Issues and concerns regarding the diagnosis and treatment of two cases: one initially thought to be aphallia but actually having very severe proximal epispadias with a tiny buried penis (hypophallia) and the second a post-pubertal individual who required further surgery after having surgery as an infant. Subsequent surgery is expected if initial phalloplasty is done before puberty will involve device implantation. Further outcome data is needed to identify the advantages and disadvantages of currently refined techniques. Reviews of the changing techniques reviewed in the discussion document the continuing refinement. The second case discusses an 18-year old young adult born who had penile agenesis with phalloplasty during early childhood who returned and asked for further phalloplasty involving glanuloplasty and implantation of an erectile device. Surgery during infancy or early childhood to create a penis appears to be very important for gender development in a boy especially if there were functional testes during fetal life, even though currently this surgery will be only the first stage. Hence, one cases points out that what may be initially presumed to be aphallia may not be while subsequent surgery is expected if initial phalloplasty before puberty likely even if current techniques are used.