Urological issues in masculinising genital surgery: a Delphi consensus study

To establish international expert consensus on indications, contraindications, risk factors, and complication management in masculinising genital surgery (MGS) for assigned female at birth individuals, addressing the current lack of evidence-based selection criteria.

A two-round Delphi study was conducted between May and July 2025 using an on-line platform, followed by a final consensus meeting in September 2025. A total of 27 internationally recognised urologists with ≥5 years of independent experience in gender-affirming genital surgery were invited; response rates were 96% and 89% in rounds one and two, respectively. In all, 83 statements related to metoidioplasty and phalloplasty were evaluated using a Likert scale. Consensus was pre-defined as ≥75% agreement or disagreement.

Consensus was achieved on 75 of 83 statements. No strict upper age limit was recommended for metoidioplasty or phalloplasty; however, advanced age and comorbidities were recognised as risk factors for prolonged healing and severe complications. A body mass index >24.9 kg/m², diabetes mellitus, smoking, and cardiovascular disease were identified as relevant risk factors. A Charlson Comorbidity Index ≥3 was considered a relative contraindication for phalloplasty but not metoidioplasty. Multidisciplinary preoperative assessment was strongly endorsed. No consensus was reached regarding perioperative testosterone suspension. In urethral complications, staged reconstruction with a 6-month interval and consideration of perineostomy in high-risk patients were preferred. Penile prosthesis re-implantation was considered acceptable after one failure but discouraged after multiple complications.

This international Delphi consensus provides structured, expert-based guidance for patient selection and complication management in MGS, emphasising individualised risk assessment, multidisciplinary evaluation, and cautious surgical planning in older or comorbid patients.