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Gender-Affirming Surgery

Gender-affirming surgery (GAS) is the operative arm of multidisciplinary gender-affirming care, governed by the WPATH Standards of Care v8 (2022), the ACOG 2021 Committee Opinion, the Endocrine Society 2017 Clinical Practice Guideline, and the AAFP 2023 Position Paper. This atlas section is focused exclusively on the genitourinary / reconstructive-urologic component of GAS — top surgery / chest, facial feminization, and voice surgery sit outside the reconstructive-urologic scope and live on the corresponding clinical-conditions pages in Special Populations.

The decision space splits cleanly into three cohorts; each has its own tabbed Decision Framework + searchable Treatment Database. Choose the cohort below.

  • Masculinizing SurgeryGoal-directed pathway selection (metoidioplasty vs phalloplasty), phalloplasty flap selection (RFFF / ALT / abdominal / Big Ben / fibula), urethral lengthening decision, vaginectomy timing & technique, staged sequencing for scrotoplasty / testicular implants / erectile prosthesis, and lifelong urologic surveillance. Anchored on Bordas 2021, Wang 2026, Berli 2025 Big Ben, Veerman / Waterschoot complication data, and Levy 2026 implant consensus.
  • Feminizing SurgeryEligibility & readiness, goal-directed GU pathway (orchiectomy / vulvoplasty / full-depth vaginoplasty), vaginoplasty technique selection, peritoneal-vs-PIV-vs-sigmoid sub-comparison, component-procedure decisions (clitoroplasty / urethroplasty / labiaplasty), preoperative preparation, dilation protocol, and long-term urologic surveillance. Anchored on van der Sluis 2023, Opsomer 2021 Ghent 15-yr, Fakin 2021, Castanon 2022, Lee 2025, Blasdel 2024 "blind spots", and AFFIRM (Huber 2021).
  • Non-Binary / NullificationVariant GGAS framework: identifying genital goals, matching goals to procedure (genital nullification / phallus-preserving vaginoplasty / vagina-preserving phalloplasty / standalone gonadectomy), UL decision in vagina-preserving anatomy, and counseling considerations unique to non-binary patients. Anchored on Ascha 2024, Claeys 2025 BJU Int SR, Chen-Berli 2021 OHSU, Moorefield 2024, Pletta 2025 JAMA Netw Open, and Klemm 2024 PU long-term outcomes.

For the clinical-condition-style write-ups — eligibility, perioperative-hormone management, regret data, lifelong follow-up, mental-health and access barriers, and the non-GU components (top surgery, FFS, voice) — see the dedicated articles in Special Populations: Gender-Affirming Surgery.

Cross-cutting Foundations references: Radial Forearm Free Flap, Anterolateral Thigh Flap, Peritoneal Flap, Vastus Lateralis Flap, Buccal Mucosa Graft, Genital Reconstruction Principles, and Pharmacology — Gender-Affirming Hormone Therapy.