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Clitoroplasty — Preputial-Skin Flap with Dorsal Neurovascular-Bundle Pedicle

Clitoroplasty using a preputial-skin flap with dorsal neurovascular bundle (NVB) pedicle is the gold-standard technique for constructing a sensate neoclitoris during feminizing genital GAS.[1][2] A pedicled island neurovascular flap of the glans penis — with the paired dorsal penile nerves and dorsal penile arteries preserved as the vascular and sensory pedicle — is combined with preputial (foreskin) or distal-shaft skin to simultaneously construct the neoclitoris, clitoral hood, and labia minora.[3][4][5] Across contemporary series, 85–97% report preserved clitoral sensitivity, 83–86% achieve orgasm, and the largest prospective series (Mañero 2018, n = 97) reports 0% total flap necrosis.[4][6][7]

This is the dedicated atlas page covering the canonical preputial-skin technique and its named variants. For the cohort-level decision framework, see Feminizing Gender-Affirming Surgery. For the host PIV operation, see Penile Inversion Vaginoplasty.

Anatomic Foundation​

The technique is grounded in the embryologic homology between the glans penis and glans clitoris, and between the penile prepuce and the clitoral hood / labia minora.[8][9]

Dorsal neurovascular bundle (NVB)​

  • Dorsal nerves of the penis — paired somatic sensory nerves, terminal branches of the pudendal nerve (S2–S4); the primary sensory supply to the glans and homologous to the dorsal nerves of the clitoris. They run dorsally along the penile shaft, deep to Buck's fascia, on either side of the deep dorsal vein.[8][10]
  • Dorsal arteries of the penis — paired branches of the internal pudendal artery within Buck's fascia, providing the primary arterial supply to the glans.[9]
  • Deep dorsal vein — midline venous drainage between the paired dorsal arteries and nerves.
  • The NVB fans out into the glans; the dorsal nerve is ~2–4 mm diameter at the crura, narrowing to ~1 mm at the distal clitoral body.[8]
  • Nerve density is significantly greater in the dorsal half than the ventral half — the anatomic rationale for dorsal-based flap harvest.[8]

Glans penis and prepuce​

  • Glans — densely neural, non-erectile; highest concentration of free nerve endings, Meissner corpuscles, and Pacinian corpuscles of any penile structure.[9]
  • Corona (coronal ridge) — particularly rich in sensory innervation; the most erogenous zone of the glans.[2]
  • Inner preputial layer — thin, pliable mucocutaneous tissue with natural oily secretions; embryologically homologous to the clitoral hood and contributes to the labia minora.[5][11]

Surgical Technique — Canonical Preputial-Skin Clitoroplasty (Ghent / Monstrey)​

The most widely practiced technique, developed at Ghent University Hospital by Monstrey and colleagues and subsequently modified by multiple groups.[3][5][7][12]

Uncircumcised patient​

  1. Penile degloving — penile skin degloved as a tube; prepuce kept attached to the glans.
  2. Dorsal NVB dissection — paired dorsal nerves, paired dorsal arteries, and deep dorsal vein dissected off the dorsal corpora cavernosa from pubic root to glans. The bundle is elevated with a strip of tunica albuginea to protect the nerves.[12][13]
  3. Corpora cavernosa excision — both corpora excised, leaving only NVB pedicle, glans, and urethra.
  4. Glans reduction — glans reduced to ~5–8 mm; medial glans and urethral mucosa excised; the entire corona is preserved for maximum erogenous-nerve density.[2][3]
  5. Neoclitoris formation — corona approximated ~1 cm from midline to create a visible ovoid neoclitoris; lateral coronal tissue is preserved as buried "clitoral corpora" providing additional erogenous sensation.[3]
  6. NVB folding and fixation — dorsal NVB folded on itself and fixed in the suprapubic area to shorten the pedicle and position the neoclitoris at the adductor-longus-tendon level.[3]
  7. Clitoral hood and labia minora — inner preputial skin used for:
    • Clitoral hood — draped over the neoclitoris superiorly.
    • Labia minora — extending inferiorly to frame the vestibule and introitus.[5][14]
  8. Clitoro-urethral inset — ventral urethra spatulated and approximated to the clitoris; preputial skin sutured proximally as tension allows; clitoro-urethral complex inset into an opening in the penile skin flap.[3]

Circumcised patient​

Two pathways depending on residual tissue (Fascelli 2024 anatomy-guided framework):[3][5]

  • ≥ 2 cm inner preputial skin distal to the circumcision scar AND ≥ 8 cm proximal shaft skin — preputial-skin clitoroplasty still performed using residual inner preputial skin for the hood and distal-shaft skin for labia minora.[3]
  • Insufficient preputial skin — switch to urethral-flap clitoroplasty (Brassard, variant F) with a collar of preputial skin sewn to spongiosum and urethral mucosa.[3]

Named Variants​

VariantGlans designHood / labia sourceBest fitKey advantage
A. Ghent / preputial skin (canonical)Entire corona; medial glans excisedInner prepuceUncircumcised or ≥ 2 cm inner prepuceGreater coronal tissue volume; best aesthetics[3][7]
B. M-Flap (Mañero)Central triangle of M-shaped flapBoth legs of M + attached prepuceUncircumcised; aesthetic refinementSingle composite flap; 0% total necrosis in n = 97[4]
C. Corona glans (Giraldo)Bifid dorsolateral coronal flapSemicircular preputial flapUncircumcised; maximises coronal erogenous tissueOpen-lotus / bull's-horn design; full coronal circumference preserved[2]
D. Mons veneris (Soli)Small glans portion on tunica-albuginea stripSeparate constructionEitherFaster (saves 30–45 min); natural mons[13]
E. Butterfly flap (Balik)Standard glans reductionSuperior-180° NVB-fed butterfly flap; urethra as mesh graftCircumcisedSensate labia minora when prepuce is absent[11]
F. Urethral flap (Brassard)Standard glans reductionUrethra creates hoodCircumcised / insufficient skinWorks without prepuce[3]
G. Dorsal-glans chip (Fang 1992, classic)Dorsal chip of glansVariableHistorical baselineSimple; well-established[24]

B. M-Flap (Mañero / IMCLINIC)​

Pedicled island neurovascular flap of the glans penis harvested in a letter-"M" fashion with attached preputial skin; the central triangle of the M forms the neoclitoris and both legs plus attached prepuce form the labia minora and clitoral prepuce. n = 97: 0% total / deep flap necrosis; 8.2% partial / superficial skin necrosis without sequelae; 1 labial abscess; 1 urethral hematoma. 100% tactile and erogenous sensitivity at 6 months.[4]

C. Corona glans (Giraldo / Andalusia)​

Instead of a dorsal glans chip, a bifid dorsolateral coronal flap ("open lotus" / "bull's horns") plus a semicircular preputial flap is retained to improve vestibular cosmesis and prevent perineoclitoral hair; a small dorsal urethral spongiomucosa flap (pencil-tip shape) is added between neoclitoris and urethral neomeatus. Rationale: the corona contains the highest nerve-ending density — preserving the full coronal circumference (vs a single dorsal chip) maximises erogenous tissue.[2]

D. Mons veneris (Soli / Bologna)​

A strip of tunica albuginea carrying the dorsal NVB and a small glans portion is bent on itself and fixed in the suprapubic area, creating both mons veneris and neoclitoris. Saves 30–45 min vs standard. n = 15: 100% preserved neoclitoral trophism / sensitivity; 47% reported some form of climax; 73% satisfied with mons appearance; short transient postoperative hypersensitivity.[13]

E. Butterfly flap (Balik) — for circumcised patients​

Superior-180° NVB-supplied butterfly flap creates the sensitive inner surface of the labia minora; most of the urethra is used as a mesh graft for additional coverage. n = 19 (10 with 1-yr follow-up): sensate labia minora in all patients; 74% reported sensation that is erogenous and distinct from tactile sensation on the penile body; Semmes–Weinstein monofilament testing confirms preserved sensitivity at 1 yr.[11]

F. Urethral-flap clitoroplasty (Brassard / GRS Montréal)​

Indications and rationale. Reserved for circumcised patients with insufficient preputial / shaft skin who do not meet the Fascelli 2024 thresholds (≥ 2 cm inner prepuce + ≥ 8 cm proximal shaft) for the canonical preputial-skin technique.[3] Particularly relevant in populations with high circumcision rates (North America, Middle East, parts of Africa and Southeast Asia) where most patients presenting for vaginoplasty may be circumcised.[3][11]

Anatomic basis. The technique leverages two structures available regardless of circumcision status:[3][26][24]

  • Penile urethra + corpus spongiosum — the male urethra is shortened from ~20 cm to a female-appropriate ~4 cm during PIV, with excess tissue typically discarded; the Brassard variant repurposes that excess urethra and surrounding spongiosum to create a well-vascularised mucosal clitoral hood rather than discarding them.
  • Dorsal NVB pedicle — the neoclitoris itself is still constructed from the glans on the dorsal-NVB pedicle, identical to the canonical technique, so the intrinsic sensory potential is preserved.[3]

Step-by-step (deviations from canonical Ghent technique highlighted):

  1. Penile disassembly and NVB dissection — identical to canonical (dorsal NVB elevated with a strip of tunica albuginea).
  2. Glans reduction and neoclitoris formation — similar to canonical but the neoclitoris–urethra relationship is configured differently.
  3. Urethral preparation — the key distinguishing step:
    • More corpus spongiosum is preserved than in the canonical technique.[3]
    • A dorsal urethrotomy is performed (urethra opened along its dorsal surface).
    • This creates a urethral flap that can be draped over and around the neoclitoris to form the hood.
  4. Neoclitoris inset — neoclitoris on its NVB pedicle inset following the dorsal urethrotomy; a small collar of preputial skin (whatever residual tissue remains) is sewn to the spongiosum and urethral mucosa, bridging mucosal-to-skin transition.[3]
  5. Urethral transection and urethroplasty — urethra transected ~ 1 cm distally beyond the hood construction; ventral urethra spatulated to create the feminised neomeatus.
  6. NVB folding and fixation — identical to canonical (suprapubic fixation at adductor-longus-tendon level).

Do not confuse with the Perovic 2000 urethral-flap vaginoplasty — a distinct operation that uses a long vascularised urethral flap to line the deep neovaginal canal (not the clitoral hood); the urethral flap is embedded into the inverted penile-skin tube and the resulting neovagina is fixed to the sacrospinous ligament. Perovic n = 89: good cosmetic and functional results in 87% (77/89); one rectovaginal fistula; mean follow-up 4.6 yr.[26]

Trieste Y-shaped urethral-flap modification (Ongaro 2020). The Trieste group (Ongaro, Garaffa, Liguori) developed a Y-shaped urethral flap for vulvar / vestibular augmentation as part of their vaginoplasty technique. n = 47 since 2014; 88.9% (40/45) reached climax at 12 mo; 75.6% (34/45) having neovaginal intercourse; median depth 11 cm (IQR 9–13.25) with no significant decrease at follow-up; only 1/45 dissatisfied with aesthetics; no severe (Clavien–Dindo ≥ III) complications.[27]

Spongiosum-pedicle vs dorsal-NVB-pedicle — historical context. The Brassard technique should be distinguished from the earlier spongiosum-pedicled clitoroplasty (Rubin 1980) which used the corpus spongiosum as the vascular pedicle for the neoclitoris itself. That approach carried a recognised urine-leakage problem because the spongiosum surrounds the urethra and its use as a pedicle compromised urethral integrity. Fang 1992 (variant G above) switched to the dorsal NVB pedicle, eliminating urine leakage while providing superior sensory innervation — all 9 neoclitorides survived with preserved light-touch and sexual sensation and no urine leakage.[24] The Brassard urethral-flap technique is therefore a hybrid: neoclitoris on the dorsal-NVB pedicle (Fang-style) with the surrounding hood constructed from urethral / spongiosal tissue (leveraging the Rubin concept for the hood rather than the pedicle).

Trade-offs vs canonical (Fascelli / Dugi OHSU framework):[3]

  • Less coronal tissue volume for erogenous sensation (Fascelli / Dugi explicitly prefer canonical for this reason).
  • Potentially inferior aesthetics (same group prefers canonical for "better esthetics").
  • Increased urethral manipulation — more extensive urethral dissection and reconfiguration may raise meatal-stenosis, urethral-stricture, and stream-direction risks.[28][29]
  • Avoids skin grafting for the introitus — by using urethral tissue for the hood, more penile / scrotal skin is preserved for the canal and introitus, potentially reducing supplemental skin grafts (which carry introital-stenosis risk).[3]
  • Identical sensory foundation — glans on dorsal NVB.

Urinary outcomes — the technique-specific safety concern. Across all MtF vaginoplasty series, meatal stenosis rates range 4–40% and usually require meatotomy.[30] Misdirected urinary stream: surgeon-reported rates 9.5–33% but patient-reported rates 33–55% in the Blasdel 2024 "surgical complication blind spots" analysis — a substantial under-reporting gap that may be most pronounced in techniques involving extensive urethral reconfiguration.[29] Raigosa 2020 demonstrated that adding labia-minora and clitoral-hood creation (with preputial skin, canonical technique) significantly reduced neomeatal stenosis from 15.5% to 1.5% (p = .003) and hemorrhage from 31% to 12.5%, while halving aesthetic-revision rates from 20.3% to 4.6%. This is the closest existing evidence on how periclitoral construction technique affects urethral outcomes — by inference, the urethral-flap variant may be at higher meatal-stenosis risk, though no head-to-head data exist.[28]

Evidence-base caveat. The Brassard urethral-flap technique is attributed to Pierre Brassard (GRS Montréal) but has no dedicated published outcomes series under his name. The most detailed description is the Fascelli / Dugi 2024 anatomy-guided framework, which presents it as one of two options while explicitly preferring the canonical preputial-skin technique. Sensory outcomes specific to the urethral-flap variant have not been separately reported — all available sensory data come from mixed series using the dorsal-NVB-pedicled glans flap regardless of hood-construction method.[3][6][17]

G. Classic dorsal-glans chip (Fang 1992)​

Historical baseline; a dorsal chip of glans on the NVB pedicle. Simple and well-established but provides less erogenous tissue than corona-preserving designs.[24]

Postoperative Neoclitoral Anatomy​

Critical for gynecologists providing ongoing care:[15]

  • Neoclitoris — reduced glans penis at the anterior commissure, analogous to the cisgender clitoris.
  • Dorsal NVB — folded and buried suprapubically; may be palpable as a cord beneath the mons pubis.
  • Clitoral hood — preputial skin or urethral tissue, draping the neoclitoris.
  • Labia minora — preputial skin or shaft skin, extending inferiorly.
  • No crura or vestibular bulbs — the neoclitoris is a surface structure without deep erectile extensions.
  • Variable residual erectile capacity from preserved spongiosum.
  • Perceptual thresholds at the neoclitoris are much lower than at neovagina or anal sites — confirming it as the primary erogenous structure.[16]

Sensory Outcomes​

SeriesnFollow-upTactile sensitivityOrgasm rateAnchor
Sigurjónsson 2017[6]2237 mo (12–63)12.5 g/mm² (Semmes–Weinstein)86%Majority satisfied
Selvaggi / Ghent 2007[12]30Long-term11.1 g/mm² pressure; 0.5 μm vibration85%High satisfaction
Opsomer / Ghent 2021[7]38415 yrNot formally tested83.4%97.2% able to have intercourse
Mañero M-flap 2018[4]976 mo100% preserved—100% tactile + erogenous
Mañero prospective 2022[17]8412 mo96% clitoral sensitivity81% initiated intercourse90% aesthetic satisfaction
Rehman 1999[18]10VariableGood in 8/10—8/10 satisfied
Soli 2008[13]153–20 mo100% preserved47% reported climaxHigh
Amend 2013[19]2439.7 mo97% good / excellent33% regular intercourseSatisfactory
Canale 2022 (SSEP)[16]6—SSEPs confirmed intact dorsal-column pathwayCorrelated with OrgasmometerConsistent

Cross-study findings:

  • Sensory recovery yields high orgasmic ability, largely through the neoclitoris, plus a neovagina with vibratory and pressure sensation similar to natal vagina.[20]
  • SSEPs confirm intact large-fibre dorsal-column / medial-lemniscus pathway after surgery, with the neoclitoris showing the lowest perceptual thresholds among genital sites.[16]
  • Genitoplasty patients appear to experience faster and more complete sensory recovery than other peripheral-nerve-regeneration scenarios — mechanisms incompletely understood.[20]
  • No statistical correlation between objective pressure / vibratory thresholds and subjective neoclitoral satisfaction — perception is multifactorial.[6]

Complications​

ComplicationIncidenceNotes
Partial / superficial flap necrosis1.9–8.2%Heals without sequelae; no long-term sensory impact[4][6]
Total neoclitoral necrosis0–20% (0% in largest series; 20% in early Rehman series)Devastating; complete loss of erogenous sensation[4][18]
Clitoral hypersensitivityCommon earlyUsually transient[13]
Loss of clitoral sensitivity at 12 mo3–4%May be permanent; NVB-injury–related[17]
Wound dehiscence9.7–20.3%Higher in cohorts with labia-minora creation[12]
Periclitoral / labial hemorrhage12.5–31%Reduced with labia-minora technique[12]
Buried / retracted clitorisCommon revision indicationRepositioning surgery[21][22]
Excessive clitoral prominenceCommon revision indicationReduction / repositioning
Inadequate hoodingCommon revision indicationHood reconstruction
Diverted urinary stream5.6% (Ghent)Clitoro-urethral-complex–related[5]

Two-stage caveat. Performing clitoroplasty as a second-stage procedure on previously operated tissue increases dorsal-pedicle compromise — 4.8% neoclitoral necrosis in two-stage PIV vs 0% in single-stage (Fakin 2021); see the PIV page single-stage-vs-two-stage section.

Revision clitoroplasty​

Clitoral revision is the second most common cosmetic revision after labiaplasty — 23.3% of all cosmetic revisions in Mañero's series (354 primary vaginoplasties) and 57.1% of vulvar revisions in the NYU series (35 revision patients).[21][22] Common indications: buried/retracted clitoris, excessive prominence, inadequate hooding, malposition. Boas 2019 (n = 117 primary PIV) — 23.9% underwent revision labiaplasty and/or clitoroplasty; 7.7% had both; minor postoperative complications predicted revision; after revision, 82.4% reported satisfaction and 76.5% reported resolution of genital-related dysphoria.[23]

Impact of Circumcision Status​

StatusTissue availabilityPreferred technique
UncircumcisedFull prepucePreputial-skin clitoroplasty (Ghent A) — preferred
Circumcised with ≥ 2 cm inner prepuce + ≥ 8 cm proximal shaftSufficient for preputial-skin techniquePreputial-skin clitoroplasty (Ghent A)
Circumcised with insufficient skinCritical tissue deficitUrethral-flap (Brassard F) or butterfly flap (Balik E)

The Ghent 15-year experience (n = 384) reported that creation of labia minora and clitoral hood was achievable in all patients regardless of circumcision status using distal shaft skin when prepuce was absent.[5][7] The butterfly flap specifically addresses the circumcised population with sensate labia minora in 74% reporting erogenous sensation distinct from tactile sensation.[11]

Electrophysiologic Evidence​

Canale 2022 (n = 6, the only study using SSEPs):[16]

  • SSEPs confirmed intact large-fibre dorsal-column / medial-lemniscus pathway after surgery.
  • Perceptual thresholds much lower at the neoclitoris than at neovagina or anal sites.
  • Trend toward correlation between clitoral SSEPs and self-perceived orgasmic intensity (Orgasmometer) at the clitoral level, but not at vaginal or anal levels.
  • Confirms the dorsal-NVB-pedicled technique successfully preserves the afferent sensory pathway and that the neoclitoris is the primary erogenous structure.

Evidence Limitations​

Retrospective single-centre case series with heterogeneous techniques, variable follow-up, and non-standardised outcome measures.[20][25] No RCTs compare clitoroplasty variants. Sensory outcomes use heterogeneous instruments (Semmes–Weinstein monofilaments, Bio-Thesiometer, SSEPs, self-report) that don't permit clean cross-study comparison.[6][20] The SSEP study included only 6 patients.[16] Long-term sensory outcomes beyond 5 years are poorly characterised. Patient-reported orgasm rates vary widely (33–86%) depending on instrument and definition; validated sexual-function questionnaires specific to transfeminine GAS are lacking.[6][12][20] The long-term impact of circumcision status has not been formally compared in a controlled study.[5]

References​

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2. Giraldo F, Esteva I, Bergero T, et al. Corona glans clitoroplasty and urethropreputial vestibuloplasty in male-to-female transsexuals: the vulval aesthetic refinement by the Andalusia Gender Team. Plast Reconstr Surg. 2004;114(6):1543–1550. doi:10.1097/01.prs.0000138240.85825.2e

3. Fascelli M, Peters BR, Dy GW, Dugi DD. Gender-affirming clitoroplasty and construction of the clitoro-urethral complex: an anatomy-guided selection of two techniques. Urology. 2024;183:e320–e322. doi:10.1016/j.urology.2023.10.009

4. Mañero Vazquez I, García-Senosiain O, Labanca T, Gómez Gil E. Aesthetic refinement in the creation of the clitoris, its preputial hood, and labia minora in male-to-female transsexual patients. Ann Plast Surg. 2018;81(4):393–397. doi:10.1097/SAP.0000000000001532

5. Opsomer D, Gast KM, Ramaut L, et al. Creation of clitoral hood and labia minora in penile inversion vaginoplasty in circumcised and uncircumcised transwomen. Plast Reconstr Surg. 2018;142(5):729e–733e. doi:10.1097/PRS.0000000000004926

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9. O'Connell HE, Sanjeevan KV, Hutson JM. Anatomy of the clitoris. J Urol. 2005;174(4 Pt 1):1189–1195. doi:10.1097/01.ju.0000173639.38898.cd

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11. Balik O. Construction of sensitive labia minora–clitoris–clitoral hood complex in sex reassignment surgery in circumcised populations: butterfly flap. Ann Plast Surg. 2023;91(3):370–375. doi:10.1097/SAP.0000000000003585

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16. Canale D, Molinaro A, Marcocci C, et al. Genital sensitivity and perceived orgasmic intensity in transgender women with gender dysphoria after gender-affirming surgery: a pilot study comparing pelvic floor evoked somatosensory potentials and patient subjective experience. J Sex Med. 2022;19(9):1479–1487. doi:10.1016/j.jsxm.2022.06.002

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18. Rehman J, Melman A. Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome. J Urol. 1999;161(1):200–206.

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21. Dy GW, Salibian AA, Blasdel G, Zhao LC, Bluebond-Langner R. External genital revisions after gender-affirming penile inversion vaginoplasty: surgical assessment, techniques, and outcomes. Plast Reconstr Surg. 2022;149(6):1429–1438. doi:10.1097/PRS.0000000000009165

22. Mañero I, Arno AI, Herrero R, Labanca T. Cosmetic revision surgeries after transfeminine vaginoplasty. Aesthet Plast Surg. 2023;47(1):430–441. doi:10.1007/s00266-022-03029-9

23. Boas SR, Ascha M, Morrison SD, et al. Outcomes and predictors of revision labiaplasty and clitoroplasty after gender-affirming genital surgery. Plast Reconstr Surg. 2019;144(6):1451–1461. doi:10.1097/PRS.0000000000006282

24. Fang RH, Chen CF, Ma S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast Reconstr Surg. 1992;89(4):679–682; discussion 683.

25. Morrison SD, Claes K, Morris MP, et al. Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol. 2023;20(5):308–322. doi:10.1038/s41585-022-00705-y

26. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 2000;86(7):843–850. doi:10.1046/j.1464-410x.2000.00934.x

27. Ongaro L, Garaffa G, Migliozzi F, et al. Vaginoplasty in male to female transgenders: single center experience and a narrative review. Int J Impot Res. 2020;33(7):726–732. doi:10.1038/s41443-021-00470-3

28. Raigosa M, Avvedimento S, Descarrega J, et al. Refinement procedures for clitorolabiaplasty in male-to-female gender-affirmation surgery: more than an aesthetic procedure. J Sex Med. 2020;17(12):2508–2517. doi:10.1016/j.jsxm.2020.08.006

29. Blasdel G, Dy GW, Nikolavsky D, et al. Urinary reconstruction in genital gender-affirming surgery: checking our surgical complication blind spots. Plast Reconstr Surg. 2024;153(4):792e–803e. doi:10.1097/PRS.0000000000010813

30. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res. 2020;33(8):793–800. doi:10.1038/s41443-020-0304-y