Laparoscopic-assisted versus conventional vaginal hysterectomy for gender-affirming surgery in female-to-male transgender men.

BACKGROUND

Studies comparing the surgical routes for sex-affirming hysterectomy in female-to-male (FtM) transgender individuals remain limited. This study compared the perioperative outcomes of vaginal total hysterectomy (VTH) and laparoscopic-assisted vaginal hysterectomy (LAVH) in an Asian FtM cohort.

METHODS

We retrospectively reviewed the data of individuals who were FtM transgender and underwent sex-affirming hysterectomy with bilateral salpingo-oophorectomy at a tertiary referral center between January 2016 and May 2026. Patients who underwent combined major sex-affirming procedures, vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy, or vaginectomy alone were excluded. The perioperative outcomes and complications in the VTH and LAVH groups within 14 days were compared.

RESULTS

The study included 132 of 153 screened patients: 89 underwent VTH and 43 underwent LAVH. The baseline characteristics were comparable, although the body mass index (BMI) of the LAVH group was higher. The duration of surgery was significantly longer for the LAVH group than for the VTH group (152.4 ± 78.7 vs 121.2 ± 57.6 minutes; p = 0.024). Immediate postoperative pain at 2 hours was milder after LAVH than after VTH (4.1 ± 0.9 vs 4.6 ± 1.0; p = 0.007), but pain scores were comparable at 24 and 48 hours. Estimated blood loss, hospital stay, Foley catheter duration, and time to first flatus were similar. The overall complication rate was significantly lower in the LAVH group than in the VTH group (18.6% vs 37.1%, p = 0.032). One patient with VTH required conversion to abdominal hysterectomy because of severe adhesions, and one had incomplete bilateral salpingo-oophorectomy.

CONCLUSION

LAVH was associated with fewer perioperative complications and less immediate postoperative pain than VTH, although it required a longer operative time in individuals who were FtM transgender. The improved pelvic visualization and adnexal access afforded by LAVH may offer technical advantages when the pelvic anatomy is challenging. This supports its use as a minimally invasive surgical option for this population.