aesthetic dissatisfaction, which may lead to revision labiaplasty.

### Postoperative Care

Postoperative care emphasizes vaginal dilation, which is critical for maintaining neovaginal depth and width. Dilation typically begins 5 to 7 days after surgery and requires lifelong commitment, although the frequency of dilation usually decreases over time. Pelvic floor physical therapy may improve functional outcomes. Long-term screening does not require cervical cancer screening, but the urethral meatus and neovaginal canal should be monitored for granulation tissue and stenosis.

## Masculinizing Genital Surgery (FTM/Transmasculine)

### Metoidioplasty

Metoidioplasty utilizes the hormonally enlarged clitoris, which grows under testosterone therapy, as the neophallus. This procedure offers several advantages: it is a single-stage surgery, preserves erogenous sensation, has a lower complication rate, and avoids donor site morbidity. However, the neophallus typically measures only 4 to 6 centimeters, which may be insufficient for standing urination in some patients, and penetrative intercourse is often not possible. Urethral lengthening is optional and involves using vaginal mucosal flaps or buccal mucosa to extend the urethra to the tip of the neophallus, enabling standing micturition. Scrotoplasty is performed using labia majora tissue to create a scrotum, with testicular prostheses placed at a later stage. Vaginectomy and hysterectomy may be performed concurrently or in staged procedures.

### Phalloplasty

Phalloplasty involves creating a neophallus using either a free flap or a pedicled flap. The radial forearm free flap (RFFF) is the most common donor site, providing thin, pliable tissue ideal for urethral construction using the "tube within a tube" technique. This procedure requires microvascular anastomosis. The anterolateral thigh (ALT) flap is an alternative for patients wishing to preserve their forearm, though the tissue is bulkier and may require debulking. The musculocutaneous latissimus dorsi flap is another option with a concealed donor site. Phalloplasty is typically a multi-staged procedure involving three to four stages: the first stage includes flap creation, urethral lengthening (either pre-stage or concurrent), and hysterectomy or vaginectomy; the second stage involves glansplasty, urethral hookup, and scrotoplasty; the third stage includes placement of testicular and erectile prostheses. Erectile prostheses, either semi-rigid (such as the Coloplast Genesis) or inflatable devices, are implanted within the neophallus to enable penetrative intercourse.

<image>Comparison diagram of metoidioplasty and radial forearm free flap phalloplasty, showing the surgical approach, expected neophallus dimensions, urethral construction techniques, and functional outcomes for each procedure, with donor site illustrations for the forearm free flap</image>

### Complications

Urethral complications are the most common and challenging issues following phalloplasty. Urethral fistulas occur in 25-60% of cases, while strictures develop in 15-35%. Urethral fistulas are managed with staged repair, although some may close spontaneously. Urethral strictures can be treated with dilation, direct visual internal urethrotomy, or staged urethroplasty. Flap loss, either partial or total, occurs in 1-5% of RFFF cases and requires close microvascular monitoring during the first 72 hours postoperatively. Donor site morbidity includes forearm scarring, reduced grip strength, and sensory changes. Complications related to erectile prostheses include erosion, infection, and malposition, which occur at higher rates than in the natal penis due to the absence of the tunica albuginea.

## Long-Term Urologic Follow-Up

Long-term follow-up involves urethral surveillance to monitor for strictures, fistulas, and diverticulum formation. Transgender women retain their prostate after vaginoplasty, so prostate-specific antigen (PSA) screening may be considered based on age and risk factors, although prostate cancer remains rare in this population. Cancer screening in retained organs is important for transgender men who retain their cervix or uterus, requiring Pap smears, and ovarian cancer surveillance if ovaries are retained. Voiding function should be assessed regularly to detect urethral stricture, urinary retention, or incontinence. Sexual function assessment ensures adequate erogenous sensation and satisfactory functional outcomes.

## Key Clinical Pearls

Hair removal from genital skin intended for urethral or vaginal construction must be completed prior to surgery to prevent intraluminal hair growth and stone formation. After vaginoplasty, neovaginal dilation is essential to maintain depth and width, with non-compliance being the most common cause of stenosis. Urethral complications such as fistulas and strictures are the most frequent surgical issues following phalloplasty and often require staged repair. It is important to remember that transgender women retain their prostate after vaginoplasty, which should be factored into age-appropriate screening discussions. Optimal outcomes for gender-affirming surgical patients are achieved through a multidisciplinary team approach involving urology, plastic surgery, endocrinology, mental health, and primary care.

## References

1. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. *Int J Transgend Health*. 2022;23(Suppl 1):S1-S259.  
2. Dy GW, Granieri MA, Engel J, et al. Presenting complications to a reconstructive urologist after phalloplasty: a case series. *J Urol*. 2019;202(6):1227-1233.  
3. Massie JP, Morrison SD, Van Maasdam J, Kavanagh A. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. *Plast Reconstr Surg*. 2018;141(6):911e-921e.  
4. Morrison SD, Shakir A, Vyas KS, et al. Phalloplasty: a review of techniques and outcomes. *Plast Reconstr Surg*. 2016;138(5):594e-615e.