Masculinizing Gender-Affirming Surgery
Masculinizing genital gender-affirming surgery (GAS) is informed by WPATH Standards of Care v8 (2022) for surgical care, ACOG Committee Opinion 823 (2021; reaffirmed 2024) for general gynecologic care, and the Endocrine Society 2017 Clinical Practice Guideline for hormone management.[1][2][39] The procedures include metoidioplasty, phalloplasty (with or without urethral lengthening), vaginectomy, scrotoplasty, testicular implants, and erectile prosthesis. Chest masculinization is covered in the Masculinizing Procedures clinical-conditions article.[1][2][3]
The masculinizing GAS plan depends on four patient priorities: (1) standing micturition (drives urethral lengthening), (2) penetrative intercourse (drives phalloplasty and erectile prosthesis), (3) phallus size (mean erect length 5.5 cm after metoidioplasty versus 14.1 cm after phalloplasty in a patient-reported survey), and (4) tolerance for staged morbidity (metoidioplasty is generally a single-stage operation whose urethral complication rate depends heavily on whether urethral lengthening is added; phalloplasty is usually staged and carries a high urethral complication burden).[1][2][4][10] The main supporting evidence is WPATH SOC v8 for eligibility and timing[1], the Bordas 2021 Front Endocrinol 813-patient metoidioplasty series, the Wang 2026 Microsurgery flap-by-flap complication comparison (57 patients, single institution), the Berli 2025 Big Ben two-stage urethral lengthening series (73 first-stage patients, 71 of whom proceeded to stage 2, single surgeon; 27% urologic complication rate; 96% standing micturition), the Veerman 2020 and Waterschoot 2021 urethral-complication cohorts, and the Levy 2026 Delphi consensus protocol on penile implants after phalloplasty.[5][6][7][8][9][11]
Decision Framework
Goal-Directed Pathway Selection
| Patient Priority | Recommended Pathway | Alternative | Rationale |
|---|---|---|---|
| Standing micturition without penetrative function; minimize complications | Metoidioplasty with urethral lengthening (UL) | Phalloplasty + UL when phallus size or appearance is a separate priority; counsel on greater surgical burden | Single-stage; metoidioplasty recipients reported erogenous sensation of 4.8/5 in a patient survey; urethral complications are frequent when urethral lengthening is added[6][10] |
| Standing micturition + penetrative intercourse | Phalloplasty + UL (often staged); consider delayed erectile prosthesis if rigidity is insufficient for the patient's penetrative goals | Metoidioplasty first → conversion to phalloplasty later (option preserved) | Penetration without an implant has been reported, although many recipients use a prosthesis.[35] The fibula osteocutaneous flap provides intrinsic rigidity for intercourse.[36] Phalloplasty and urethral reconstruction are commonly staged, and implantation is considered after healing.[1][11][9] |
| Penetrative intercourse without standing micturition | Phalloplasty without UL, retaining the native meatus or creating a perineal urethrostomy if vaginectomy/perineoplasty is planned; discuss a delayed prosthesis if needed for penetration[45][35] | Metoidioplasty + phalloplasty conversion | In Waterschoot’s 74-patient metoidioplasty cohort, additional UL was associated with fistula (OR 6.07) and stricture (OR 24.5).[6] In a separate retrospective phalloplasty cohort (91 with UL; 45 without), fistula occurred in 39/91 versus 1/45, stricture in 55/91 versus 0/45, and reoperation under general anesthesia for surgical or urological complications in 74/91 versus 12/45 at median follow-up of 32 versus 30 months; flap types differed between groups.[46] |
| Maximal sensation prioritized; size acceptable | Metoidioplasty | Phalloplasty (erogenous sensation 3.4/5 in the same survey) | Metoidioplasty preserves native clitoral neurovasculature; sensation 4.8/5 (Robinson 2021)[10] |
| Active smoker | Counsel smoking cessation before elective UL and assess perioperative risk | Metoidioplasty or phalloplasty without UL when aligned with the patient’s goals; first counsel smoking cessation and assess perioperative risk | In a 74-patient metoidioplasty cohort, active smoking was associated with fistula (OR 6.54) and permanent fistula (OR 3.76)[6] |
| Uncertain / wants to preserve pathway flexibility | Metoidioplasty as first operation | — | All phalloplasty techniques have been reported to remain feasible after metoidioplasty (Bordas 2021)[5] |
A 2026 international Delphi panel identified smoking, diabetes, cardiovascular disease and higher BMI as factors for perioperative risk assessment, and considered Charlson Comorbidity Index ≥3 a relative contraindication for phalloplasty but not metoidioplasty. It found no consensus on perioperative testosterone interruption.[49]
Phalloplasty Flap Selection
| Clinical Scenario | First-Line Flap | Alternative(s) | Avoid |
|---|---|---|---|
| Default candidate; values aesthetics + sensation | Radial forearm free flap (RFFF) with tube-in-tube urethra (Garaffa 2010 separately reported a radial-forearm urethral flap placed inside an existing pedicled pubic phalloplasty in 27 patients: all who completed both stages voided standing at median follow-up of 9.2 months)[21] | Pedicled ALT (concealed donor site) | Assuming tube-in-tube ALT is routinely feasible: D'Arpa used it in 5/86 ALT cases seeking urethral reconstruction (5.8%; 93 total, including 7 without urethral reconstruction); suitability depends on flap anatomy[22] |
| Wants concealed donor site, accepts debulking | Pedicled ALT with a separately planned urethra; in a 2025 single-center ALT–SCIP series, complete urethral SCIP loss occurred in 5/33 cases.[47] | RFFF with cosmetic forearm-scar counseling | ALT with single-stage tube-in-tube urethra |
| Considering a pedicled abdominal shaft | In one 57-patient retrospective center, complications occurred in 9/22 abdominal, 6/10 ALT and 20/25 RFFF recipients; abdominal urethroplasty was separately staged with RFFF, unlike index-operation RFFF urethras[7] | Choose RFFF or ALT according to urethral goals, donor sites and tolerance for staged surgery | Treating these non-equivalent pathways as a flap-only risk ranking |
| Considering staged urethral lengthening | No established first-line flap; two-stage “Big Ben Method” is one described approach (Berli 2025 single-surgeon series: stricture 8% and fistula 16.4% among 71 second-stage patients; standing urination 96% among 73 first-stage patients)[8] | Single-stage RFFF | Single-stage tube-in-tube in active smokers |
| Intrinsic rigidity preferred (no prosthesis required) | Fibula osteocutaneous free flap (limited centers) | RFFF + delayed IPP | Fibula in patients with peripheral vascular disease |
| Microsurgery unavailable or contraindicated | Pedicled ALT or abdominal flap can construct the shaft without free-flap transfer | If urethral lengthening to the phallic tip remains a goal, plan referral or a separate urethral reconstruction; abdominal recipients in Wang 2026 received later RFFF urethroplasty[7] | RFFF or fibula at a center without microsurgical capability |
Girth counseling. An exploratory study measuring bestselling realistic dildos as a proxy for penetrative-toy and phallus size preferences reported average bestselling girth of 12.7 ± 0.8 cm (matching natal erect penile girth, 12.3 ± 1.3 cm) and average top-3-largest-selling girth of 15.1 ± 0.9 cm. Four index patients seeking neophallus revision for girth that precluded penetrative intercourse had a mean girth of 17.6 ± 1.3 cm, 4 to 5 SD wider than natal erect girth. The authors suggest a conservative neophallus girth of 13–14 cm, with 15.1 cm (2 SD above natal average) as an upper limit after prosthesis implantation.[29]
Urethral Lengthening Decision
| Clinical Scenario | First-Line | Alternative | Avoid |
|---|---|---|---|
| Standing micturition desired + non-smoker + adequate vaginal-wall tissue | Full UL with anterior vaginal-wall flap + labia minora flaps + buccal mucosa graft (modified Belgrade for metoidioplasty); RFFF tube-in-tube or two-stage Big Ben for phalloplasty | Ring-flap metoidioplasty UL (11/69 fistulas and 4/69 strictures in one retrospective series)[48]; UL with pre-laminated buccal mucosa onto the phalloplasty flap | UL in active smoker (defer) |
| Standing micturition desired + previously failed UL | Map stricture site and length, healing interval, and prior endoscopic attempts. The 2026 EAU guideline strongly recommends deferring endoscopic incision or urethroplasty until at least six months after neophalloplasty and avoiding more than two endoscopic incisions except for palliation; it weakly recommends staged urethroplasty for a neophallic-urethral stricture requiring open repair.[40] Staged repair of long pendulous strictures had reported recurrence of 0–25% across heterogeneous studies.[38] BMG urethroplasty may augment staged repair of selected neophallic strictures; technique depends on site, length, healing interval and local tissue quality.[40] | Conversion to perineal urethrostomy | Assuming repeat single-stage UL has the same recurrence risk as staged reconstruction |
| Penetrative function only; standing micturition not required | Phalloplasty without UL, retaining the native meatus or creating a perineal urethrostomy if vaginectomy/perineoplasty is planned (avoids complications from a lengthened neourethra)[45] | Metoidioplasty without UL; a short (about 2 cm) cosmetic distal neourethral segment with a closed proximal end, anchored to the shaft's Scarpa fascia with two or three sutures to reduce prolapse, has been described to create a cosmetic meatus while voiding continues through the native meatus[26] | Urethral lengthening "just in case" |
| Preserves vaginal canal; non-binary anatomical goals | Metoidioplasty without UL or vaginectomy | Shaft-only phalloplasty with vaginal preservation (Chen, Moorefield); phalloplasty with UL and vaginal preservation is also feasible, with urethral complications in 67% of nine preservation patients versus 27% of 215 vaginectomy patients in one retrospective cohort[37] | Coercive vaginectomy when not patient-aligned |
Patients likely to need frequent cystoscopy or other transurethral procedures — for example, a history of bladder cancer or stones — should be counseled specifically that urethral lengthening can make later transurethral access more difficult and may increase urethral complications.[27] Before UL is planned, documenting urologic history and assessing baseline emptying with uroflowmetry and postvoid residual, along with renal ultrasound to look for upper-tract abnormalities that may be harder to address after reconstruction, has been recommended.[23] For a skin-lined phallic urethra, map hair-bearing donor skin before transfer and discuss preoperative depilation; it reduced but did not eliminate neourethral hair in a retrospective 25-patient study.[50]
Vaginectomy Timing & Technique
| Clinical Scenario | First-Line | Alternative | Avoid |
|---|---|---|---|
| Phalloplasty with UL planned | Discuss concurrent transperineal vaginectomy, preserving anterior vaginal-wall tissue for UL when used[15] | Vaginal preservation with UL is feasible, but urethral complications occurred in 67% of nine preservation patients versus 27% of 215 after vaginectomy in one retrospective cohort[37]; electrocautery fulguration has comparative data in a 70-patient metoidioplasty cohort[16] | Presenting vaginectomy as mandatory or omitting counseling on the small-cohort urethral risk signal |
| Metoidioplasty + UL planned | Vaginectomy remains optional based on the patient's goals and dysphoria burden. A systematic review of 23 case series (all at high risk of bias) reported more urethral complications with vaginal preservation after metoidioplasty or phalloplasty with UL.[43] In a retrospective vaginectomy comparison, fulguration was associated with shorter OR time and, among patients without hysterectomy, lower EBL.[16] | Sharp excision when AVW flap is needed for UL | Mandating vaginectomy for all UL candidates |
| Metoidioplasty without UL | Optional vaginectomy (patient-aligned, dysphoria-driven decision) | Vaginectomy deferred indefinitely | Coercive vaginectomy |
| Non-binary patient retaining vaginal canal | No vaginectomy | — | Vaginectomy as default in non-binary care |
| Concurrent laparoscopic hysterectomy | Vaginectomy concurrent with laparoscopic hysterectomy: Gomes da Costa 2016 obtained adequate vaginal mucosa for UL in all 23 laparoscopic-assisted cases; Kim-Ortega 2025 reported 31 concurrent transvaginal vaginectomies.[17][41] | Two-stage (laparoscopic hysterectomy → later transperineal vaginectomy) | Treating transvaginal or transperineal vaginectomy as unsuitable solely because laparoscopy is available; concurrent laparoscopic hysterectomy and transvaginal vaginectomy have been described[15][41] |
Robotic transabdominal vaginectomy with perineal assistance. A described technique preserves anterior vaginal mucosa as a flap to extend the native urethra for UL, completes distal dissection near the meatus to limit diverticulum formation, and can thin the posterior mucosa for use as a urethral-lengthening graft; the cavity is closed robotically, with a gracilis flap preferred as an additional measure to reduce cavity recurrence. In an initial series of 16 patients undergoing this approach as a primary procedure, mean operating time was 423.6 ± 84.6 minutes, and no patient developed a urinary fistula at the urethroplasty site at a mean follow-up of 361 ± 176 days.[51] The chapter reports that five patients (31.2%) had minor postoperative complications managed conservatively, none developed a proximal urethral fistula, and three presented with distal fistulas after second-stage phalloplasty at a mean postoperative day of 349 ± 51.4.[28]
Scrotoplasty, Testicular Implants, Erectile Prosthesis (Staged Sequencing)
| Stage | Operation | Timing | Notes |
|---|---|---|---|
| Stage 1 | Hysterectomy ± BSO | Timing individualized; may be combined with other procedures | Laparoscopic or transvaginal approaches are described; vaginal approach is technically challenging due to testosterone-induced vaginal atrophy and absent uterine descent. Oophorectomy decision is patient-specific (fertility, hormone plans). Few patients change testosterone dosing after HBSO regardless of BSO[4] |
| Stage 2 | Metoidioplasty or phalloplasty ± UL, with vaginectomy and scrotoplasty selected according to the patient's goals and reconstruction plan | Timing individualized; some metoidioplasty components were combined with hysterectomy, while vaginectomy with laparoscopic hysterectomy has also been reported[5][17] | Hoebeke pedicled-labia-majora U-flap scrotoplasty (most frequently performed; implant explantation 11.5% [6/52] versus 20.8% [43/206] in the whole series); Pigot 2020 stepwise scrotoplasty without UL[12][18] |
| Stage 2 or 3 (metoidioplasty or phalloplasty) | Testicular implants | At index metoidioplasty in Bordas 2021[5]; ≥6 mo after genital surgery in Pigot 2019 institutional practice[12] | The series describes a shift toward smaller / lighter prostheses and delayed implantation, alongside lower explantation rates over time. Smoking is a major risk factor[12] |
| Stage 4 (if phalloplasty) | Erectile prosthesis (inflatable or malleable; ZSI 100 FtM is malleable, and device-class superiority has not been established)[13][20][42] | Delayed after phalloplasty; interval set by center protocol | Levy 2026 Delphi consensus protocol : confirm flap vascularity and reliable micturition before proceeding; cylinder wrapping and pubic-bone fixation are used. In a separate retrospective cohort of 50 patients undergoing 85 ZSI implant procedures (50 primary, 35 secondary), prior UL was associated with late implant complications (HR 2.6, 95% CI 1.3–5.0).[42] In a systematic review of 792 implant recipients (including 30 non-transgender patients), 287/792 (36.2%) had a prosthesis complication requiring or potentially requiring further surgery, 305/508 (60.0%) retained the original implant at latest follow-up (mean 2.6 years reported for 433 of these 508 patients), and 193/230 (83.9%) achieved penetration; mean follow-up was 3.0 years among 580 patients (Rooker 2019).[13] A separate retrospective cohort of 694 first-time three-piece IPPs reported 15-year cumulative incidence of revision for mechanical failure of 30.6% and overall revision incidence of 65.1%.[44] Sun 2023 infrapubic malleable in transmen; Pigot 2020 ZSI 100 FtM cohort[9][13][19][20] |
Long-Term Urologic Surveillance
SOC 8 suggests that surgeons encourage lifelong urological follow-up after metoidioplasty or phalloplasty (statement 13.9), and patients with UL in particular need it.[1] Urinary retention warrants urgent assessment. New or worsening dribbling, pelvic pain or fullness, recurrent UTI, a suspected vaginal remnant, or neomeatal narrowing warrants timely urologic evaluation; isolated dribbling can occur after phalloplasty.[23] Urethral complications may present weeks to years after the index operation.[1][3][14]
Evaluating New Lower Urinary Tract Symptoms
A structured workup for new lower urinary tract symptoms after phalloplasty starts with a post-void bladder ultrasound to assess emptying. Urinalysis and urine culture are often positive from chronic bacterial colonization of the neourethra, so a symptom-based assessment for infection is more informative than culture alone. Flexible cystoscopy, often with a flexible ureteroscope to navigate the neourethral lumen, rules out stricture, stone, and retained hair, and standard urologic causes such as stone disease and malignancy remain part of the differential.
Caliber assessment. Blind passage of a catheter, dilator, or bougie to assess urethral caliber after metoidioplasty or phalloplasty carries an injury risk and has been discouraged in favor of direct-vision assessment: a 16 Fr flexible cystoscope when it passes, or an 8 Fr pediatric flexible cystoscope or ureteroscope for a tighter lumen, advanced over a guidewire through a tortuous neourethra. If the distal urethra is completely obliterated, antegrade flexible cystourethroscopy through a suprapubic tract has been described. Retrograde urethrography paired with a voiding cystourethrogram is a reasonable initial imaging workup.[30]
Hematuria. Bleeding from granulation tissue along the neourethral suture line is a common early cause of hematuria after phalloplasty; acidic urine is thought to often allow the tissue to subside without intervention. For persistent granulation, diathermy through a flexible cystoscope has been described, with a catheter left for a few days afterward because heat-related edema can narrow the neourethra.[31]
Acute retention. Repeated blind catheter passes after masculinizing urethral reconstruction should be avoided. In early retention after neophalloplasty when a stricture is suspected, the 2026 EAU guideline identifies suprapubic drainage as first-line.[40] For later or other causes, a clinician familiar with the reconstruction may consider one gentle, well-lubricated 14 Fr Coudé attempt; stop if passage is difficult and use direct-vision guidance when transurethral access is needed. Protect the phallus vascular pedicle during suprapubic access.[32]
Post-void dribbling was reported by 79% of 24 phalloplasty survey respondents in one series.[23] One mechanism is pooling of urine within the pars fixa from the caliber mismatch between the pars fixa and the phallic urethra and the absence of the bulbospongiosus muscle; some patients manage this by manually compressing the perineum to empty the pooled urine after voiding. Apparent leakage can also reflect urine pooling in the perineal urethra or a persistent vaginal remnant rather than stress urinary incontinence; for pain, dribbling, pooling, dysuria, or leakage, urologic evaluation with cystoscopy and/or retrograde urethrogram when indicated should exclude anatomic causes before sling consideration.[32] A retained vaginal remnant or urethral diverticulum is a distinct, correctable cause of dribbling and voiding symptoms and can be excised, including by a robotic transabdominal approach.[24][25] A described technique defines a symptomatic remnant with preoperative CT cystography, retrograde and voiding urethrography, and cystoscopy under anesthesia; during robotic transabdominal excision, a transurethral cystoscope set to near-infrared can be used to visualize the cystoscope light through the remnant and guide dissection away from adjacent structures, with a urethral defect oversewn robotically, a Foley catheter left 1–2 weeks, and the urethra assessed by voiding or peri-catheter retrograde urethrogram at catheter removal.[28]
Stress Incontinence After Phalloplasty
Apparent stress incontinence after phalloplasty should first be evaluated for an underlying anatomic cause, as above. If true SUI remains after other abnormalities are excluded, a procedure may be considered after less-invasive options, with care to protect the neophallus vascular pedicle during dissection and sling-trocar passage. Because a true bulbar urethra is absent, a standard artificial urinary sphincter or bulbar male sling may not be feasible in this anatomy.[34] The supporting evidence for periurethral bulking in this population is an early two-patient report (one trans man, one trans woman) of periurethral collagen injection that produced symptomatic improvement and a rise in abdominal leak point pressure, with no long-term outcome reported.[33]
Treatment Database
| Procedure | Domain | Best for / indication |
|---|---|---|
| Simple Metoidioplasty | Phallic Construction | Patients prioritizing low urethral complication burden over standing micturition. |
| Modified Belgrade Metoidioplasty | Phallic Construction | Metoidioplasty with urethral lengthening for standing micturition. |
| RFFF Phalloplasty | Phallic Construction | Aesthetics and sensation when a forearm scar is acceptable. |
| ALT Phalloplasty | Phallic Construction | Concealed donor site without shaft microsurgery; plan urethral reconstruction separately. |
| Phalloplasty — Pedicled Abdominal Flap | Phallic Construction | Pedicled shaft construction without microsurgery; plan urethral lengthening separately if desired. |
| Phalloplasty — SCIP Flap | Phallic Construction | Selected shaft or urethral reconstruction, including ALT pairing or revision; counsel on reported SCIP urethral-flap losses. |
| MLD Phalloplasty | Phallic Construction | Large phallic volume and a concealed back scar when tactile sensation matters less. |
| Fibula Phalloplasty | Phallic Construction | Patients accepting permanent rigidity to avoid erectile prosthesis. |
| "Big Ben Method" — Two-Stage Urethral Lengthening Phalloplasty | Phallic Construction | Patients considering two-stage urethral lengthening with phalloplasty. |
| Pars Fixa Urethral Construction | Urethral Reconstruction | Construction of the fixed perineal urethra from native meatus to phallus base. |
| Phallic (Pendulous) Urethra — Tube-in-Tube | Urethral Reconstruction | Single-flap pars pendulans within thin hairless RFFF tissue. |
| Phallic Urethra — Prelaminated Buccal Mucosa Graft | Urethral Reconstruction | Selected primary phallic-urethra construction using prelaminated BMG. |
| Phallic Urethra — Separate Flap (e.g., SCIP, ALT-perforator) | Urethral Reconstruction | Dedicated urethral flap for ALT phalloplasty in selected cases. |
| Perineal Urethrostomy (no UL) | Urethral Reconstruction | Phalloplasty without UL or salvage after failed UL. |
| Vaginectomy / Colpectomy | Vaginectomy | Often paired with urethral-lengthening phalloplasty for vascularized coverage; vaginal preservation remains possible, or the canal may be removed as a standalone goal. |
| Scrotoplasty | Scrotoplasty | Neoscrotum construction during masculinizing GAS using labia majora for testicular-implant pocket. |
| Testicular Implants | Testicular Implants | Neoscrotal augmentation at index surgery or after tissue healing, according to technique and risk. |
| Penile Implant After Phalloplasty | Erectile Prosthesis | Penile-prosthesis placement after phalloplasty for erectile function; staged 9–12 mo postop. |
| Hysterectomy ± Bilateral Salpingo-Oophorectomy (HBSO) | Hysterectomy / BSO | Standalone gender-affirming surgery; coordinate hysterectomy before or with complete vaginectomy. UL phalloplasty can preserve the vagina, and oophorectomy is individualized. |
See Also
- GAS Overview (Special Populations)
- Masculinizing Procedures (Special Populations)
- Revision & Salvage GAS
- Pharmacology — Gender-Affirming Hormone Therapy
- Foundations — Radial Forearm Free Flap
- Foundations — Anterolateral Thigh Flap
- SCIP Phalloplasty
- Fibula Phalloplasty
- Foundations — SCIP Flap
- Foundations — Buccal Mucosa Graft
- Penile Implants
Podcasts
Videos
References
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