BJU Int. 2026 Aug 20. doi: 10.1111/bju.70428. Online ahead of print.
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: 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.
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.
PMID:42619492 | DOI:10.1111/bju.70428