Postoperative Urogynecologic Complications After Gender-Affirming Surgery: A Narrative Review

Gender-affirming surgery (GAS) has witnessed a worldwide surge in demand due to societal and medical advances. Despite improved access, postoperative urogynecologic complications remain underrecognized and poorly documented. This review aims to classify complication patterns by surgical type, discuss their management, and highlight critical knowledge gaps to improve care for transgender and non-binary (TGNB) individuals.

A literature review was conducted using PubMed, Embase, Cochrane, and Web of Science. After screening the articles for relevance, data were synthesized to present a narrative review to evaluate the patterns, management, and knowledge gaps surrounding urogynecologic complications following GAS, with a focus on TGNB populations.

Transfeminine vaginoplasty frequently leads to urethral stricture (10-18%), meatal stenosis (5-10%), neovaginal stenosis (up to 30%), and dyspareunia (20-40%). Transmasculine procedures such as phalloplasty and metoidioplasty are associated with urethral fistulas (15-60% and 10-25%, respectively), strictures (25-58% and ~ 20%), and urinary retention (25-58% and 15-25%). Lower urinary tract symptoms are also common. Pelvic floor dysfunction (PFD) affects up to 94.1% of transgender men, impacting urinary and sexual function. Pelvic floor physical therapy (PFPT) before and after surgery can significantly reduce dysfunction rates.

Urogynecology complications after GAS are prevalent and significantly impact quality of life, contributing to dysphoria and distress. Major evidence gaps remain, including inconsistent complication definitions, a lack of TGNB-specific patient-reported outcome measures (PROMs), and limited longitudinal data. Addressing these gaps and expanding access to trauma-informed, specialized rehabilitation are essential to improving long-term outcomes for TGNB individuals.