Gender-affirming surgery: Female to male

INTRODUCTION — Transgender individuals can present to medical providers at various stages of their transition, which may include medical and/or surgical treatment. For individuals transitioning from female to male (transgender men), medical treatment includes hormonal therapy with testosterone. Gender-affirming surgery includes "chest" surgery, such as mastectomy, and "genital" or "bottom" surgery, such as hysterectomy, oophorectomy, vaginectomy, metoidioplasty, and phalloplasty. The anatomy after genital reconstructive procedures such as metoidioplasty and phalloplasty may be unfamiliar to many providers. Understanding the transition process and the surgical procedures will assist medical providers in the management of transgender patients.

This topic will discuss the procedures and resultant anatomy for patients transitioning from female to male. Related topics on the care of transgender patients is presented separately.

●(See "Primary care of transgender individuals".)

●(See "Transgender women: Evaluation and management".)

●(See "Gender-affirming surgery: Male to female".)

●(See "Transgender men: Evaluation and management".)

In this topic, when discussing study results, we will use the gender terms as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.

TERMINOLOGY — The language and terminology used to describe gender and sexuality are presented in the table and reviewed in detail separately (table 1).

●(See "Primary care of transgender individuals", section on 'Terminology'.)

ISSUES IN GENDER-AFFIRMING SURGERY — Gender dysphoria is the discomfort or distress caused by a discrepancy between a person's natal sex (sex assigned at birth, usually according to external genitalia or chromosomes) and that person's gender identity (innate sense of being male or female) (table 1) [1].

●Reduction in gender dysphoria – Transgender (trans) individuals affected by gender dysphoria may choose to undergo a variety of treatments, both medical and surgical, to transition physically and socially to the gender role that they feel to be their true selves. A study of 2015 United States survey data reported that undergoing one or more types of gender-affirming surgery was associated with reduced rates of past-month psychological distress, past-year smoking, and past-year suicidal ideation [2].

●Spectrum of transition changes – The transition process exists on a spectrum, as not all transgender individuals transition in a similar way. Some choose to transition with gender marker changes only, while others choose to undergo medical transition with cross-sex hormones including testosterone therapy. Some patients choose surgical transition and seek the masculinizing procedures described in this review. The transition process can take several years to accomplish; the duration of transition is dependent on which affirmation procedures and treatments the patient chooses to undergo. The World Professional Association for Transgender Health (WPATH) provides Standards of Care, free of charge and in multiple languages, to aid clinicians caring for transgender patients [1].

●Potential need for staged procedures and impact – To completely achieve the patient's goals, genital reconstruction may require multiple staged procedures, such as hysterectomy, phalloplasty with concurrent vaginectomy, and penile prosthesis placement. Each procedure requires time off from work with consequent loss in productivity and income. Even for procedures that are covered by insurance, there may be substantial costs related to copayments and travel for surgery [3]. Since the procedures may be spaced out over a period of months to years, patients who have work- or school-based insurance that covers transgender surgery may feel tied to the school or work until the surgical transition is complete.

●Lack of standardized and validated reporting outcomes – Surgical outcomes of interest typically include patient-centered, functional, and adverse outcomes. Standardized and validated tools that are informed by patient preferences to assess outcomes of gender-affirming surgeries would facilitate reporting of research and patient care [4,5].

Additional discussions on the transition process, standards of care, reporting outcomes, and management of estrogen therapy are presented in detail in related content. (See "Gender-affirming surgery: Male to female", section on 'Issues in gender-affirming surgery'.)

CHANGES IN CLINICAL PRACTICE DUE TO SURGICALLY ALTERED ANATOMY

●Neophallic urethra

•Avoid blind urethral catheter placements or blind urethral dilations, which can create false passages and preferentially pass under the native urethral meatus into previously obliterated vaginal cavity. These procedures should only be performed under direct endoscopic or radiographic visualization. Emergency placement of a suprapubic tube by a urologist or an interventional radiologist is the safest option when a patient presents in acute urinary retention and catheterization under direct visualization is not possible or expediently available.

•Avoid passing rigid endoscopic instruments into the urethra after phalloplasty or metoidioplasty. Neophallic urethras are not large or elastic enough to permit safe passage of rigid adult cystoscopes/resectoscopes. Flexible cystoscopes, flexible ureteroscopes, or pediatric cystoscopes are used instead. If large caliber instruments must be used (ie, for large stone treatment), percutaneous procedures should be considered.

●Neophallus vascular supply – Avoid any compromise to the vascular pedicle of the neophallus, such as positioning the patient in high-lithotomy position. The extreme hip flexion may compress and obstruct blood supply to the neophallus. Know the location of the pedicle, and avoid it during invasive procedures near the neophallus or groin (ie, placement of a penile prosthesis or a transobturator sling). The location of the vascular pedicle typically arises from the inferior epigastric artery or the femoral artery. Review of operative notes and Doppler ultrasound may help with identification of the pedicle.

CHEST SURGERY — Patients may opt for breast removal, often referred to as "chest" or "top" surgery, as part of their gender-affirming therapy. Overall, breast or chest surgery is the most commonly performed group of gender-affirming surgeries performed based on US data [6].

Options to minimize breast appearance — Options to reduce the appearance of female breasts, include non-surgical breast binding or surgical breast removal. While testosterone therapy decreases glandular tissue and increases fibrous connective tissue in pathologic samples, it does not cause significant change in breast size, appearance, or tissue pathology [7,8].  

●Breast binding – Breast binding involves using tight material to hold the breasts against the torso to create a flat chest appearance. It is not clear whether long-term binding has significant health effects or if it affects the outcome of reconstructive surgery should patients choose to pursue it.

●Chest (top) surgery – Chest (top) surgery involves mastectomy, relocation of the nipple-areola complex, and chest contouring. Observational data suggest patients undergoing gender-affirming mastectomy experience high satisfaction and low regret [9-11]. Potential for surgical regret is discussed in related content. (See "Gender-affirming surgery: Male to female", section on 'Regret'.)

Surgical criteria — The World Professional Association for Transgender Health's provides criteria for gender affirming surgery [1]. Patients must have (1) persistent, well-documented gender dysphoria; (2) capacity to make a fully informed decision and to consent for treatment, including understanding the effect of surgery on reproduction; and (3) good control of any concurrent medical or mental health concerns. Continuous use of testosterone therapy is not required to undergo chest surgery.

Peri-operative management — All chest surgery techniques can be performed as outpatient procedures. The planned surgical incisions should be marked with the patient in the upright position.

●Screen for hereditary cancer risk – Patients considering breast removal should be evaluated for increased breast cancer risk and referred for genetic testing as appropriate [1,12]. (See "Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes".)

●Surgical marking – The reference points to be marked include the inframammary crease, the mid-breast meridian, the lateral border of the pectoralis major muscle, the axillary tail of the breast, midline, and the anticipated position of the nipple-areola complex. To ensure a good aesthetic outcome, the areolas should be positioned medial to the lateral border of the pectoralis major muscle, approximately 1 to 2 cm above the inferior insertion of the pectoralis major muscle [13]. Once marking is complete, the patient is positioned supine, with the arms abducted with flexion at the elbow, with generous padding. The operating table should be able to flex the patient's back such that assessment of the symmetry of the nipple-areola grafts can be achieved.

●Chemoprophylaxis – Routine chemoprophylaxis for prevention of surgical site infection and thromboembolism is given.

Procedure — Chest surgery in transgender males involves subcutaneous mastectomy, and the main goals of the surgery are to remove the breast tissue and excess skin, reduce and reposition the nipple-areola complex, contour the chest, and release the inframammary crease. The cisgender male chest differs significantly from the cisgender female chest in that the female has glandular tissue and skin, subcutaneous fat, and a well-defined inframammary fold [14]. Factors affecting chest surgery outcomes include preoperative breast volume, breast ptosis, nipple-areola size and position, degree of skin excess, and loss of skin elasticity as a result of long-term breast binding [15]. Important, albeit secondary, goals are to minimize chest scars and to preserve nipple sensitivity. Regardless of the technique used, surgeons should avoid removal of too much glandular tissue from the flaps, as it may lead to insufficient contouring and poor appearance. Surgical technique varies depending upon the above factors [7,15-19].

●When there is less tissue (as determined by the surgeon) and non-ptotic, the "limited incision" technique may be performed using periareolar incisions only without repositioning the areola and performing a wedge resection only to reduce breast size.

●When there is more breast tissue, without or minimal ptosis, the "purse string" technique may be performed using circumareolar incisions with free nipple-areola grafts.

●For patients with more breast tissue and ptosis, more skin must be removed, and a "double incision" technique is done using inframammary crease incisions and free nipple-areola grafts. In some cases, adjunctive liposuction is necessary.

Postoperative care — Following chest surgery, an elastic compression wrap is placed and remains in place for up to three to four weeks (with once daily removal allowed for showering only). In addition, closed suction drains are placed bilaterally, to avoid hematoma and seroma formation, and are removed once output is determined to be low (in the authors' practice, this is generally <30 mL per day over 48 hours). Patients are advised to sleep on their back, at an incline, for one week after surgery. Recovery may take 6 to 12 weeks depending on wound healing.

Chest surgery complications — Immediate postoperative complications associated with chest surgery include hematoma, seroma, infection, poor healing, and necrosis of the nipple graft [20]. Up to 10 percent of patients may need a reoperation for an acute complication, with hematoma being the most common reason for reoperation [20-22]. Revision surgeries are considered later complications and are performed to improve the cosmetic outcome. Indications for revision surgery include scar revision (12.6 percent), chest contour revision (17.8 percent), and nipple-areola revision (8.9 percent) [21].

GENITAL SURGERY

Preoperative planning — Genital surgery is essential and medically necessary to alleviate gender dysphoria in some, but not all, affected individuals [23].

●Criteria for surgery – All patients considering extirpative surgery should also meet the World Professional Association for Transgender Health (WPATH) criteria prior to surgery [1], which include:

•If written documentation is required, one letter of assessment from a clinician with demonstrated competency in care of gender diverse people

•Persistent, well-documented gender incongruence and, in regions where required, meets diagnostic criteria for gender incongruence

•Capacity for informed decision making and consent, including ability to understand effect of gender-affirming surgery on reproduction

•Evaluation for other potential causes of gender incongruency

•Assessment for conditions, both mental and physical, that could negatively impact surgical outcome and discussion of relevant risks and benefits

•Stable use of hormone therapy (time duration varies by age of patient), unless hormone therapy is not desired or is medically contraindicated

●Extirpative versus reconstructive procedures – Genital surgery can be divided into extirpative procedures for removal of female organs (hysterectomy, oophorectomy with possible fertility-preservation procedures, and vaginectomy) and reconstructive procedure for creation of masculine functions such as standing to void or penetrative intercourse (metoidioplasty, phalloplasty, prosthetics). While extirpative procedures follow standard techniques that have been adapted for gender-affirming surgery, reconstructive procedures are currently in a state of development and innovation, with techniques tailored toward achieving individual goals while balancing morbidity and complication profiles.

●Prevalence data for genital surgery – Data on the frequency with which transgender men elect some or all procedures are limited. In a study of patients presenting to a gender identity clinic in Amsterdam, 82 percent of transgender men and 76 percent of transgender women underwent gonadectomy within five years of starting hormonal therapy [24]. The number of patients who also underwent reconstructive surgery such as phalloplasty was not reported. For comparison, a study from Boston Medical Center reported that only 7 percent of transgender men underwent hysterectomy and oophorectomy [25]. The large difference in surgery rates may, in part, reflect differences in insurance coverage between the locations, as gender-affirming surgery is covered in the Netherlands. For transgender men who pursue reconstruction, the number of operations depends on patient and surgeon preference and patient goals. At some centers, hysterectomy, vaginectomy, metoidioplasty, and testicular prosthesis are all performed together [26]. At other centers, the operation is separated into multiple stages [27].

Removal of female organs

Fertility preservation — It is paramount to discuss fertility-preserving options with patients prior to any extirpative surgery, and the effects of hysterectomy and oophorectomy must be considered separately. We educate patients about the role of the uterus in carrying a pregnancy; the ovaries in providing eggs; and the options for oocyte, embryo, or ovary cryopreservation to maintain the possibility of future genetic parenthood. Patients who are interested in fertility preservation are referred to a reproductive endocrinologist skilled in these techniques for further consultation. One study comparing 26 transgender men who had been receiving testosterone therapy with a cisgender cohort reported similar oocyte yield and estradiol levels with ovarian stimulation for fertility preservation [28]. A different review reported that oocyte retrieval was not impaired by prolonged androgen exposure [29]. (See "Fertility and reproductive hormone preservation: Overview of care prior to gonadotoxic therapy or surgery", section on 'Fertility preservation'.)

If the patient desires to become a parent but does not wish to carry his own child and plans to have a current partner, future partner, or a gestational carrier be pregnant, he may be a candidate for hysterectomy (ie, removal of the uterus only). Separately, if he does not wish to have his own genetic child, or has already undergone fertility preserving procedures, then he may be a candidate for oophorectomy as well.

This discussion can be particularly challenging with young transgender male patients as their ability to project their goals for family planning may be compromised by the dysphoria that they are experiencing. In addition, a study of 22 transgender adolescents reported that one-third were concerned about the impact of interrupting their gender-affirming hormone therapy to preserve fertility [30]. It is important to address this to ensure that patients are aware of the option of an isolated hysterectomy with staged future oophorectomy.

Hysterectomy — Transgender men may elect hysterectomy to address benign gynecologic disease, to achieve gender affirmation, or both. In one study of 72 transmasculine individuals undergoing hysterectomy, 90 percent reported pelvic pain as the leading indication for surgery while 40 percent had multiple indications [31].

For patients planning hysterectomy to treat gynecologic conditions, the counseling and perioperative planning are the same as for the cisgender woman; however, some of the considerations below remain important.

●Surgical route – Most gender-affirming hysterectomies are performed laparoscopically, as this route is minimally invasive and allows for an outpatient procedure. Given that many transgender male patients are nulliparous, providers may be hesitant to perform a vaginal hysterectomy. In a small cohort of transgender men undergoing hysterectomy at the University of California San Francisco, one in four patients had a successful vaginal hysterectomy [16]. The American College of Obstetricians and Gynecologists recommends this route when appropriate in order to limit complications and morbidity while maximizing cost-effectiveness [17]; and while there are limited data, vaginal hysterectomy seems to be feasible in a subset of the population presenting for gender-affirming hysterectomy and should always be considered. If a patient is nulliparous, has minimal pelvic organ descent, and/or a narrow pelvis, a laparoscopic approach is very reasonable.

●Rate of complications – The incidence of perioperative complications associated with hysterectomy performed for gender affirmation in transgender men is reported to be the same as for cisgender women undergoing hysterectomy for benign indications. An analysis of nearly 160,000 hysterectomies from the American College of Surgeons' National Surgical Quality Improvement database reported similar rates of complications for hysterectomies performed in male patients for gender affirmation compared with cisgender control individuals (composite rate 3.4 transgender male versus 3.3 percent controls) [32].

Oophorectomy — Transgender men who either do not desire genetic parenthood or who have undergone fertility preservation therapy may wish to have their ovaries removed. Concurrent oophorectomy at the time of hysterectomy remains a topic of debate among gynecologists performing hysterectomy for surgical transition. Concerns include that gonadectomy places patients at significant risk for osteopenia at an early age and that the long-term effects of testosterone on bone density have not been well studied. However, small studies have reported that, for patients on long-term testosterone therapy, larger cortical bone size has been observed in transgender men compared with cisgender women, and long-term bone density is not significantly different among cisgender men, transgender men, and cisgender women [18,33]. In addition, concern about bone density persists for those patients who stop or cannot use exogenous testosterone following oophorectomy. These patients have not been well studied, but it is clear that this particular subset needs bone health surveillance and appropriate supplementation.

Per the University of California San Francisco Center of Excellence for Transgender Health guidelines, transgender men should begin bone density screening at age 65, and screening between ages 50 and 64 should be considered for those patients with known risk factors for osteoporosis. Transgender men who have undergone gonadectomy and who have been off of testosterone therapy for at least five years should also be considered for bone density screening, regardless of age. Vitamin D and calcium supplementation recommendations are extrapolated from those that currently exist for postmenopausal women. In addition to both health screenings, transgender men who have undergone gonadectomy and who have been off of testosterone therapy for at least five years require appropriate supplementation.

Hysterectomy with staged oophorectomy planned for a future date, as described above, requires two different surgical events and potentially increases surgical risk. (See 'Fertility preservation' above.)

Vaginectomy — Vaginectomy is a procedure undertaken by some transgender men. Many patients will opt to undergo hysterectomy only, without vaginectomy, unless they are undergoing concurrent phalloplasty procedure. The procedure involves either resection of the full-thickness epithelium of the vagina or de-epithelialization followed by obliteration of the vaginal canal. Patients who have significant dysphoria from their vagina and who do not engage in penetrative vaginal activities may request excision or obliteration of the vagina. Typically, vaginectomies are reserved for patients desiring reconstructive external genitalia surgery or "bottom surgery" and are done concomitantly, as the vaginal mucosa and full-thickness vaginal flaps are used in phalloplasty techniques for creation of the neourethra.

There is no standard of care for performing concurrent vaginectomy at the time of hysterectomy. The two procedures are often performed independently of one another because a portion of the vaginal epithelium is frequently used for phalloplasty procedures. Thus, preservation of the vagina until the time of genital reconstruction (ie, hysterectomy only) may be beneficial for these patients. Vaginectomy is not performed on patients with an in situ uterus, as such surgery would prevent screening for cervical cancer and premenopausal patients would develop hematometra.

Vaginectomy can be performed either transvaginally or abdominally (open, laparoscopically, robotically) by experienced surgeons. Approach to the procedure depends solely on the surgeon's choice and experience with the technique.

●Transvaginal – When concurrent phalloplasty is planned, transvaginal vaginectomy is the most common approach. This approach is also more commonly used in patients who have previously undergone hysterectomy. This procedure is similar to colpocleisis (vaginal closure) procedures performed for the treatment of vaginal prolapse. An incision is made at the level of the vaginal introitus, the vaginal epithelium is circumferentially dissected and excised, and an obliterative procedure is performed.

In some cases, vaginectomy is performed at the time of the first stage of phalloplasty when a multi-stage phalloplasty approach is taken [19]. In these cases, a full- or partial-thickness anterior vaginal wall flap is used to reconstruct the bulbar urethra in order to lengthen the urethra. The vaginal epithelium is excised as above, but an anterior wall flap is salvaged and transposed out of the vagina.

●Abdominal – Full-thickness resection of the upper vagina can be done with an approach similar to most oncologic procedures. This approach can be performed at the time of concurrent hysterectomy and less commonly in post-hysterectomy patients. Mode of surgery (open, laparoscopic, or robot-assisted) is surgeon-dependent [34].

Perioperative concerns

●Testosterone – There are no guidelines regarding cessation or continuation of testosterone perioperatively. While some providers are concerned about increased risk of venous thromboembolic events related to perioperative testosterone use, there are no supporting data. The risk of postoperative vaginal cuff bleeding both on and off testosterone has also not been well studied. Patients who are advised to preoperatively stop their testosterone should be well counseled, and prepared to manage, the severe mood swings and malaise that will likely ensue.

●Vaginal cuff care – For transgender men undergoing hysterectomy, data regarding the subsequent risk of vaginal cuff dehiscence are lacking. To counterbalance the atrophic effect of testosterone on the vagina and attempt to avoid cuff evisceration, we perform a two-layer closure of the vaginal cuff. For patients with severe vaginal atrophy, short-term vaginal estrogen may be used to promote healing in amenable patients. We also advise no vaginal penetration for up to 12 weeks following surgery to avoid sequelae associated with cuff evisceration.

●Vaginal bleeding after hysterectomy – Vaginal bleeding that occurs following hysterectomy may be bothersome to transmasculine patients. In a cohort study of 25 patients, 13 (52 percent) reported concerns with vaginal bleeding following surgery [35]. Of the patients with bleeding concerns, 10 (77 percent) experienced these concerns within two weeks of surgery and six (46 percent) experienced resolution without treatment [35]. It is unclear if vaginal bleeding is more significant in this patient population compared with cisgender individuals who undergo hysterectomy. Additionally, the impact of gender dysphoria on the distress associated with postoperative vaginal bleeding is not known. Patients should be counseled thoroughly about postoperative expectations related to vaginal bleeding and supports should be in place for those needing unscheduled evaluation.

Male genital reconstruction — Options for male genital reconstruction include metoidioplasty or phalloplasty with complete reconstruction. Issues for consideration when discussing male genital reconstruction include the patient's preferences regarding phallus appearance, standing micturition, sexual sensation, and/or coital ability [1]. There are several components of reconstruction and not every component need be performed to achieve the patient's goals.

Given the number of goals and the complex anatomy of female-to-male genital reconstructive surgery, it is useful to divide the reconstruction process into its component procedures:

●Phalloplasty – Creation of the penile shaft

●Penile urethroplasty – Creation of the urinary conduit within the penile shaft

●Perineal urethroplasty – Lengthening the urethra up to the penile shaft (ie, creation of the pars fixa)

●Vaginectomy with colpocleisis

●Scrotoplasty

●Clitoroplasty – Transposing the clitoris under the phallus or, in some cases, leaving it exposed

●Glansplasty

●Testicular implants

●Penile prosthesis

Metoidioplasty — Durfee and Rowland are credited with describing metoidioplasty technique in 1973 [36]. The term was derived from Greek "meta-" or "meto-" as a prefix for "change," an archaic word "aidoio" for "genitals," and suffix "-plasty" from the word "plastos" meaning "shaping" [37].

●Surgical technique – Several modifications of this procedure have been described, but in general, the procedures involve release of clitoral attachments, elongation to form the glans, and lengthening of native urethra by means of local vaginal and labial flaps. This allows for creation of a sensate (innervated) neophallus potentially long enough for urination in standing position and, in some cases, permitting for penetrative intercourse (although this function cannot be guaranteed). The techniques in many ways are analogous to proximal hypospadias repairs in pediatric patients [38]. The steps of the procedure typically involve (1) obliteration of vaginal cavity, (2) dissection of the hormonally enlarged clitoris free from its attachments to elongate the neophallus and to form the glans, (3) tubularization of labia minora to partially form the distal urethra, and (4) creation of neoscrotum from labia majora. Additional steps may include correction of ventral (downward) curvature by means of urethral elongation using local flaps or distant grafts (ie, oral mucosa or vaginal epithelium) [39]. As a result, the urethra after metoidioplasty consists of two distinct parts: (1) the proximal native urethra with its meatus connected to (2) a distal constructed neourethra. Metoidioplasty is typically performed in a single procedure of three to four hours' duration.

●Advantages and disadvantages compared with phalloplasty – Metoidioplasty is an attractive choice for patients who wish to avoid other more invasive phalloplasty options that utilize distant tissue flaps and grafts that may leave large visible scars at the donor sites (ie, radial forearm phalloplasty leaves a large identifiable scar on the patient's forearm (picture 1)). The main disadvantage of metoidioplasty is thought to be inadequate length and girth of the resultant neophallus, which may limit or preclude its use for penetrative intercourse. However, in a systematic review comparing metoidioplasty (7 studies, 324 patients) with radial forearm phalloplasty (11 studies, 665 patients), patient-reported outcomes for the two procedures included satisfaction with aesthetic outcome (87 versus 70 percent), erogenous sensation (100 versus 69 percent), and successful penetrative intercourse (51 versus 43 percent), respectively [40]. A longitudinal study of 10 patients who underwent "extensive metoidioplasty" reported an average maintained penile length of 8.7 cm (range 6 to 12 cm) at 5.7 years of follow-up [41].

●Complications – Complications of metoidioplasty are typically minor and may involve infrequent urethrocutaneous fistulae and/or urethral stricture at the level of neourethra and remnant vaginal cavity. In the above systematic review comparing metoidioplasty with radial forearm phalloplasty, the rates of urethral stricture/fistula were 27 versus 51 percent, respectively [40]. A single-institution analysis of 74 patients undergoing metoidioplasty reported urethral complications in 57 percent; fistulas occurred in 34 (45.9 percent) and strictures in 14 (18.9 percent) [42]. A 2022 systematic review of metoidioplasty complications reported stricture rates ranging from 1 to 63 percent, fistula rates of 8 to 50 percent, and remnant vaginal cavity/mucocele rates of 1 to 12 percent [43].

●Phalloplasty at a future date – Some patients who initially undergo metoidioplasty may later desire phalloplasty. A multi-institutional retrospective study reported that, among 83 patients who underwent secondary phalloplasty after initial metoidioplasty urologic, complications were comparable to those of primary phalloplasty [44]. Specifically, urethrocutaneous fistulae and strictures occurred in 30 and 36 percent, respectively.

Phalloplasty with genital reconstruction — While phalloplasty provides the most complete genitoperineal reconstruction (picture 2), it involves complex and staged procedures, the use of tissue from remote sites, and the inherent risks of complications associated with urethral reconstruction and implantable prostheses [45]. In addition to creation of a neophallus, these procedures may involve staged or concurrent vaginal cavity obliteration (vaginectomy or colpocleisis), urethroplasty, scrotoplasty, and testicular prosthesis placement, as discussed below.

Patient goals for surgery — To be considered successful, phalloplasty must meet patient-specific goals that include aesthetics, sensation, urination while standing, and penetrative intercourse. Patient goals for surgery impact the selection of the specific components of female-to-male reconstructive surgery. Minimizing complications and morbidity is a goal for both the patient and surgeon. The surgery should be tailored toward the patient's goals and acceptance of morbidity. For example, if standing micturition is not an important goal for the patient, he can elect to avoid the morbidity of urethroplasty. Patients who are not dysphoric with having a vaginal canal or who are using the vaginal canal for sexual intercourse may elect to avoid vaginectomy. A candid discussion of the patient's expectations and the risks of surgery cannot be over-emphasized. It is critical for the surgeon and patient to reach agreement regarding whether the patient's expectations can be met with current surgical techniques and whether the risks are acceptable to the patient.

The anatomic location of the penis points anteriorly, with its base superior to the tendon of the adductor longus, which is the position of its analogous female structure, the clitoris. The native female urethra is below the clitoris and points downward. Thus, to allow for urination while standing, the urethra must be lengthened from the native female urethral meatus up to the level of the clitoris and then connected to a neophallus with a urinary conduit. The segment of the urethra from the native female urethral meatus extending to the neophallus is known as the horizontal urethra, or pars fixa. The scrotum is usually constructed from labia majora to allow for increased bulk of the scrotum and testicular implants. Most flaps used to construct the neophallus consist of only skin and subcutaneous tissue. Thus, a penile prosthesis is necessary to allow for adequate rigidity of the neophallus for penetrative intercourse. Due to risks of prosthetic infections and erosion, penile prosthesis placement is usually performed after the neophallus has healed and tactile sensation has recovered.

The first reported phalloplasty for female-to-male transition was performed by Gillies in 1945 using staged abdominal pedicled flaps [46]. Abdominal flaps had the drawback of diminished sensation due to absence of neurorrhaphy. In the 1980s, the tube-within-a-tube radial forearm phalloplasty was developed from the radial forearm free flap (RFFF) used for cervical neck reconstruction (picture 3) [47,48]. This technique has become the most commonly used technique in contemporary practice. Complete genital reconstruction often requires two to four separate surgical procedures. While operative time varies by surgeon and surgical site, in the author's experience (Zhao), phalloplasty typically requires approximately five hours, and vaginectomy with urethroplasty requires two hours. Additional time may be required if the patient elects later insertion of a penile prosthesis and/or testicular implants.

Preoperative planning and care

●Depilation (hair removal) – For tube-within-a-tube radial forearm phalloplasty, the skin of the forearm is rolled to create the phallic urethra. Thus, to reduce the risk of infections and stone formation, permanent hair removal in the form of electrolysis or laser hair removal is recommended. Hair removal is important for cosmetic reasons also, as hair on the phallus may detract from an aesthetically pleasing appearance. (See "Removal of unwanted hair".)

●Smoking cessation – Smoking affects wound healing through vasoconstriction, platelet aggregation, and tissue hypoxia. Besides wound healing problems, smoking during the perioperative period results in increased complications from pneumonia, myocardial infarction, and thromboembolic events [49]. Given the complex and elective nature of phalloplasty, smoking cessation is an important component of preoperative preparation. (See "Overview of smoking cessation management in adults".)

●Postoperative social support – Due to expertise and experience needed to perform phalloplasty, there is a limited number of surgeons, and many patients travel long distances for surgery. Social support for bringing the patient to appointments and assisting with wound care is advised. Due to the unpredictable complications from phalloplasty, patients may need flexibility from their places of employment for more time off from work.

Types of phalloplasty — There are several donor sites for creation of the neophallus. The phalloplasty procedure may be divided into free and pedicled flaps. Free flaps are tissue transfer from distant sites, in which the blood supply is detached, and microsurgical vascular anastomoses are performed. Pedicled flaps are transposed to a new location via rotation, while the blood supply is left intact. There is variation among centers regarding the donor site, the flap design, specific recipient vessels, neurorrhaphy, and urethral prelamination, which indicates that this field is undergoing active investigation toward improvement in phalloplasty outcomes.

●Free flaps

•Radial forearm free flap – For free flaps, the most common phalloplasty technique is the RFFF, which has been made possible by microsurgical techniques [50,51]. This flap consists of the forearm skin, subcutaneous tissue, sensory medial and lateral antebrachial cutaneous nerves, cephalic vein, venae comitantes, and the radial artery. A 3 cm strip of skin is tubularized, and the rest of the flap is rolled around the urethral tube to create a "tube-in-tube" construction (picture 3). While the exact design of the flap may vary based on surgeon and patient preference for length, many advocate a minimum dimension of 15 by 17 cm for adequate size for tube-in-tube construction (picture 4) [52]. The size of this flap can result in circumferential excision of the forearm skin, which is then covered with a skin graft (picture 5 and picture 1). Phalloplasty using RFFF provides an excellent cosmetic result (picture 2).

In an effort to reduce the size of the flap needed, prelamination of the urethra has been advocated by some authors [53]. Prelamination involves creating a urethra within the donor site first and then harvesting the flap at a later date [51,52]. Skin is first wrapped around a catheter to create a tube, which is then buried under the skin of the forearm. The flap with embedded tube is then removed at a later date.

When the flap is reattached, the radial artery is anastomosed to the recipient vessels, which may include the femoral artery or the inferior epigastric artery. Similarly, a venous anastomosis may be performed to the femoral or saphenous vein. Nerve anastomosis is performed to the ilioinguinal nerve and/or the clitoral nerve. Patients who do not have a complete vascular palmar arch are not candidates for RFFF because the palmar arch provides the blood supply to the hand from the remaining ulnar artery.

•Osteocutaneous flaps – Osteocutaneous flaps have been considered as a method to create sufficient rigidity to allow for penetrative intercourse without additional penile prosthesis [54]. In these flaps, a portion of vascularized bone is transferred along with the skin and subcutaneous tissue to provide rigidity. The fibula osteocutaneous free flap is one such technique [55]. Although these flaps have the theoretical advantage of using bony tissue to provide rigidity, bone resorption may occur, and patients may be dissatisfied with having a continuously erect phallus.

•Musculocutaneous latissimus dorsi (MLD) flap – The MLD free flap phalloplasty has been used for female-to-male patients [56]. The drawback of this donor site is its need for repositioning during surgery, and the thickness of the flap means that a tube-within-a-tube design cannot be used to create the urethra. Thus, penile urethroplasty is necessary in subsequent stages to lengthen the urethra along the shaft of the neophallus.

●Pedicled flaps – Among pedicled flaps, the anterior lateral thigh (ALT) is commonly performed as an alternative to RFFF for patients with incomplete palmar arch, who want to avoid the forearm scar, or have inadequate forearm size to meet the patient's goal in terms of phallus length or girth.

The ALT is a skin flap based on a perforator from the lateral circumflex femoral artery. The ALT is typically pedicled, although if the pedicle is not long enough, it can be converted to a free flap. The primary disadvantages of the ALT is that the thigh is frequently thick in many patients. Tube-in-tube ALT phalloplasty has a higher rate of urethral complications [57]. A single tube construction can be performed for ALT, but additional stages for urethral reconstruction would be necessary. The urethral reconstruction can be performed with a separate flap (eg, a smaller RFFF) or as a two-staged urethroplasty using skin or other epithelial grafts. Additional stages for thinning may be needed to reduce the size of the phallus [58].

Inferiorly based pedicled abdominal flap phalloplasty is another option and was the predominant technique prior to microsurgical techniques allowing for radial forearm phalloplasty [55]. This flap has fallen out of favor due to poor sensation of this flap due to an absence of neurorrhaphy and need for additional staged urethral reconstruction [59].

Genital reconstruction — With the exception of prosthesis placement, the following procedures are typically performed in conjunction with phalloplasty.

●Urethroplasty – Urethroplasty consists of urethral formation (penile urethroplasty) and urethral lengthening (perineal urethroplasty).

•Penile urethroplasty – Penile urethroplasty is the creation of the urinary conduit within the shaft of the neophallus. For RFFF, this is most often performed with the tube-within-a-tube design of the flap (picture 3) (see 'Types of phalloplasty' above). Prelamination, in which the urethra is created prior to transfer of the flap, is a variant of the RFFF technique. For other types of phalloplasty, the penile urethroplasty may be performed as a staged urethroplasty procedure using skin, buccal, vaginal, or uterine grafts [60].

•Perineal urethroplasty – Regardless of the technique for creation of the neophallus, for the patient to achieve the goal of standing micturition, the urethra is lengthened from the native female urethral meatus to join the urinary conduit within the neophallus. This lengthened urethra is known by several terms: the horizontal urethra, the fixed urethra, or the pars fixa [61]. Urethral anatomy after phalloplasty can be divided into the native urethra, the pars fixa, the anastomotic urethra, the phallic urethra, and the meatus (image 1). The pars fixa can be created via an anterior vaginal flap and tubularization of labia minora flaps (picture 6). The pars fixa is anastomosed to the phallic urethra.

●Vaginectomy – While vaginectomy can be an extirpative operation, the performance of the vaginectomy has profound influences on the urethral reconstruction because the native female urethral meatus is located within the anterior vagina. In a single-center study of 224 patients undergoing phalloplasty with urethral lengthening, concurrent vaginectomy was associated with decreased rates of urethral stricture and urethral fistula formation compared with vaginal preservation [62].

●Glansplasty – The circumcised glans shape can be created by making a circumferential incision on the shaft of the phallus and suturing the local skin back upon itself to create a coronal ridge. The gap in skin is filled with a skin graft or two separate skin grafts to create a constricted coronal sulcus (picture 3) [63].

●Scrotoplasty – Scrotoplasty is performed by a 90° rotation of the labia majora to create the scrotum [51].

●Clitoroplasty – Typically, the clitoris is de-epithelialized and set under the base of the neophallus ("buried clitoris"). In some patients, conservation of clitoral sensation is of paramount importance. These patients can have the clitoris left unburied, with the potential that preservation of the skin on the glans clitoris will increase erogenous sensation. Both groups can experience orgasm as a result of clitoral nerve stimulation.

●Testicular and penile prostheses – Testicular implants have been used in cisgender men after orchiectomy for trauma or malignancy. These testicular implants can also be used to enhance the cosmetic appearance of the scrotum in transgender men. However, because of concerns for potential infection of the implants, placement of testicular implants and/or penile prostheses is performed in a separate surgery from the phalloplasty and scrotoplasty.

Options to increase the rigidity of the neophallus to allow for penetrative intercourse include malleable and inflatable penile prostheses, the same as used for cisgender men with erectile dysfunction. Malleable prostheses are rigid rods placed within the neophallus that can be flexed to change the position of the neophallus. Inflatable prostheses are a multicomponent device that consist of a pump in the scrotum that transfers fluid from a reservoir into a hollow cylinder within the neophallus. Transfer of fluid inflates the cylinder, thus creating an erection. Placement of penile prostheses in transgender men can be particularly challenging because there is no corpora cavernosa in the neophallus, which increases the risk of vascular or urethral injury at the time of implant insertion. The implants also require proximal fixation to mitigate the risk of migration or distal erosion. Proximal fixation can be performed by inserting the rear tip extender into the pubic bone or by suturing neotunical sheaths made from Gore-Tex to the pubic rami [64,65].

In addition to increasing perioperative risk, the absence of corporal tissue in the neophallus results in higher rates of postoperative infection, migration, extrusion, and revision surgery compared with cisgender men who receive implants.

•Infection – While prosthetic infection is approximately 1 percent in cisgender men with erectile dysfunction, the infection rate is reported to be 12 percent in the largest series of transgender patients undergoing penile prosthesis after RFFF phalloplasty (65 patients, 95 procedures) [66,67].

•Device migration and/or extrusion – Migration of the device can occur if the device becomes untethered to the bone. Extrusion through the glans and erosion of the prosthesis into the neourethra has been reported in 4 to 8 percent of patients, which then requires explantation of the device [67,68].

•Mechanical failure – Mechanical failure is another cause of revision surgery and occurs in over 10 percent of patients [67,68].

•Device removal – An observational study including 80 patients undergoing penile prosthesis placement reported an overall explant rate of 21 percent by nine months of follow-up [69].

There are few patient-reported outcomes regarding penile prosthesis placement in this population. One study reported the rate of satisfactory sexual intercourse at 51 percent [70].

UROLOGIC COMPLICATIONS — Urologic complications are the most commonly encountered complications following male genital reconstructive procedures [51].

Type and frequency

Overall incidence — Common complications after phalloplasty or metoidioplasty procedures include urethral strictures, urethrocutaneous fistulae, and persistent vaginal cavities. Overall, phalloplasty techniques carry a higher rate of urethral complications compared with metoidioplasties because of their inherent higher complexity, including additional lengthening of the urethra if the patient desires the ability to void from the tip of the neophallus [42].

Supporting data include:

●Overall complication and revision rates – A multicenter international study evaluating patient-reported outcomes identified 129 patients who underwent phalloplasty (79 patients, 61 percent), metoidioplasty (32 patients, 25 percent), or phalloplasty after metoidioplasty (18 patients, 14 percent) [71]. The patients self-reported a total of 281 complications necessitating 142 revisions, including urethrocutaneous fistula (51 patients, 40 percent) and urethral stricture (41 patients, 32 percent).

●Frequency of specific complications – A multi-institution retrospective study of 55 patients who underwent masculinizing genital surgeries reported complications including urethral strictures (86 percent), fistulae (56 percent), and persistent vaginal cavities (47 percent) [72]. Seventy-three percent of patients were found to have two or more concurrent complications. Most urologic complications are apparent a few weeks to months after surgery with a mean time to diagnosis of four months [72]. A 2022 systematic review of complications from radial forearm flap and ALT flap phalloplasty reported stricture rates ranging from 11 to 81 percent, fistula rates of 10 to 79 percent, wound complication rates of 2 to 17 percent, and flap necrosis rates of 3 to 21 percent [43].

●Urethral complication rates – A systematic review of 50 studies (1351 patients) reported an overall urethral complication rate of 39 percent for transgender phalloplasty surgeries (range of 22 to 46 percent across multiple surgical techniques) [73]. Higher complication rates were reported for staged surgery compared with combined procedures. Urethral complication rates for fibula, abdominal, and radial forearm flaps were 22, 33, and 41 percent, respectively.

●Complications by technique for urethral creation – A meta-analysis of 21 studies (1555 patients) compared complications of phalloplasty based on various techniques of urethral creation [74]. The tube-in-tube approach was used in 1061 patients, double flap in 221, and prelaminated/staged techniques in 273.

•Fistula – The overall fistula rate was 23.9 percent (range 5-75%; 95% CI, 18.1-30.8) with surgery-specific rates of 25, 16, and 29 percent, respectively.

•Stricture – Stricture rate was 25 percent (range 14-87%; 95% CI, 16.7-35.5), 15 versus 18 versus 41 percent, respectively, for each technique.

•Revision – Overall revision rates were 30.4 percent (range 18-56%; 95% CI, 23-39), 25.4 versus 25.1 versus 40 percent.

●Complications by flap type – A different single-institution study reported higher rates of urethral complications with anterolateral pedicle thigh flap phalloplasty compared with radial forearm free flap (RFFF) phalloplasty (33 versus 24 percent) [57].

Specific urologic complications

●Urethral strictures – Urethral strictures are constrictions or obliterations of urethral lumen, typically from scar tissue around the lumen, that obstruct urine flow and can result in urinary retention or a weak urinary stream. Urethral stricture disease has been reported in 25 to 58 percent of patients following transgender phallus reconstruction (multiple procedures) [75-77]. An observational study of 118 urethroplasties performed in 79 patients reported stricture occurrence by anatomic site in the graft: 41 percent in the anastomotic urethra, 28 percent in the phallic urethra, 15 percent at the meatus, and 13 percent in the fixed urethra [78]. An additional 8 percent occurred in more than one anatomic location along the urethra. The majority of urethral strictures presented in combination with fistulae. As above, the presumed mechanisms are ischemia and backflow of pressurized urine. The anastomosis between the skin of the glans and the edge of distal neourethra forming the meatus is also vulnerable to ischemia, contracture, and meatal stenosis or obliteration.

In an attempt to avoid ischemic complication, several authors have evaluated phalloplasty modification techniques that create independently vascularized urethral flaps. However, in two studies, urethral complications including fistulae or stricture remained high despite the surgical modification [79,80]. In a retrospective review, of the 19 patients who had anterior lateral thigh phalloplasties combined with radial forearm urethral flap, 47 percent resulted in urethral strictures [80].

●Urethrocutaneous fistulae – Urethrocutaneous fistulae, abnormal communications between the urethra and skin, are the most common postoperative urethral complications following genital reconstructive surgery. For the RFFF phalloplasty, fistula formation has been reported in 22 to 75 percent of patients [70,75,81,82]. While fistulae may develop anywhere along the neourethra, they more commonly occur at the anastomotic sites between the phallic urethra and the fixed urethra and in the ventral suture-line area between the fixed urethra and the native urethra (image 1) [75,83]. Although most fistulae ultimately require surgical repair, conservative management has resulted in spontaneous resolution in as many as 36 percent of patients within two months after diagnosis [84].

Presumed mechanisms include insufficient vascular perfusion of the flap at the level of the urethra, poor quality (or inadequate amount) of local tissue used in multilayer closure over the suture lines, and obliteration or partial obstruction (ie, urethral stricture) of distal lumen during the healing period. Fistulae commonly occur in combination with urethral strictures (up to 40 percent) and typically occur just proximal to the associated stricture [75]. The relative obstruction of urine flow likely leads to increased urinary pressure and formation of a fistula [75]. In addition, fistula formation appears to be more common in patients who elect vaginal preservation compared with vaginectomy at the time of phalloplasty (56 versus 14 percent, respectively) [62]. The authors hypothesized that the additional vaginal tissue used as local flaps in patients undergoing simultaneous vaginoplasty resulted in reduced rates of fistula and stricture formation.

●Remnant vaginal cavity – Fistula communication with a remnant vaginal cavity has been reported in nearly half of patients with strictures of the neophallic urethra, despite their history of vaginectomy (total removal of vagina) or colpocleisis (removal of vaginal epithelium and vaginal cavity obliteration) [85]. It is believed that, in the presence of distal obstruction, pressurized urine tears through the ventral suture lines of the fixed urethra and through the sutures used to obliterate the vaginal cavity [85]. Inadequate vaginal de-epithelization during colpocleisis or incomplete vaginectomy is thought to predispose patients to this condition. Resultant urine- and mucus-filled pelvic cavities can be quite large, are unlikely to spontaneously close, and often require complete cavity re-excision and obliteration at the time of the fistula repair [86].

In a study of 47 patients with urethral complications after masculinizing genital-affirming surgeries that included history of prior vaginectomy, 18 (38 percent) were found to have remnant vaginal cavities in addition to strictures and/or fistula [87]. The lining of these cavities was completely excised during revision surgeries and sent for histological evaluations, revealing typical vaginal epithelium. Clinicians should have a high level of suspicion that fistula and persistent vaginal cavity have developed in post-phalloplasty patients who present with complaints of prolonged post-urination dribbling or post-urination "incontinence," pelvic/perineal pain and/or fullness, and/or persistent urinary tract infections.

Patient presentation and initial evaluation following prior gender affirmation surgery — Patients who have undergone gender affirmation surgery can present within days to months postoperatively for evaluation of dysuria, suprapubic pain, weakened urinary stream, straining, post-urination dribbling, or urinary retention [85]. We take the following approach to evaluate these patients:

●History – We begin by obtaining a thorough medical and surgical history and emphasize the use of open-ended questions to gain a full understanding of the patient's condition. In addition, thorough review of previous reconstructive operative reports and postoperative hospital and clinic notes is of highest importance to complete the history of present illness. The goals are to establish exactly what type of phalloplasty was done and in how many stages; what types of flaps and grafts were used; how the vascular and urethral anastomoses were done; whether vaginectomy was performed (and at what stage); whether any additional concurrent or staged procedures were performed (ie, prosthetics, urethral prelamination); what the postoperative course in terms of complications, drains, catheters, and timing/sequence of their removal was, as well as outcomes of trials of spontaneous urination (trials of void); what the timing of symptoms onset was; and what the prior attempts to alleviate symptoms were (ie, new catheters, dilations, urinary diversion, revisions).

Specific complications are suggested by the history, including [85]:

•Urethrocutaneous fistula is suspected in patients with drainage of urine or purulent material from a site other than the urethral meatus.

•Persistent vaginal cavity communicating with urethra is suspected in patients complaining of urinary leakage after completion of micturition (postvoid dribble) and is usually due to pooling of the urine in the vaginal remnant.

•A symptomatic vaginal remnant may also cause persistent or recurrent urinary tract infections, pelvic pain/pressure, and perineal bulging after urination. Some of these patients may be able to alleviate symptoms by compressing the perineal bulge to push the residual urine back into the urethra.

●Physical examination – After a general assessment of the patient, the physical examination mainly consists of comprehensive abdominal and genitourinary examinations. We evaluate the suprapubic and the flank regions for evidence of infection or urinary retention. Suprapubic tenderness may indicate cystitis or pyelonephritis in a patient with fever, chills, dysuria, hematuria, pyuria, and/or elevated white blood count. Patients with a palpable suprapubic bulge, stranguria, elevated postvoid residual, and/or hydronephrosis on ultrasound may have urinary retention.

Next, we inspect the neophallus, neoscrotum, perineum, and surrounding areas for wound dehiscence, erythema, induration, fluctuance, and fistula formation (eg, presence of purulent drainage from a site other than the urethral meatus). The urethral meatus is visually checked for patency. A complete evaluation would also include flexible cystoscopy with a 16 French cystoscope; passage of a 16 French scope through the meatus confirms adequate caliber of the meatus and distal urethra. No blind calibration with catheters or bougies should be performed.

●Laboratory evaluation – We request a clean-catch urine sample for urinalysis and urine culture on any patient with lower urinary tract symptoms or prior to any urologic intervention. A positive culture is treated with antibiotic therapy appropriate to the cultured organisms. Of note, culture-positive urine samples collected through long-term catheters (suprapubic or chronic urethral) are usually a result of bacterial colonization rather than true infection. Blood cultures, complete blood count, and basic metabolic panel may be useful per clinical judgment. A noninvasive uroflowmetry study is performed to measure the maximal urine flow rate and evaluate for postvoid residual urine volume with ultrasonography.

●Imaging and endoscopic evaluation – Imaging and endoscopic evaluations are performed to identify the location, length, caliber, and number of any strictures; location(s) of any fistula(e); and presence of a persistent vaginal cavity. The anatomy associated with complications of prior gender affirmation surgery can be quite intricate and may require an examination under anesthesia. With the patient anesthetized, the clinician can perform a complete physical examination, radiographic and endoscopic evaluations, and, if needed, placement of a suprapubic catheter.

Initial radiographic imaging to evaluate urethral anatomy includes either retrograde urethrogram, in which contrast material is injected retrograde through the urethra, or voiding cystourethrogram, in which injected contrast material is voided by the patient. These studies are invaluable in determining the presence and the location of a stricture, a fistula, or persistent vaginal cavity [88]. Adjunctive radiographic studies may include pelvic magnetic resonance imaging, computed tomography scan, or sonography as indicated by the history and physical examination [89].

In special cases where the distal urethra is completely obliterated, or the anatomy remains unclear despite radiographic imaging, suprapubic flexible cystoscopy can be performed through a previously established suprapubic catheter tract. Additionally, flexible narrow pediatric cystoscopes or narrow caliber flexible ureteroscopes may be helpful to complete urethral evaluation when a standard 16 French flexible cystoscope cannot be passed through a neophallus with a neourethra. Use of a flexible safety guidewire can allow gradual advancement of the flexible scope through a tortuous neourethra. In addition, simultaneous retrograde urethrogram can be performed by injecting contrast via the working channel of the endoscope during cystourethroscopy.

Bladder drainage and preoperative planning — Bladder drainage should be performed to relieve any urinary retention and avoid resultant acute kidney injury. Frequently, consultation for emergency suprapubic catheterization may be necessary to avoid attempts at blind, and potentially traumatic, urethral catheterization. Placement of a suprapubic catheter for urinary diversion may be the first necessary step in the preoperative management of the urologic complications after phalloplasty. This procedure could be done by a urologist in the operating room (or in emergency cases in a procedure room in the emergency department) or by an interventional radiologist in a specialized radiology suite. Ultimately, a drainage catheter of adequate size should be placed through the lower abdominal wall into the bladder 2 to 3 cm above the pubic bone. A catheter of at least 16 French ensures adequate urine drainage and can serve as a channel for future flexible endoscopy instruments.

Most urologic complications following genital gender affirmation surgeries are treated with either reconstructive surgery (such as urethroplasty or fistula repair), urinary diversion (such as perineal urethrostomy), or conservative management (such us self-catheterizations or repeat dilations). Patients must be educated regarding their options as well as the risks and benefits of pursuing each option to make an informed decision. The possible management options will depend on the severity of the problem, availability of healthy tissue for reconstruction, and the patients' personal preferences. For example, a patient may have to weigh his desire to eventually void upright against the possible need for multistage urethral reconstructive procedures.

The preoperative discussion should include detailed information regarding the risks of each possible intervention, including the need for multistage procedures and partial or total loss of the neophallus or loss of previously placed penile or testicular prosthetics. Preoperative optimization should also include, where appropriate, cessation of nicotine products and/or recreational drugs, nutritional support, aggressive control of diabetes, and appropriate treatment of any ongoing infections.

Surgical techniques

Fistula repair — General rules for reconstruction of urinary fistula include (1) excision of the fistula tract, (2) use of absorbable sutures and tension-free closure, (3) use of well-vascularized tissue that is closed in multiple layers, (4) creation of nonoverlapping suture lines, and (5) establishment of infection-free, low-pressure healing.

At the start of each fistula repair, patients are brought to the operating room, anesthetized, and placed in a dorsal lithotomy position. A flexible cystourethroscopy is performed to delineate the lower urinary tract anatomy. Exposure of the fistula tract for external probing during cystourethroscopy can assist in the identification of the fistula tract within the neourethra, especially within a tortuous neourethra and in the absence of other anatomic landmarks. Probing with an epidermal needle, flexible guidewire, or a lacrimal duct probe from the external opening of the fistula into the neourethral lumen allows for easier visualization during the endoscopic evaluation [85]. The excision is further facilitated by placing concentric retraction sutures at the edges of the fistula tract. Once the fistula tract is sharply excised, the resultant opening to the urethra can be closed in several nonoverlapping layers using well-vascularized tissue. Additional flap coverage may be required to reduce the risk of fistula recurrence. A fasciocutaneous groin flap, a labial fat pad flap, or musculofascial gracilis flap can be used to cover the site of fistula repair. Any communicating remnant vaginal cavity or neourethral stricture causing distal obstruction must be repaired during (or before) the fistula surgery as these increase the risk of fistula recurrence [90].

Postoperatively, low-pressure maximal urinary drainage is achieved by placing the catheter (and/or suprapubic tube) to drain by gravity for three to four weeks and by preventing bladder spasms with oral anticholinergic medications (ie, oxybutynin). We also maintain patients on low-dose prophylactic antibiotics until the catheter removal. The fistula resolution is assessed on the day of catheter removal using radiographic imaging such as retrograde urethrogram or voiding cystourethrogram, whichever is available. Occasionally, persistent contrast extravasation found on imaging requires catheter reinsertion for an additional two to three weeks of drainage and healing.

Obliteration of persistent vaginal cavity — A suspected vaginal cavity remnant may not be immediately apparent during preoperative evaluation, and its absence needs to be proven at the time of reconstructive surgery. If found, it needs to be completely excised and any remaining cavity obliterated. Either an open perineal approach, similar to colpocleisis, or a robotic-assisted transabdominal approach can be used to perform removal and cavity obliteration [86,87,90]. Complications of either surgical approach include hemorrhage, injury to the bladder and ureters, and infection. Intraoperative bleeding may be controlled by injecting vasoconstrictive agents into the subepithelial lining of the cavity (ie, lidocaine with epinephrine solution). Preoperative placement of ureteral stents and a bladder catheter may aid the surgeon in identifying and avoiding these structures during tissue dissection. During robotic dissection, endoscopic transillumination of the bladder or vaginal cavity by the assistant can also be helpful.

Stricture management — Stricture resolution can be achieved with either endoscopic resection or, in cases of recurrent, long, or multifocal strictures, urethral reconstruction.

●Endoscopic resection – Minimally invasive first-line treatment options for urethral strictures include dilation or endoscopic stricture incision (ie, direct visualization internal urethrotomy [DVIU]). Unfortunately, these procedures have traditionally had low rates of durable success, with recurrence rates as high as 88 percent reported for endoscopically treated strictures of the neourethra [77]. The high recurrence rate has thought to result from the lack of a corpus spongiosum in a neophallus and poor blood supply to the phallic urethra and its anastomosis. However, a subsequent observational study of 32 endoscopic urethrotomies reported a durable success rate in 44 percent at a mean of 51 months [91]. In this study, only uncomplicated strictures shorter than 3 cm were eligible for endoscopic incision, which was thought to improve the success rate.

Dilations or stricture incisions must be performed under direct endoscopic or radiographic guidance to avoid creation of false passages in the urethra and to avoid dilations into the fistulae or remnant vaginal cavity. After an endoscopic incision, it is customary to leave an indwelling transurethral bladder catheter for several days to allow re-epithelization of the urethrotomy. Additionally, some patients are taught self-catheterization or self-calibration techniques to maintain urethral patency long term. Again, care must be taken to avoid creation of false passages.

●Reconstructive techniques – For patients with recurrent, long (>3 cm), or multifocal strictures, urethral reconstruction techniques, collectively referred to as urethroplasty, appear to be the best options. These techniques may include open stricture excision, augmentation or substitution with local tissue vascularized flaps, or use of distant tissue-free grafts. The choice of technique(s) largely depends on the location and length of the stricture and the availability and quality of local tissue surrounding the stricture.

As examples:

•Strictures isolated to the urethral meatus can often be cured with a simple ventral incision called meatotomy. The main drawback is the resultant hypospadiac-appearing meatus, which may cause unpredictable direction of urine flow.

•Short strictures at the penile urethral anastomosis can be excised and the open ends re-anastomosed over an indwelling bladder catheter (ie, excision-primary anastomosis [EPA]). Alternatively, a nonexcisional anastomotic technique utilizing the Heineke-Mikulicz principle has been used in which the urethrotomy is made longitudinally and closed transversely [92]. Both of these techniques may be less successful in repairing strictures of the neophallic urethra compared with cisgender male urethras, possibly due to decreased tissue mobility and inadequate blood supply, although success rates of 47 to 57 percent have been reported [77,91-96].

An alternate approach to repair of uncomplicated anastomotic strictures involves single-stage repair with oral mucosa grafts. For individuals with well-vascularized local tissue but without concurrent infection/abscess, a study of 31 individuals reported success rates of 75 percent at a mean follow-up of 31 months [97]. A subsequent study evaluated 15 patients with short anastomotic strictures who were treated with either single-stage augmentation urethroplasty (nine patients) or a staged urethroplasty (five patients) [98]. At a mean follow-up of 34 months, single-stage repairs demonstrated 78 percent success rate while staged repairs at 35 months were successful in all patients.

•For long penile and recurrent anastomotic strictures, a variety of techniques exist including single-stage or multistaged procedures with frequent use of oral mucosa grafts and local tissue flaps [85]. For longer or recurrent strictures, staged techniques are the methods of choice and have reported success rates of 70 to 88 percent [78,91,93,99]. These techniques frequently involve complete ventral spatulation of the affected urethral segment and creation of a new neourethral plate (most commonly with oral mucosa grafts). The urethra is left exposed at the ventral portion of the neophallus for several months to allow for urethral plate maturation. During the second stage, the open urethral plate is tubularized over a catheter in a method similar to a hypospadias repair.

Overall, stricture recurrence rates are up to >60 percent regardless of the technique used, and many patients need several additional interventions [75,78]. For patients who want to avoid numerous reconstructive procedures, a perineal urethrostomy is an alternate option. In this procedure, a perineal urethra is created under the neoscrotum to allow unobstructed urine flow. Patients retain their native continence mechanism since both the native urethra and the bladder neck are not manipulated or altered by these more distal procedures.

NONUROLOGIC COMPLICATIONS — While less frequent than urologic complications, common nonurologic complications of phalloplasty surgery include flap necrosis (partial or total), wound problems (dehiscence, infection), and general surgical complications such as pulmonary embolism or nerve compression (table 2) [51]. Several studies have reported flap-related complication rates of approximately 7 to 11 percent [51,73,100,101].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Transgender health".)

SUMMARY AND RECOMMENDATIONS

●Language and terminology – The language and terminology used to describe gender and sexuality is presented in the table (table 1). (See 'Terminology' above.)

●Standards for treatment of gender dysphoria – Transgender individuals affected by gender dysphoria may choose to undergo a variety of treatments to transition physically and socially to the gender role in which they feel to be their true selves. The World Professional Association for Transgender Health (WPATH) provides Standards of Care, free of charge and in multiple languages, to aid clinicians caring for transgender patients. (See 'Issues in gender-affirming surgery' above.)

●Clinical implications of genital surgery – Clinicians should be aware of the multiple potential anatomic changes that can result from genital surgery for transgender men and avoid common practices or procedures that could injure the reconstructed tissue. (See 'Changes in clinical practice due to surgically altered anatomy' above.)

●Chest surgery – Chest, or "top," surgery typically consists of subcutaneous mastectomy to remove breast tissue and excess skin after a period of masculinizing hormone therapy. (See 'Chest surgery' above.)

●Genital surgery – Genital, or "bottom," gender-affirming surgery generally consists of extirpative procedures (eg, hysterectomy, oophorectomy, and vaginectomy) and genital reconstructive procedures (eg, metoidioplasty and phalloplasty), which may be performed as combined procedures or independently. WPATH provides criteria to help assess candidate appropriateness. (See 'Preoperative planning' above.)

•Fertility preservation – It is paramount to discuss fertility-preserving options with patients prior to any extirpative surgery, and the effects of hysterectomy and oophorectomy must be considered separately. (See 'Fertility preservation' above.)

•Options for male genital reconstruction – Options for male genital reconstruction include metoidioplasty or phalloplasty with complete reconstruction. Issues for consideration include the patient's preferences regarding phallus appearance, standing micturition, sexual sensation, and/or coital ability. There are several components of reconstruction and not every component need be performed to achieve the patient's goals. (See 'Male genital reconstruction' above.)

-Metoidioplasty – Metoidioplasty generally involves release of clitoral attachments, elongation to form the glans, and lengthening of native urethra by means of local vaginal and labial flaps. This allows for creation of a sensate (innervated) neophallus long enough for urination in standing position and, in some cases, permitting for penetrative intercourse (although this function cannot be guaranteed). Metoidioplasty is typically less invasive than phalloplasty procedures but may result in a neophallus of unacceptable length and girth from the patient's perspective. (See 'Metoidioplasty' above.)

-Phalloplasty – Phalloplasty with genital reconstruction includes phalloplasty, urethroplasty, scrotoplasty, clitoroplasty, glansplasty, testicular implants, and penile prosthesis. Procedures are selected to meet the patient's goals, such as aesthetics, sensation, standing urination, and penetrative intercourse; not every component need be performed to achieve patient satisfaction. (See 'Male genital reconstruction' above.)

•Complications

-Urinary tract – Urinary complications are common after metoidioplasty and phalloplasty. Complications include urethral strictures, urethrocutaneous fistulae, and retained vaginal cavity. Additional surgery is usually needed to repair these complications. (See 'Urologic complications' above.)

-Nonurologic – Common nonurologic complications of phalloplasty surgery include flap necrosis (partial or total), wound problems (dehiscence, infection), and general surgical complications such as pulmonary embolism or nerve compression (table 2). (See 'Nonurologic complications' above.)