Reconstructive urology has historically been a difficult subspecialty to define with overlap into other aspects of urology including oncology, andrology, prosthetics, incontinence, voiding dysfunction, pediatrics, robotics, and plastic surgery.¹ Perhaps sadly, Wikipedia may provide the best definition of reconstructive urology as a “specialized field of urology that restores both structure and function to the genitourinary tract.”² Historically, much of reconstructive urology has focused on urethral reconstruction. But in addition to urethral disease, the genitourinary reconstruction umbrella often includes genital surgery, gender affirming surgery, male incontinence, cancer survivorship, erectile dysfunction, Peyronie’s disease, neurogenic bladder, urinary diversion, transitional urology, urological trauma, and urinary fistulae. While this practice variability exists, historically urethral reconstruction has been the “tie that binds” reconstructive urology.

The first formal fellowship training program in adult and pediatric genitourinary reconstructive surgery was formed in 1975 at Eastern Virginia Medical School by Dr Charles Devine. Thereafter, the male genitourinary reconstruction and trauma fellowship at University of California, San Francisco, was created by Dr Jack McAninch in 1989. Shortly afterward, a fellowship in reconstructive urology was founded at Duke University by Dr George Webster. For many years, these 3 programs were the pillars of male reconstructive urology training, at least in North America. Each fellowship was unique in its training experience. Additionally, equally diverse and distinguished fellowships existed in Europe throughout this time frame. In the early 2000s, as the understanding of genitourinary diseases, anatomy, tissue transfer, and surgical techniques evolved, reconstructive urology blossomed while “standing on the shoulders of these giants.” In the 2000s, the number of fellowship programs grew dramatically. In response to the growth of reconstructive urology worldwide, the Society of Genitourinary Reconstructive Surgeons (GURS) developed a formal fellowship match program. For the 2012 cycle, GURS began developing a formal reconstructive match, which initially offered 13 different programs and has grown to 27 programs during the most recent 2023 match.

GURS fellowship training typically offers a robust clinical experience. Recent case log analysis from 25 different programs over 11 years of the GURS match has shown increases in urethral reconstruction, genital reconstruction, abdominal reconstruction, and male sexual dysfunction (I. Calvo, unpublished data, 2023). The typical urethroplasty experience for a GURS program is a mean volume of 88 cases/y, 16 cases/y for genital reconstruction, and a mean of 24.5 cases/y for abdominal reconstruction. Programs also provide a mean of 32.7 cases/y for male sexual health with a stable number of male incontinence cases at a mean of 30.5 cases/y. Despite an increase in the number of fellowship programs, the GURS fellow operative experience remains robust. This growth likely reflects the growth of reconstructive urology as a discipline combined with consolidation of cases to academic centers and expansion of service lines offered by GURS surgeons in areas such as gender-affirming surgery, robotics, and adult congenital care.

GURS fellowship training is also of high quality. In a recent survey of GURS fellowship graduates, 92% reported being pleased with their training, 100% felt competent to enter unsupervised reconstructive urology practice, 100% readily found employment in reconstructive urology, 92% practice in a location that they consider one of their top 3 destinations, and 92% were satisfied with their clinical practice as a reconstructive urologist.³ While generally a satisfying and robust experience for fellows and fellowship program directors, there is significant variability among fellowship programs, likely reflecting the growing diversity of reconstructive urology practice. Rather than programs potentially withdrawing from GURS because of an inability to satisfy any one specific case log threshold, the consensus of program directors has been to adopt this emerging diversity in training. Urethral reconstruction remains a mainstay of GURS training with 76% of program directors identifying this as a mandatory category for fellowship qualification. However, GURS training has recently been redefined by consensus into 4 main categories including urethral reconstruction, genital reconstruction, abdominal/pelvic reconstruction, and genitourinary prosthetics with associated necessary case log thresholds.

As reconstructive urology continues to grow and evolve, there will be a need to educate more broadly. Work is actively underway to develop an online reconstructive urology curriculum to ensure every graduating fellow and otherwise interested GURS member possesses a core set of reconstructive knowledge and technical skills. Additionally, in order to address the substantial need to train internationally, GURS will work to develop mini-fellowship programs and establish formal exchanges between centers to help disseminate technical advances in reconstructive urology worldwide. Since the majority of GURS fellowships are in North America, further worldwide outreach and collaborative creation of new fellowship programs in other regions will help address the large international need in reconstructive urology.