Urological issues in masculinising genital surgery: a Delphi consensus study

OBJECTIVE: 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. METHODS: 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. RESULTS: , 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. CONCLUSIONS: 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.

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Journal
British Journal of Urology
Published
2026-08-20
DOI
https://doi.org/10.1111/bju.70428
Primary Topic
Female Genital Mutilation/Cutting Issues
Type
article
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article

Urological issues in masculinising genital surgery: a Delphi consensus study

Łukasz Białek, Patrizio Vicini, Malte W. Vetterlein, Juan Diego Tinajero et al.
British Journal of Urology
Female Genital Mutilation/Cutting Issues
article

Urological issues in masculinising genital surgery: a Delphi consensus study

Łukasz Białek, Patrizio Vicini, Malte W. Vetterlein, Juan Diego Tinajero, Silke Riechardt, Wesley Verla, Jochen Heß, Jordán Scherñuk, Marco Capece, Francesco Chierigo, Marco Falcone, Andrea Cocci, Mirko Preto, Miroslav L. Djordjević, Francesca Vedovo, Marjan Waterloos, P. Neuville, Maren Juliane Wenk, Michele Rizzo, Mattia Lo Re, Marta Pezzoli, Valeria Pizziconi, Lisa Szyper, Julia Bohr, Guglielmo Mantica, Wai Gin Lee, Francois Xavier Madec, Saskia Morgenstern, Andrea Minervini, Tim Ludwig
article en

Abstract

OBJECTIVE: 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. METHODS: 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. RESULTS: , 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. CONCLUSIONS: 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.

British Journal of Urology
University College London Hospitals NHS Foundation Trust (GB), University of Trieste (IT), Universität Hamburg (DE), Heidelberg University (DE), Medical University of Warsaw (PL), Chelsea and Westminster Hospital NHS Foundation Trust (GB), Ghent University Hospital (BE), University Hospital Heidelberg (DE), Hospital Italiano de Buenos Aires (AR), University of Belgrade (RS), Azienda Ospedaliera Citta' della Salute e della Scienza di Torino (IT), Saint Camillus International University of Health and Medical Sciences (IT), Hospices Civils de Lyon (FR), University Medical Center Hamburg-Eppendorf (DE), Hôpital Lyon Sud (FR), Azienda Ospedaliero-Universitaria Careggi (IT), Medizinisches Versorgungszentrum Prof. Mathey, Prof. Schofer (DE), Essen University Hospital (DE), AZ Maria Middelares (BE), Kliniken Essen-Mitte (DE), Ospedale Policlinico San Martino (IT), Agaplesion Markus Hospital (DE), University Medical Centre Mannheim (DE), Hôpital Foch (FR), University College London (GB), University of Duisburg-Essen (DE), University of Naples Federico II (IT)
Gender equality, Good health and well-being
Openalex Percentile: Top 7%
Female Genital Mutilation/Cutting Issues
DOISourceOpenAlex
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