Urology and Gender-Affirming Care: Inclusive Innovations

As the medical community advances toward inclusive, patient-centered care, urology is playing a vital role in gender-affirming treatment for transgender and gender-diverse individuals. Gender-affirming urological surgeries such as neophalloplasty and vaginoplasty are critical components of many patients’ transitions, directly influencing quality of life, physical comfort, and psychological well-being. In tandem with these surgical advancements, urologists are addressing urinary health challenges unique to transgender patients, incorporating innovation, sensitivity, and multidisciplinary collaboration. This article explores the current landscape of gender-affirming urologic care and outlines emerging techniques, patient needs, and future directions.

The Role of Urology in Gender-Affirming Care

Urologists are instrumental in performing or supporting surgical procedures related to gender affirmation. These include:

Neophalloplasty: The surgical creation of a penis for transmasculine individuals.
Vaginoplasty: The construction of a vagina for transfeminine individuals.
Urethral lengthening and reconstruction: To enable standing urination or sexual function.
Scrotoplasty, metoidioplasty, orchiectomy, and other adjunct procedures.

Each of these interventions is highly complex and requires a combination of surgical expertise, knowledge of urinary tract anatomy, and sensitivity to the diverse goals and identities of patients.

Neophalloplasty: Surgical and Urological Considerations

Neophalloplasty, or phalloplasty, involves the creation of a neopenis using tissue grafts, typically harvested from the forearm (radial forearm flap), thigh (anterolateral thigh flap), or other donor sites. Urological involvement is especially critical in:

Urethral Lengthening and Anastomosis

For patients desiring the ability to urinate while standing, urethral lengthening is performed during or following the phalloplasty. This involves connecting the native urethra to a newly constructed urethral channel within the neopenis. Urethral complications such as strictures and fistulas are common, affecting up to 50% of patients. Advances in surgical technique and postoperative management have helped reduce these rates, but careful monitoring remains essential.

Implantable Prosthetics

To achieve erectile function, penile implants may be placed after healing from initial surgery. Innovations in prosthetic design and surgical approach aim to reduce complications such as infection, mechanical failure, and erosion. Collaboration between urologists and reconstructive surgeons ensures a functional, aesthetically satisfactory outcome.

Vaginoplasty: Functional and Aesthetic Goals

Vaginoplasty for transfeminine individuals typically involves the inversion of penile skin to form the vaginal canal, supported by additional grafts when necessary. Urologists contribute significantly to this process, particularly regarding urethral shortening and positioning.

Urethral Management

During vaginoplasty, the urethra is shortened and repositioned to reflect typical female anatomy. Attention must be paid to preserving urinary continence, avoiding strictures, and ensuring proper urinary stream alignment. Postoperative care often includes monitoring for urinary tract infections (UTIs) and bladder dysfunction.

Urinary Complications

Studies show that a significant number of patients experience urinary issues post-vaginoplasty, including dysuria, spraying, or retention. These may stem from anatomical changes, infection, or scarring. Urologists play a key role in long-term management, using cystoscopy, imaging, and behavioral therapies to address such concerns.

Urological Complications and Long-Term Care

Even with successful gender-affirming surgery, urinary complications are not uncommon. Transgender patients may face long-term urological issues requiring specialized follow-up:

Urethral strictures from scar formation post-surgery.
Recurrent UTIs due to anatomical changes or hygiene challenges.
Bladder dysfunction from neurogenic injury or hormonal influences.
Incontinence in both transmasculine and transfeminine patients.

To optimize outcomes, many centers have established multidisciplinary gender-affirming clinics where urologists work alongside endocrinologists, mental health professionals, and pelvic floor specialists.

Patient-Centered Approach and Informed Consent

Respecting patient autonomy and ensuring comprehensive informed consent are essential pillars of ethical care. Transgender individuals may have diverse goals—some may desire urinary function changes, while others prioritize aesthetic outcomes. Urologists must clearly communicate surgical options, expected outcomes, and potential complications in a supportive, nonjudgmental environment.

Affirming Language and Communication

Using correct pronouns, inclusive terminology, and trauma-informed practices can enhance trust and satisfaction. Training in culturally competent communication is now a part of many urology residency programs, reflecting the growing awareness of the importance of inclusivity in surgical care.

Urinary Health Beyond Surgery

Not all transgender patients undergo gender-affirming surgery, but many still require urological support. For example:

Hormone therapy (e.g., testosterone or estrogen) may affect bladder function or risk of UTIs.
Pelvic floor dysfunction may occur in both transmasculine and transfeminine individuals due to hormonal changes, tucking, binding, or trauma.
Stone disease and hematuria may present unique diagnostic challenges due to anatomical variation or surgical history.

These patients benefit from individualized assessments and care plans that account for both biological and gender-affirmed anatomy.

Innovations and Future Directions

Technological advances are continuously improving outcomes in gender-affirming urology. Key areas of innovation include:

3D Surgical Planning

Computer-assisted modeling allows surgeons to plan complex neophalloplasty or vaginoplasty procedures with enhanced precision, reducing complications and operative times.

Tissue Engineering

Experimental efforts are underway to develop bioengineered tissues for neovaginal and neourethral construction. These scaffolds, combined with autologous cells, may one day offer alternatives to skin grafts and reduce donor site morbidity.

Non-invasive Monitoring

Emerging wearable technology and smart catheters could help monitor urinary flow, detect infections, or assess bladder pressure in real time, enhancing postoperative care and early detection of complications.

Barriers to Care

Despite advances, transgender individuals often face significant barriers to accessing gender-affirming urologic care:

Lack of provider training in transgender health and surgical procedures.
Geographic disparities in access to experienced surgical centers.
Insurance coverage limitations for gender-affirming procedures and follow-up care.
Stigma and discrimination within healthcare settings.

Addressing these challenges requires advocacy, policy reform, and expanded medical education.

Medical Education and Advocacy

Urology training programs are increasingly integrating education on gender-affirming procedures. Workshops, simulation training, and interdepartmental collaboration with plastic surgery are enhancing surgical competency and cultural competence. Professional organizations, such as the American Urological Association, have issued statements supporting inclusive care and are developing guidelines for best practices.

Research Priorities

There remains a critical need for more robust, long-term research into outcomes of gender-affirming urologic surgeries. Patient-reported outcome measures (PROMs), quality-of-life assessments, and large cohort studies are necessary to inform evidence-based practice. Moreover, involving transgender individuals in research design ensures that studies reflect real-world needs and priorities.

Conclusion

Urology is at the forefront of supporting the health and dignity of transgender patients through gender-affirming care. With continuous innovation in surgical techniques, personalized urinary health management, and a commitment to inclusivity, the specialty is helping bridge gaps in care and improve lives. As medical understanding grows and societal awareness increases, urologists will remain vital allies in advancing equitable, affirming care for all individuals, regardless of gender identity.

For more information and recent research in this area, visit Urology Journal.