Comparing Routes of Hysterectomy for Gender Affirming Hysterectomy

Objectives: While vaginal hysterectomy is the recommended route of hysterectomy for cisgender women, there is currently no guidance or data comparing route of hysterectomy for transgender men and gender diverse people undergoing hysterectomy for gender affirmation. Our objective was to compare the demographics, peri-operative variables, and post-operative complications between patients who undergo gender affirming hysterectomy (GAH) via vaginal versus laparoscopic route.

Methods: This was a retrospective study using the National Surgical Quality Improvement Program (NSQIP) database. Using CPT codes and ICD9/10 codes, we identified all patients who underwent vaginal, laparoscopic-assisted vaginal, total laparoscopic hysterectomy for the indication of gender dysphoria from 2010 to 2022. Demographics, peri-operative variables including concomitant vaginectomy, and post-operative complications were extracted for identified patients. Patients who underwent concomitant chest or vocal reconstruction surgeries were excluded. Patients were divided into those who had vaginal hysterectomy (VH) or laparoscopic hysterectomy (LH). Univariable comparison was performed using Chi-square, Fisher’s Exact, Student’s t or Mann-Whitney U test as appropriate. A multivariable logistic regression was performed to identify variables associated with LH versus VH.

Results: 1,982 patients were identified during the study period, representing 0.05% of all hysterectomies in the study period (393,306). 96 (4.84%) underwent VH and 1,886 (95.16%) LH [1,590 total laparoscopic and 296 laparoscopy-assisted vaginal]. Concomitant vaginectomy was performed for 39 (1.96%) of these patients. The overall patient population had the following characteristics: Mean age (SD) 28.71 (7.88), 1938 (97.78%) were para 0, 1,269 (64.02%) were White, 143 (7.21%) were Hispanic, and the mean BMI (SD) was 29.13 (7.18) m2/kg. Patients in the VH group were older and had greater parity, and more were White and had chronic obstructive pulmonary disease (Table 1). While there was no statistically significant difference, vaginectomy was performed more often with VH than LH (4.17% versus 1.86%, respectively). There were no differences in post-operative complications. Multivariable logistic regression adjusted for any covariates identified during univariable analysis with p< 0.2 was completed to determine variables associated with receiving VH versus LH (aOR 95%CI). Those with greater parity had increased odds of undergoing VH (1.61, 1.15-2.25).

Conclusions: Laparoscopic approach is much more common than vaginal approach for gender affirming hysterectomy, however those with greater parity have increased odds of undergoing VH. Although not statistically significant, vaginectomy was more commonly performed concomitantly with VH than LH. Overall, there were no significant differences in demographic, peri-operative variables, or post-operative complications between those who underwent LH versus VH.