Urethral Complications After Masculinizing Genital Gender-affirming Surgery

Masculinizing genital gender-affirming surgery includes metoidioplasty and phalloplasty, with or without urethral lengthening. Construction of the neourethra remains the main determinant of postoperative morbidity, with fistulas and strictures representing the most frequent complications. Reported rates vary widely because of heterogeneity in surgical techniques, patient populations, and outcome reporting. Urethral lengthening is consistently associated with higher complication rates, whereas procedures without lengthening demonstrate lower morbidity without clear differences in patient-reported outcomes. Additional factors such as staging of reconstruction and vaginectomy may influence outcomes, although current evidence remains inconclusive. Given the substantial risk of complications, shared decision-making is essential to align surgical goals with patient expectations. Careful preoperative counseling should balance the desire for standing micturition against the increased risk of urethral complications. PATIENT SUMMARY: We reviewed complications after genital gender-affirming surgery. Procedures that lengthen the urethra have higher risks of problems such as narrowing or leakage. Patients should discuss all options carefully with their surgeon to choose the safest approach for their goals.