This chapter focuses on urologic and pelvic complications arising from gender-affirming genital surgery (GGAS). It describes both feminizing (vaginoplasty) and masculinizing (phalloplasty and metoidioplasty) GGAS procedures and reviews complications such as vaginal stenosis, urethral strictures, and fistulas. Diagnostic and management strategies for these complications are discussed, emphasizing the importance of appropriate patient selection, meticulous surgical techniques, and comprehensive postoperative care, including pelvic floor physical therapy. The reconstructive complexity underscores the vital role urologists play in managing these complications and fostering culturally sensitive healthcare environments for transgender and gender-diverse (TGD) individuals.