The most common combination of gender affirming genitourinary surgeries includes metoidioplasty/phalloplasty with UL, vaginectomy, scrotoplasty, and perineal reconstruction. However, some patients who want and need metoidioplasty or phalloplasty may or may not want UL, vaginectomy, or scrotoplasty. There has been an increase in need and desire for metoidioplasty/phalloplasty with UL, and scrotoplasty, but no vaginectomy. Another variation includes scrotoplasty, but no UL and no vaginectomy. Some patients also want to avoid native penis burial. Below are photos of patients who underwent individualized surgeries to meet their surgical goals. Some of these surgeries, especially the ones with UL but no vaginectomy, have a high risk of urethral complications. Recent modifications to the surgical staging (i.e. delaying rotational advancement flap scrotoplasty) may reduce the risk of fistulas after UL with no vaginectomy.