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. 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.