International Delphi consensus on feminising genital surgery in assigned-male-at-birth individuals.

OBJECTIVE

To achieve an international expert consensus among surgeons on the indications, contraindications, and perioperative management of feminising genital surgery (FGS) for assigned-male-at-birth (AMAB) individuals, using a Delphi process.

METHODS

A two-round on-line Delphi survey (May-July 2025) followed by a final consensus meeting (September 2025) was conducted among 27 urological surgeons specialised in gender-affirming genital surgery. The survey explored eligibility criteria, risk factors, hormone therapy, counselling, and perioperative care. Consensus was defined a priori as ≥75% agreement or disagreement, with descriptive statistics summarising results.

RESULTS

In all, 26 experts (96%) completed Round 1, and 24 (89%) completed Round 2. Consensus was achieved on 63 of 68 statements. Advanced age alone was not a contraindication but should be evaluated alongside comorbidities. Body mass index >24.9 kg/m2, diabetes, smoking, and cardiovascular disease were identified as significant risk factors for postoperative complications. Major psychiatric disorders and spinal cord injury were relative contraindications for FGS. Previous pelvic surgery or radiotherapy, as well as Charlson Comorbidity Index ≥3, were considered relative contraindications for vaginoplasty only. No consensus was reached on the timing of hormone therapy interruption or re-initiation. Preoperative counselling was essential for adherence to wound care and dilation protocols and for addressing complications such as infection, thromboembolism, bleeding, and bowel injury. Experts recommended genital hair removal, enoxaparin prophylaxis, postoperative dressings and catheterization for 3-5 days, and pelvic rehabilitation before and after surgery. A dilation protocol of three daily 30-min sessions was advised. FGS improved quality of life even in older or comorbid patients, although healing and function may be less optimal.

CONCLUSION

This study presents the first international Delphi consensus on indications and perioperative management of FGS in AMAB individuals, emphasising individualised, comorbidity-based assessment, structured counselling, and multidisciplinary care. Unresolved issues regarding hormone therapy require further study.