Vaginal natural orifice transluminal endoscopic surgery for gender affirmation

To describe outcomes of using a vaginal assisted natural orifice transluminal endoscopic surgery (vNOTES) approach to perform hysterectomy among transgender men as part of their gender-affirming care.

This is a retrospective observational cohort study conducted at a single university-affiliated tertiary medical center, including all patients undergoing hysterectomy by vNOTES approach between February 2022 and April 2023. Patients who underwent the surgery for gender-affirming care (exposure group) were compared with those who underwent surgery for all other indications (comparison group). vNOTES was used to perform hysterectomy with bilateral salpingectomy as recommended by the Society of Gynecologic Oncology. Patients' demographic, medical, and obstetrical and gynecological histories, and operative and postoperative follow-up (24 h post-surgery) were collected from the electronic medical files. Pain at postoperative follow-up was evaluated using the visual analog scores. The primary outcome was defined as the conversion rate from vNOTES to an alternative surgical approach.

The study population included 38 patients, of whom 13 were operated on for gender affirmation and 25 for non-gender-affirming indication. Patients in the transgender group were significantly younger (29 [25-31] vs. 42 [37-47] years; P = 0.001) than those in the comparison group. All the transgender patients were nulliparous and had been under testosterone treatment for more than a year. The median preoperative hemoglobin level was significantly higher in the transgender patients (15.50 [15.10-16.30] vs. 12.75 [11.65-14.30] g/dL; P = 0.001). The estimated blood loss was comparable between the groups (P = 0.09). None of the cases required conversion from vNOTES to an alternative approach. No extensive bleeding or organ damage was reported in any of the cases. For one patient in the transgender group, a small vaginal laceration requiring suture was documented. At 24-h postoperative follow-up, pain scores were low and comparable between the groups (P = 0.310).

Hysterectomy performed for gender affirmation by the vNOTES approach has comparable outcomes to hysterectomies done by vNOTES for other indications, with a low surgical complication rate and low self-reported pain.