FEATURE G enital gender afrmation surgery (GAS) is the fnal step in the transition journey for transgender men. Genital GAS involves a combination of procedures to surgically align physical characteristics with one’s gender identity. These needs change between each individual depending on their gender identity (see below), desire for childbearing, personal preferences and tolerance for potential complications relating to these operations. What is gender identity and gender dysphoria? Terminology in the feld of gender identity is constantly evolving but an understanding of the nomenclature is helpful when interacting with transgender patients. Sex assigned at birth refers to the sex assigned to a newborn baby by a clinician based on external genitalia and / or through prenatal diagnostics like ultrasound. Gender identity refers to a person’s psychological sense of their gender as female, male or non-binary. Increasingly, the concept of gender identity is changing from binary concepts (female or male) to a more fuid spectrum. Gender dysphoria results when the sex assigned at birth is incongruent with the gender identity of the person resulting in psychological distress. Sexual orientation is distinct to gender identity and is defned by the types of person towards whom one is sexually and / or emotionally attracted to. Referral pathway for gender afrmation surgery The medical care (including monitoring of testosterone supplementation) and psychological support for transgender men are both provided by gender dysphoria clinics. Patients require a ‘two signature referral’ by two gender physicians in order to access services for genital GAS. Genital GAS for the UK has been centralised at St Peter’s Andrology in London. The patient would need to be aged 18 or over, have lived in the gender role that is congruent with their gender identity for greater than a year and used gender afrming hormone therapy for greater than a year prior to referral. These criteria are mandated by the World Professional Association for Transgender Health (WPATH) Standards of Care version 7 published in 2011 [1]. Version 8 is due for release in 2021. Goals of surgery Genital GAS further ameliorates gender dysphoria in the properly selected patient. Body satisfaction scores were higher following gender afrming hormone therapy with surgery compared to hormone therapy alone [2]. Transgender men receiving hormone therapy while awaiting genital GAS had lower satisfaction scores compared to men receiving hormone therapy who did not wish to have genital GAS. Importantly, not all transmen desire or request any or all of the procedures encompassing genital GAS. Broadly speaking, these involve the removal of the female reproductive organs (vaginectomy, hysterectomy and / or salpingo-oophorectomy) and reconstruction of the male sexual organs including penile reconstruction, urethral lengthening (joining the phallus urethra to the native urethra), glansplasty (fashioning a glans for the neophallus), clitoral transposition (repositioning or burying the clitoris) and scrotoplasty (reconstruction of a scrotum) followed by insertion of an erectile device and testicular prosthesis. Surgical considerations The role of the surgeon is to guide the patient to make the right choice for their needs taking into account what is surgically achievable. There is no ‘one size fts all’ approach to GAS given that around a third of transgender men do not seek genital GAS due to the complex surgery required and risk of complications [3]. Our preference is to perform the surgery in several stages. Some centres abroad ofer so-called ‘single stage’ phalloplasty by combining penile reconstruction, scrotoplasty, glansplasty and urethral lengthening. The erectile and testis prosthesis are always inserted at a later stage. We prefer to perform urethral lengthening in the second stage of the operation to allow any complications to be more easily managed in a routine fashion without needing urinary diversion or any additional stages. We reconstruct a neophallus in the frst stage of genital GAS. The two options for penile reconstruction available to the transgender man are metoidioplasty or phalloplasty. Metoidioplasty Metoidioplasty is where the clitoris is lengthened to form a micropenis following hypertrophy in response to gender afrming hormone therapy (testosterone). We recommend at least two years of testosterone supplementation in order to achieve maximal hypertrophy of the clitoris prior to surgery. The metoidioplasty normally measures between 4cm and 10cm (median 5.7cm) [4]. Metoidioplasty is therefore best suited for transmen who are of smaller stature and build (body mass index <25kg/m²). Most will be able to void while standing (87-100%) but most patients will continue to void in a cubicle (rather than at a urinal) and penetrative intercourse is rarely possible (Figure 1). Metoidioplasty in the UK is performed in three stages. The clitoral ligaments and urethral plate are divided to lengthen the clitoris with the laying of a buccal mucosa onlay graf on the extended portion as a frst stage urethroplasty. The metoidioplasty is then completed in the second stage by urethral plate / buccal graf tubularisation and urethral lengthening, micropenis formation, scrotoplasty and removal of the female reproductive organs (if desired). Testicular prostheses are inserted in the Genital gender affirmation surgery for transgender men BY WAI GIN LEE, NIM CHRISTOPHER AND DAVID RALPH Figure 1: Patient following completion of metoidioplasty GAS. urology news | MAY/JUNE 2021 | VOL 25 NO 4 | www.urologynews.uk.com