The expansion of digitalization in the pre-, intra- and post-operative surgical phases allow the development and integration of advanced technologies such as virtual surgical planning (VSP), additive manufacturing (AM), augmented reality (AR) and virtual reality (VR) in surgical workflows, all aiming to improve the surgical precision and efficiency. However, their implementation in clinical practice leads to novel organizational challenges, such as excessive costs, inefficiencies in the use of hard- and software and availability, and the coordination of the required highly specific expertise and skill of different employees with backgrounds in different domains. We aim to provide a practical step-by-step overview of how a centralized platform within academic hospitals can solve practical and organizational problems concerning surgical digitalization. A bottom-up approach was used to ensure engagement from all stakeholders within the hospital. Hereto, a small core group identified all potential stakeholders deemed essential for a successful implementation of a centralized platform. These stakeholders were then initially approached separately by the core group and then brought together in multiple focus groups to discuss action points, identify essential components and find solutions for emerging barriers. The implementation focused on 5 essential points: (1) medical imaging segmentation process; (2) centralized Central Processing Unit (CPU) and Graphical Processing Unit (GPU) capacity with guaranteed continued collaboration with Department of Information and Communication Technologies (ICT); (3) medical device and in-house AM dealing with the production and sterilization of three dimensional (3D)-printed models; (4) Implementation of CPSD within the operating room; (5) External connection and collaboration with industry and other academic centres aimed to support interventional medical digitalization and the implementation of other innovative medical technologies. The protocol focuses on key aspects, including identifying existing innovations, naming prevailing challenges and formulating effective solutions. Centralizing digitalization in the hospital streamlines workflows, enabling faster processing and improved multidisciplinary collaboration. Success depends on coordinated input from medical, technical, and legal experts. The resulting platform fosters ongoing innovation while staying compliant and adaptable. Not applicable.

Differences of Sex Development (DSD) is a collective term for a heterogeneous group of rare congenital conditions characterized by atypical genetic, gonadal, or genital sexual development. The treatment of children with DSD, particularly the indications for and timing of surgical interventions, has been the subject of debate for decades. In recent years, social developments emphasizing children's rights to self-determination and bodily integrity, along with increasing societal acceptance of atypical sex characteristics, have encouraged a more cautious approach toward early genital surgery in children with DSD. In 2019, the European Parliament adopted a resolution urging Member States to enact legislation prohibiting elective genital surgical interventions on intersex infants and children. Since then, several countries have indeed implemented restrictive measures, including legal bans on early surgical procedures. In this paper, we share the experiences and in-sights gained in recent years as pediatric urologists working in four neighboring countries in multidisci-plinary university centers specializing in DSD care and research. We focus on current approaches to the care of children with DSD, the evolution of relevant national policies over time, and the nature and impact of recently introduced restrictive regulations on early surgical interventions. By presenting per-spectives from pediatric urologists across these four countries, we aim to contribute to ongoing discus-sions on the alignment and refinement of surgical treatment practices for children with DSD.

Adolescents and young adults with childhood-onset lower urinary tract symptoms (LUTS) face significant challenges transitioning from paediatric to adult urological care, a period often marked by disrupted care continuity, reduced adherence, and psychosocial stress. This transition remains poorly studied in urology. STREAMWAY aims to explore adolescents' perceptions, attitudes, and lived experiences during this phase. This exploratory qualitative study uses semi-structured interviews, supplemented by validated questionnaires, in participants aged 16–25 years with childhood LUTS currently undergoing or having recently completed transition to adult care. The primary endpoint is to map perceptions and experiences of transition, identifying barriers and facilitators to transition success. Secondary endpoints include current urinary symptoms, sleep quality, quality of life, bowel and genitourinary symptoms, and adverse childhood experiences. Approximately 20 participants will be enrolled. Data collection includes pre-interview completion of urological care timelines and growth curves, followed by a 60-minute semi-structured interview and validated questionnaires (ICIQ-MLUTS/FLUTS, ICIQ-LUTSqol, PSQI, EQ-5D-5L, ACE-IQ, CCCS, GUPI). Qualitative data will undergo thematic and interpretative phenomenological analysis; quantitative data will be analysed descriptively, with integration of both findings.

OBJECTIVES:To explore the association between hypospadias and morphological testicular abnormalities, assessed through testicular ultrasonography, focusing on microcalcifications and parenchyma inhomogeneity. PATIENTS AND METHODS:We conducted a cross-sectional case-control study, in which testicular ultrasonography in 244 males born with hypospadias (Tanner 1: n = 17; Tanner 2-4: n = 27; Tanner 5: n = 200) and 51 controls (all Tanner 5) was analysed by three physicians. Homogeneity and microcalcifications were scored on a four-point and three-point Likert scale, respectively. Associations were sought with clinical data and maternal, dietary and substance factors. RESULTS:Substantial interobserver agreement was found (microcalcifications: κ = 0.735; inhomogeneity: κ = 0.647). Testicular inhomogeneity was more common in patients with all forms of hypospadias compared to controls (overall: P = 0.004; mild: P = 0.006; severe: P < 0.001; complex hypospadias: P < 0.001) and increased with puberty progression. Associations were found with reduced sperm concentration, number of penile surgeries, shorter adult stretched penile length, being born small for gestational age, and unhealthy lifestyle. The positive and negative predictive values of inhomogeneity for oligozoospermia and azoospermia were 29.6% and 84.8%, respectively. No difference in the prevalence of testicular microcalcifications was found compared to controls (P = 0.599). CONCLUSION:Testicular parenchymal inhomogeneity was more common in men born with hypospadias and was associated with testicular, surgical and prenatal factors. Therefore, testicular inhomogeneity could serve as a relevant, non-invasive supporting marker to identify who could benefit from andrological evaluation. Screening may be recommended from late puberty as the first morphological changes are typically observed at this stage.

Background and objective:Intravesical injection of bulking agents is an endoscopic treatment for vesicoureteral reflux (VUR) in children. The success of the procedure depends on the surgical technique; yet, few validated simulators exist for training. This study aimed to assess the face and content validity of a porcine bladder model for training in endoscopic VUR correction. Methods:The Ghent University Hospital endoscopic reflux correction simulator, an ex vivo porcine bladder, was developed. Dextranomer/hyaluronic acid (Dx/HA) was used for bilateral subureteric injection. Participants from the 2022 European Society for Paediatric Urology Congress in Belgium completed a questionnaire evaluating the model's realism (face validity) and training effectiveness (content validity). Differences between experts and nonexperts were analyzed using the Mann-Whitney U test (p ≤ 0.05). Key findings and limitations:A total of 39 participants (12 experts and 27 nonexperts) evaluated the model, including urologists (53.8%), surgical trainees (35.9%), and pediatric surgeons (12.8%). The simulator showed high face validity, with a median Likert score of 5/5. The experts rated the realism significantly higher than the nonexperts (p = 0.011). The experts also rated content validity highly (median Likert score 5/5). Both groups agreed that the model should be included in training curricula for residents (92.3%), fellows (82%), and novice surgeons (59%). Conclusions and clinical implications:The Ghent University Hospital porcine bladder model closely mimics a human bladder and is considered valuable for teaching the Dx/HA procedure. Further studies should examine whether this leads to clinically meaningful improvements in skill performance. Patient summary:A high fidelity simulator is developed and validated in this study to improve surgical skills in endoscopic correction of vesicoureteral reflux, thereby improving patient outcomes.

INTRODUCTION:Stress urinary incontinence (SUI) affects girls & women regardless of age, posing unique challenges in Adolescents and Young Adults (AYA) seeking fertility preservation and considering pregnancy. Autologous fascia slings remain the gold standard for isolated SUI, especially with a wide bladder neck, offering a natural hammock and reducing erosion and infection risk compared to synthetic mesh. This series illustrates the RA fascia sling technique. MATERIAL & METHODS:A cases series of 5 female patients, mean age 12 years old (IQR 8,5-17) with lifelong SUI unresponsive to physiotherapy underwent video-urodynamics confirming SUI during Valsalva without detrusor overactivity and showing a wide bladder neck. RESULTS:All patients were positioned gynecologically docked with three 8-mm trocars. In 25-degree Trendelenburg, the retropubic space was dissected, exposing bladder and urethra. A tunnel was created caudally to the urethra, preserving the vaginal wall. Fascia harvested from rectus abdominis was passed through using a guide loop and secured to the pubic bone, creating a hammock for the bladder neck-urethra zone. Minimal blood loss (<5 mL) occurred; all patients were discharged on postoperative day one. Continence was maintained at one-year follow-up. CONCLUSIONS:Robotic autologous slings offer a minimally invasive solution for SUI in AYA females considering pregnancy, with excellent short- and long-term outcomes and rapid recovery.

OBJECTIVE:To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes. METHODS:A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist. RESULTS:In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias. CONCLUSION:This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

BackgroundThere is a lack of approved treatments for pediatric patients with overactive bladder (OAB) with inadequate response to anticholinergic therapy. OnabotulinumtoxinA 100U is approved to treat OAB in adults based on data from randomized, pivotal trials.ObjectiveTo investigate the efficacy and safety of onabotulinumtoxinA treatment of OAB in children aged 12 to 17 years who were not adequately managed with anticholinergics.Study designIn this multinational, multicenter, randomized, double-blind, parallel-group, multiple-dose study (NCT02097121), pediatric patients with OAB were randomized 1:1:1 to receive onabotulinumtoxinA 25U, 50U, or 100U (≤6 U/kg). Patients could request retreatment starting at week 12. The primary endpoint was change from baseline to week 12 after treatment 1 in daily frequency of daytime urinary incontinence (UI) episodes. Safety assessments evaluated treatment-emergent adverse events (TEAEs).ResultsOf 68 screened patients, 55 received ≥1 treatment. Mean age was 14 years; 85.5% of patients were female. At week 12 after treatment 1, least squares mean change from baseline in daily frequency of daytime UI episodes showed a numerically greater reduction in the 100U arm (−2.4) versus the 25U arm (−1.4; P=0.38) , with a significant within-group change from baseline in the 100U arm (P=0.0027). Achievement of treatment response was significantly greater with onabotulinumtoxinA 100U vs 25U (Figure). Median time to request retreatment was ≥16 weeks in all groups. The most frequently reported TEAEs were nasopharyngitis (10.9%) and urinary tract infection (UTI; 10.9%). Urinary retention was observed in 1 patient during treatment cycle 2; there were no serious TEAEs of UTI or urinary retention. Throughout 2 additional treatment cycles continued efficacy for the 100U dose arm was observed along with a consistent safety profile.DiscussionChange in daily frequency of UI episodes at week 12 in treatment cycle 1 was not significantly different between arms. However, ≥50% response rate was significantly higher with onabotulinumtoxinA 100U versus 25U. Enrollment challenges that lowered the sample size could have reduced statistical power. Also, the lack of a placebo arm and the observed benefit with the 25U comparator limited interpretation.ConclusionsOnabotulinumtoxinA injections were well tolerated in children with OAB at all doses studied. Although the primary endpoint was not met, the significantly greater treatment response rate observed with onabotulinumtoxinA 100U versus 25U suggests additional benefit of the higher dose, without additional safety concerns.

The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.

Background: In the last 15 years, the care provided for individuals born with differences of sex development (DSD) has evolved, with a strong emphasis on interdisciplinary approaches. However, these developments have not convinced some stakeholders to embrace the current model of care. This care model has also paid insufficient attention to socio-cultural differences and global inequalities. Summary: This article is an opinion statement, resulting from in-depth discussions and reflection among clinicians, patients, and family support organizations based in the USA and Europe, where we seek areas of common ground and try to identify opportunities to further develop resources. The product of these conversations is summarized in 10 panels. The corresponding sections provide additional discussion on some of the panel items. Key Messages: Participants identified areas of agreement, gained a deeper understanding of the reasons behind disagreements on certain matters, and identified the necessary steps to foster future consensus. We offer preliminary recommendations for guiding clinical management and resource allocation. By promoting a broader consensus, we aim to enhance the quality of care and well-being for individuals of all ages who have a DSD.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Purpose: Genital gender-affirming surgery in transmasculine patients encompasses both metoidioplasty and phalloplasty. Some patients opt to undergo staged phalloplasty by metoidioplasty first (SPMF). The aim of this study was to evaluate whether SPMF is associated with less surgical complications compared with immediate phalloplasty (IP).Methods: Our institutional database was retrospectively evaluated to identify transmasculine patients who underwent SPMF between 2006 and 2020. These patients were matched based on the type of flap (radial forearm free flap vs. anterolateral thigh flap) and for the time period in regard to patients who underwent IP. Both groups were compared on patient characteristics, perioperative and postoperative outcomes.Results: Twenty-seven patients with SPMF were matched with 27 IP patients. Median follow-up after phalloplasty was held, respectively, 32 and 33 months after the intervention for SPMF and IP (p=0.99). There were no significant differences in age, body mass index, and smoking habits between both groups. For SPMF, metoidioplasty required subsequent corrective surgery before phalloplasty in three patients (11%). For SPMF and IP, median operation time was 396 and 410 min (p=0.6), median hospital stay was 16 and 17 days (p=0.5), and median catheter stay was 19 and 20 days (p=0.9). In both groups, 16 patients (59%) needed at least one additional surgical procedure for postoperative complications, urethral complications (stricture, fistula), and/or flap-related complications.Conclusion: In our cohort, complications were not reduced by SPMF. In case metoidioplasty is considered as a step toward phalloplasty, separate morbidity of metoidioplasty must be taken into account.

Penile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology. These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual experience. This study validated the Dutch translation of the “self-assessment of genital anatomy and sexual functioning in male” (SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital anatomy and sensory function. Eight hundred and eight sexually active men with a median age of 39 years (18–79 years) and no history of genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four participants were randomly recruited to confirm the responses of the “self-assessment of genital anatomy and sexual functioning in male” questionnaire by a clinical evaluation. The “self-assessment of genital anatomy and sexual functioning in male” questionnaire comprises of multiple-choice questions and clarifying illustrations asking men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus are evaluated through this questionnaire. Only slight variability in anatomical ratings was observed. Overall discrimination between different genital areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the highest contributor to “sexual pleasure,” followed by the other regions of the glans and shaft. The same distribution was found for “orgasm intensity” and “orgasm effort.” The anal region was generally rated the lowest. “Discomfort/pain” was rated lower than any of the other sensory function indicators and the top of the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner than self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised individuals regarding overall genital sensation could be found. The Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of genital anatomy and sensation, providing a site-specific attribution of a patient's perceived sexual function. Further prospective research with this questionnaire could aid in the patient-centered improvement of genital surgery.

IntroductionPenile and genital surgery for congenital or acquired conditions is daily practice in reconstructive urology. These procedures, which carry the risk of disrupting nerves and blood vessels, may impair the genital sensation, and affect the capacity for sexual pleasure. Self-reported tools are needed to systematically assess the male genitalia before and after reconstructive surgeries in terms of genital sensation and sexual experience. AimThis study validated the Dutch translation of the "self-assessment of genital anatomy and sexual functioning in male" (SAGASF-M) questionnaire and investigated the perceptions of healthy men regarding their genital anatomy and sensory function. MethodsEight hundred and eight sexually active men with a median age of 39 years (18-79 years) and no history of genital procedures other than circumcision filled out an online version of the questionnaire. Twenty-four participants were randomly recruited to confirm the responses of the "self-assessment of genital anatomy and sexual functioning in male" questionnaire by a clinical evaluation. Main outcome measuresThe "self-assessment of genital anatomy and sexual functioning in male" questionnaire comprises of multiple-choice questions and clarifying illustrations asking men to rate their genital appearance, overall sexual sensitivity, and pain perception as well as the intensity and the effort to reach orgasm. Prespecified regions of the glans, penile shaft, scrotum, perineum, and anus are evaluated through this questionnaire. ResultsOnly slight variability in anatomical ratings was observed. Overall discrimination between different genital areas in terms of genital sensation was significant. The bottom of the glans or frenular area was rated the highest contributor to "sexual pleasure," followed by the other regions of the glans and shaft. The same distribution was found for "orgasm intensity" and "orgasm effort." The anal region was generally rated the lowest. "Discomfort/pain" was rated lower than any of the other sensory function indicators and the top of the glans and anal region were rated most likely to perceive this unpleasant sensation. Participants reported significantly more sexual pleasure and intense orgasms when stimulated by a sexual partner than self-stimulation. Homosexual and bisexual men reported a higher contribution of the perineal and anal regions in sexual pleasure and orgasm. No significant difference between circumcised and uncircumcised individuals regarding overall genital sensation could be found. ConclusionThe Dutch translation of the SAGASF-M questionnaire is a valuable and reliable tool for self-assessment of genital anatomy and sensation, providing a site-specific attribution of a patient's perceived sexual function. Further prospective research with this questionnaire could aid in the patient-centered improvement of genital surgery.

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

You have accessJournal of UrologyCME1 Apr 2023PD12-12 EXCISION AND PRIMARY ANASTOMOSIS OR STAGED URETHROPLASTY FOR ANASTOMOTIC STRICTURES AFTER PHALLOPLASTY? Mieke Waterschoot, Marlon Buncamper, Piet Hoebeke, Marjan Waterloos, Wesley Verla, Wietse Claeys, and Nicolaas Lumen Mieke WaterschootMieke Waterschoot More articles by this author , Marlon BuncamperMarlon Buncamper More articles by this author , Piet HoebekePiet Hoebeke More articles by this author , Marjan WaterloosMarjan Waterloos More articles by this author , Wesley VerlaWesley Verla More articles by this author , Wietse ClaeysWietse Claeys More articles by this author , and Nicolaas LumenNicolaas Lumen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The most common strictures after gender-affirming phalloplasty are the anastomotic strictures. Stricture treatment after phalloplasty have a high recurrence rate due to the poor vascularization of the neo-urethra. Despite, different techniques of stricture treatment described in the literature, there is no medical evidence to prefer one technique over the other. METHODS: We analyzed retrospectively 80 transmasculine patients diagnosed with an anastomotic stricture post phalloplasty between 2002 and 2022. Comparison of surgical outcome between excision and primary anastomosis (EPA) (n=53) and staged urethroplasty (n=16) was analyzed. Differences in stricture length were measured for both groups. The primary outcome was recurrence rate between both groups. Secondary outcomes were previous interventions, complications and type of phallus. RESULTS: The median follow-up after stricture treatment was respectively 24 and 10 months for EPA and staged urethroplasty. There were no significant differences for age, type of phallus and smoking habits. After EPA, recurrence rate was seen in 51% of patients (27/53) in comparison with 38% of patients after staged urethroplasty (6/16). The median stricture length was twice as long for staged urethroplasty, respectively 2 cm and 1 cm was measured in patients for staged urethroplasty end EPA. This difference was significant (p<0.001). Half of the patients who underwent EPA have had no previous interventions in the past (29/53) in comparison with 6 out of 16 patients for staged urethroplasty. Previous surgery was divided into endoscopic treatment, urethroplasty and perineostomy. For EPA, respectively 9 (17%), 9 (17%) and 6 (11%) patients underwent endoscopic treatment, urethroplasty or perineostomy whereas this was respectively the case in 1 (6%), 9 (56%) and no patients (0%) for staged urethroplasty (p=0.012). No postoperative complications were seen in 41 patients (77%) and 6 patients (38%) after respectively, EPA and staged urethroplasty. Most of the complications were low grade. Only 1 patient had a grade 3 complication, this was seen after staged urethroplasty (p=0.003). CONCLUSIONS: EPA is an optional treatment for short anastomotic strictures after phalloplasty. These patients had less previous stricture surgeries in comparison with patients for staged urethroplasty. Staged urethroplasty is a preferable treatment for strictures > 1 cm and in patients after multiple attends of other stricture therapies but more complications must be taken into account. Source of Funding: No funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e404 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mieke Waterschoot More articles by this author Marlon Buncamper More articles by this author Piet Hoebeke More articles by this author Marjan Waterloos More articles by this author Wesley Verla More articles by this author Wietse Claeys More articles by this author Nicolaas Lumen More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVE:Medical treatments that aim to modify the appearance of the genitals in children who are born with a difference of sex development/intersex (DSD/I*) condition are highly controversial. Human Rights bodies worldwide have argued that such treatments are conflicting with the child's right of personal autonomy and should be legally restricted to the unique situation where the child's physical health is in danger. DESIGN:We here review the current status of legal initiatives in Europe that have addressed the issue of medical treatments in minors who have a DSD for which they have not been able to give personal informed consent due to their young age. PATIENTS:The management of a 3 years old child who has congenital adrenal hyperplasia (CAH) and grows up with atypical-looking genitals is discussed. RESULTS:In spite of extensive psychosocial support to the child and family from birth onwards, and good medical control of CAH, the child develops signs of emotional distress, suspected to be attributable to the genital difference. Our discussions include perspectives from the multidisciplinary DSD team caring for the child, a human rights specialist, and an intersex activist. From our discussions, we conclude that with evolving medical care, new ethical and human rights challenges are raised. A truly holistic human rights approach should not only consider physical but also mental health and psychosocial and psychosexual adaptation of the child to the medical condition, when reflecting on the acceptability of medical treatments in minors for which no personal informed consent can be obtained due to their young age. In addition it is paramount to include the meaningful participation of the child in the clinical management at the earliest possible stage. CONCLUSIONS:Continued convergence of clinical management and the human rights framework can be realised based on constructive discussions involving all stakeholders, and with the best interest of the child - and adult that they will become - as a common goal.