Individuals are referred to as transgender when their personally perceived gender identity does not align with the gender assigned at birth. This incongruence can result in an inner mental unrest and is then described as gender dysphoria. Gender dysphoria is registered as a mental disorder according to the DSM-5 classification system for psychiatric conditions. Consequently, these transgender patients require individualized treatment to alleviate their distress. The complex and individualized way in which gender dysphoria is perceived, urges the implementation of an equally diverse health care team that can respond to the patient’s specific needs. Fortunately, over the last couple of decades, there has been a tendency to shift from the general perception of gender as a binary concept, to a more tolerant and fluent perspective on gender as a spectrum. The increasing awareness and acceptance of gender diversity has paved the way for healthcare professionals to explore the medical needs of this specific patient population and develop suitable treatment options. An important form of treatment is the surgical reconstruction of male- or female- like genitalia, referred to as genital-gender affirming surgery or GGAS. This thesis specifically focused on GGAS in female-to-male transgender patients. For these patients, surgical interventions include the construction of a phallus, referred to as phalloplasty or metoidioplasty. A key aspect for many patients is the ability to urinate through the tip of the neophallus. This is achieved through urethral lengthening (UL), a surgically challenging technique, accompanied by a significant complication rate. This systematic review was performed to assess the viability of a different urethral approach, namely perineal urethrostomy (PU). Perineal urethrostomy entails the diversion of the urinary stream through creation of a new urethral opening or meatus. More specifically, the perineal skin and underlying urethra are incised and the edges of the proximal tip of the urethra are sutured to the edges of the perineal skin. This way, the last part of the urethra that runs into the phallus becomes unused and the new urinary stream runs vertically through a perineal opening, forgoing standing urination. This diversion is useful in two scenarios. First, phalloplasty or metoidioplasty can be performed with a PU instead of urethral lengthening, this is referred to as a primary PU. According to the results, PU appears to be a viable alternative to UL, either chosen by the patient to avoid a significant amount of complications due to UL or recommended by the surgeon due to medical considerations. Secondly, a PU can be performed when urethral lengthening has failed and complications such as strictures or fistulae obstruct an optimal voiding function. Secondary PU is commonly considered a last resort, pursued only when other revision surgeries for UL-related complications have proven unsuccessful. However, secondary PU could be a considerable option for patients suffering from urethral complications after UL who wish to avoid undergoing one or multiple revision surgeries. This research provided insights on the shortcomings of GGAS and transgender care in general. An important aspect of optimizing GGAS lies in investing in patient counseling. Preoperative counseling should evolve toward shared decision-making, a process vital for optimizing patient satisfaction postoperative. Further insights include recommendations on how to conduct and report future research on GGAS. Studies should be conducted with extended follow-up periods, larger patient cohorts, and a comprehensive collection of postoperative outcomes related to both functional and aesthetic aspects. Additionally, gathering patient-reported outcomes would enhance the depth of understanding in this area. Furthermore, the results indicated a shortage of high-quality publications on the applications of PU within the field of GGAS. Nevertheless, these results suggest that opting for PU over UL could potentially lead to a substantial decrease in postoperative complications, the need for revision surgeries, and the associated physical, mental, and financial challenges. Considering gender identity as a spectrum implies that priorities and desired outcomes of GGAS will vary. Thus, urethral lengthening should not be considered the only desired outcome. This thesis serves as an incentive to expand the scope beyond UL and also explore options such as perineal urethrostomy.