With growing social acceptance and increasing access, transgender care is at the forefront of medicine. Urologists, especially those of us dedicated to genitourinary reconstruction, stand to play a major role in the delivery of surgical care. The challenges of primary gender-affirming surgery include the lack of formal urologic training, the historically siloed method of delivery of care, and the relative lack of comparative research regarding optimal techniques. Understanding gender-affirming surgery (genital and non-genital) is critical even to those reconstructive urologists who do not perform primary gender-affirming surgery because they may be faced with addressing the complications of primary surgery. In performing revision surgery, one needs a broad understanding of the multiple techniques for primary gender-affirming surgery to identify pitfalls and potential complications. Regardless, complication rates are high, and revisions may not be successful. We seek to provide a review of the urologic management of the transgender patient, drawing from an international set of experts with varying experiences.