Orchiectomy and scrotectomy as genital gender-affirming surgery: novel surgical technique and patient-reported outcomes

Abstract

Background

Gender-affirming orchiectomy is well described; however, a subset of patients may also seek scrotectomy to alleviate dysphoria related to the scrotum. Techniques and outcomes of gender-affirming orchiectomy and scrotectomy (GAOS) have not been described to date.

Methods

We retrospectively reviewed all patients who had undergone GAOS from 2021 to 2024 at our institution. The World Professional Association for Transgender Health criteria for surgical treatment were met preoperatively, and patients understood vaginoplasty was not recommended post-scrotectomy. Two approaches were offered: excision of a majority of scrotal tissue and primary closure of the perineal wound, or excision of all rugated skin with mons and groin (Y-flap) advancement. Patient-reported outcomes questionnaires from the PROMIS^® Sexual Function and Satisfaction Measures, version 2.0, along with questions specific to post-scrotectomy anatomy, were sent postoperatively.

Results

Eight patients, median age 31 years, underwent GAOS with a preoperative hormone duration of 26.5 months. All patients reported dysphoria related to the scrotum and testes, and wished to preserve the phallus. Five elected for primary closure, three for Y-flap perineoplasty. At median 97-day follow-up, all reported satisfaction and dysphoria relief. One patient with Y-flap experienced wound dehiscence requiring operative revision. Four reported sexual activity with the ability to achieve erection and orgasm.

Conclusions

GAOS is a well-tolerated procedure that can address dysphoria related to the scrotum and testes. Longer-term study of this emerging procedure is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-025-01867-8.

Background

In recent years, the field of gender-affirming surgery (GAS) has evolved significantly, reflecting broader societal acceptance and understanding of transgender and gender diverse (TGD) peoples’ healthcare needs. This transformation is underscored by substantial growth in the frequency of GAS procedures, with research revealing an almost threefold increase in the total number of surgeries performed between 2016 and 2020 [1]. Regarding genital gender-affirming surgeries in particular, the literature to date has focused on orchiectomy, vulvoplasty, or vaginoplasty for patients assigned male at birth (AMAB) [2].

Often, genital gender-affirming procedures are described in terms of binary gender, i.e. “transfeminine” or “feminizing” [3]. Some patients may desire external genital appearance congruent with a binary female phenotype (e.g., vaginoplasty) but do not identify as binary women, nor necessarily view the procedure as feminizing. To enhance patient-centered care, and to combat erasure of TGD identities, it is essential to explore alternatives beyond binary genital options [4, 5]. AMAB patients may not be interested in vulvar or vaginal construction as an ultimate goal [6].

While orchiectomy is well-described, techniques and outcomes for gender-affirming orchiectomy and scrotectomy (GAOS) have to date not been discussed in the literature. Here, we present our initial experience with GAOS, as a viable option for AMAB patients who experience dysphoria related to the scrotum and testes, but do not desire a vaginoplasty and/or who wish to retain the phallus.

Methods

Indications for procedure

Patients requesting gender-affirming orchiectomy may describe dysphoria related to the testes, interest in reduction or cessation of pharmacologic androgen blockade, or desire to conceal the phallus (“tucking”) more effectively [7, 8]. In addition, patients seeking GAOS specifically may also describe dysphoria owing to the presence of the scrotum itself, rugated skin, or midline raphe. While phenotypic sex presents on a spectrum determined by genetic and hormonal, the rugation of scrotal skin is a direct result of testosterone exposure in utero and thus is a primary sex characteristic.

In our practice, we routinely screen all AMAB candidates for genital gender-affirming surgery for dysphoria related to the phallus, scrotum and testes, and counsel patients on any future intentions for vaginoplasty or vulvoplasty. Patients are counseled on the permanency of GAOS, and that vulvar or vaginal construction following this would be significantly more challenging owing to limited availability of tissue. Prior to scheduling GAOS, the World Professional Association for Transgender Health (WPATH) Standards of Care version 8 criteria were met for all patients and documented with letters of support from treating providers [9].

Preoperative preparation

Patients were referred to our institution for reported dysphoria relating to both the scrotum and testes, and were counseled on GAOS. All patients underwent a shared decision-making process in which the surgical approach was tailored to their individual goals, anatomy, and priorities. Options for fertility preservation, or performing orchiectomy alone, were discussed. All patients selected for GAOS expressed no desire for other gender-affirming genital surgeries, and further expressed written understanding that vaginoplasty would not be recommended following scrotectomy.

A goals-based counseling model was used during intake to help patients define their surgical priorities. These included desired aesthetic outcomes, sources of dysphoria, and any procedures they preferred not to undergo. Surgical technique was then selected based on both anatomical feasibility and alignment with the patient’s goals. At the intake visit, patients were also screened for current sexual activity, presence of erections, and ability to achieve orgasm. BMI did not influence the choice of surgical technique; operative approach was selected based on patient goals and anatomic considerations.

Physical examination for the dimensions and elasticity of scrotal and surrounding mons and groin skin was performed, as well as the location of the testes and to rule out clinically significant inguinal hernia. The presence of a tethering phallic-scrotal web was noted. If patients did not report significant dysphoria specific to rugated skin, excision of a majority of the scrotal skin and linear perineorrhaphy was offered, preserving a scrotal web to prevent tethering of the phallus ventrally. However, if patients desired complete removal of all rugated scrotal skin and web, and specifically a flatter perineum, they were offered a mons and groin (“Y-flap”) reconstruction, and counseled that tension on the closure may result in a greater likelihood of incisional complications compared with linear closure.

The patients’ existing hormone regimens were continued perioperatively without modification if they had no prior history of venous thromboembolism [10]. Patients taking antiandrogens ceased taking these medications on postoperative day 1.

Intraoperative considerations

After induction of general anesthesia, patients are positioned in dorsal lithotomy and receive a single dose of preoperative intravenous prophylactic antibiotic coverage with cefazolin and gentamicin. A dorsal phallic and bilateral pudendal block is performed with 0.25% bupivacaine. A holding suture is placed in the glans for retraction. A Foley catheter is placed for urethral identification and removed at the end of the operation.

With the phallus on stretch, the scrotal dimensions are measured, the borders of the rugated skin are marked, and the elasticity of the surrounding mons and groin tissue is noted (Fig. 1). If a phallic-scrotal web is present, it is marked separately from the remainder of the scrotum. A full thickness excision of the rugated scrotal skin is then performed. Bilateral orchiectomy proceeds by skeletonizing each spermatic cord to the level of the external inguinal ring, excising it after clamping doubly, and suture and free-ligating the stump to achieve hemostasis with 0 Vicryl. Care is taken to ensure that the spermatic cord stump retracts fully into the external inguinal ring to prevent a postoperative inguinal bulge.

Fig. 1.

Intraoperative marking of potential areas of excision. The phallus is on stretch. The location of the phallic base is indicated by the dotted red line, and the estimated phallic-scrotal (future phallic-perineal) junction is indicated by the solid black line. Rugated scrotal skin is denoted by the dashed white line. In this patient’s case, there is a significant phallic-scrotal web

At this point, closure depends on the patient’s goal of either complete rugated skin excision, or linear closure.

Linear perineorrhaphy

The scrotal web is preserved in order to maintain ventral coverage of the phallus. Multilayered closure of the perineum with running 2-0 Vicryl suture is accomplished based on the mobility of the surrounding medial groin skin and subcutaneous tissue to recreate the midline raphe (Fig. 2).

Fig. 2.

Linear perineorrhaphy

Y-flap reconstruction

The scrotal web is excised, resulting in a ventral phallic skin deficiency. Corresponding to the dimensions of this defect, adipocutaneous advancement flaps from the mons and bilateral groin are raised to cover the ventral phallus and superior aspect of the perineal defect (Fig. 3). Multilayered closure of the remaining perineal defect via closure of the bilateral medial groin tissue is performed as above.

Fig. 3.

“Y-flap” perineal repair. Adipocutaneous flaps from the mons have been raised to provide coverage

For either technique, no drain is placed. The phallic shaft is wrapped with gauze and the perineum is dressed with a compressive bandage.

Postoperative management and follow-up

Patients are discharged on the day of the procedure once they have passed a trial of void. The dressings are removed after 24 h and patients are counseled to wrap the phallus daily to reduce postoperative edema. Restrictions in terms of strenuous exercise or sexual activity were advised for 4 weeks postoperatively. Follow up was performed at intervals of 1 week, 2 weeks, 6 weeks, 3 months postoperatively and thereafter as clinically indicated.

Study measures and analysis

A retrospective review was conducted for all patients undergoing GAOS at our institution between 2021 and 2024. We developed a questionnaire tailored to the anatomy following GAOS, including from the PROMIS^® Sexual Function and Satisfaction Measures, version 2.0, as well as novel items which we formulated to reflect the postulated post-GAOS anatomy and function, which were sent to all patients postoperatively (Additional file 1) [11]. The additional questions in the survey had potential responses on a five-point Likert scale. Descriptive statistics were used to report survey responses (Additional file 2).

Results

Preoperative

From 2021-2024, 124 patients underwent gender-affirming orchiectomy at our institution, of whom 8 patients elected for GAOS specifically. The median age at the time of surgery was 31 years (range 24–47 years). The median BMI was 27.0 (range 22.7–37.1). The median duration of hormone use was 26.5 months (range 0–110 months). Preoperatively, all patients reported no difficulty maintaining erections and no difficulty achieving orgasm. One patient reported preexisting low libido (Additional file 3).

Intraoperative

All patients were identified as having a scrotal web. Five patients elected for linear perineorrhaphy while three patients elected for Y-flap reconstruction. Overall median operative time was 143.5 min (range 118–196 min) and median blood loss was 25 ml (range 10-50 ml). The median area of tissue excision was 120 cm² (range 40–480 cm²). There were no intraoperative complications (Additional file 4).

Postoperative

Patients were followed with in-person appointments to a median of 97 days post-surgery (range 48–605 days). All patients reported preserved erections postoperatively, reduction of dysphoria, sexual activity, improvement in quality of life, and satisfaction with the surgery (Additional file 2). No patients reported pain or discomfort related to tension at the scar site, nor did any experience prolonged activity restrictions beyond the standard four-week recovery period. Typical postoperative outcomes are demonstrated in Fig. 4. All patients were sent the patient-reported outcome questionnaire at 3 months postoperatively; four patients returned completed forms. All patients, including those who did not complete the survey, were seen for in-person clinical follow-up and were doing well at their most recent visits, with no complications or ongoing concerns reported.

Fig. 4.

Typical outcome after GAOS; this patient had linear perineorrhaphy

Complications

For patients requesting complete removal of the rugated scrotal skin including scrotal web, Y-flap reconstruction may result in tension on the perineal closure. One patient in our series developed dehiscence of the ventral phallic incision (Fig. 5a) which was managed initially with wet to dry dressings and ultimately required an additional surgery for graft coverage with regenerated dermal substitute (Fig. 5b). At 3 months postoperatively, the patient had complete healing of the wound defect and excellent aesthetic and functional outcome without tethering (Fig. 5c).

Fig. 5.

Dehiscence of the ventral phallic incision after Y-flap perineal repair (a) which was managed ultimately with an additional surgery for graft coverage with regenerated dermal substitute (b). At 3 months postoperatively, the patient had complete healing of the wound defect (c)

Discussion

We present a novel description of genital gender affirming surgery that addresses dysphoria related to excess scrotal tissue and rugated skin for well-informed patients not interested in future gender-affirming vaginoplasty. In our practice, the annual prevalence of the request for scrotectomy is about 10%. Whether this reflects broader trends in other practices or regions is difficult to assess, chiefly because the literature to date, including reviews of claims databases, has described orchiectomy alone or as a bridge to vulvoplasty or vaginoplasty [12, 13]. Population-level metrics, such as the United States Transgender Survey (USTS), do not specifically query for scrotectomy [14]. We posit that patients requesting GAOS have not historically been able to access care, possibly due to lack of provider knowledge or experience regarding the procedure. Additionally, one possible contributor to barriers to care are historical antipathy towards nonbinary identities and bodily outcomes that do not reproduce a cisgender, endosex normative appearance. In our series, patients described difficulty with finding a provider willing to discuss GAOS, with one patient reporting 200 such attempts (Additional file 2). Notably, all patients in our series specifically requested GAOS prior to consultation, highlighting a gap in available options that align with the surgical goals of this population. Our experience demonstrates that patients do in fact benefit from GAOS, which can address preoperative concerns successfully.

A further barrier to care may be the idea that the ultimate goal of genital gender-affirming surgery for AMAB patients is either vulvoplasty or vaginoplasty [15, 16]. In our practice, we counsel patients extensively, and obtain preoperative written attestation of their understanding that vaginal construction following GAOS is not recommended. While one patient in our practice expressed continuing interest in vulvoplasty following GAOS, this was described as a distant future goal, and most patients were not interested in pursuing any further genital procedures (Additional file 2). Nevertheless, vaginal construction would not necessarily be absolutely contraindicated, as techniques to mitigate limited external genital tissue have been described [17]. Care should be taken in cases of expressed interest in future vaginoplasty or vulvoplasty, and counseling should emphasize the potential technical limitations imposed by prior scrotectomy.

Limitations

Sexual well-being in TGD individuals, particularly in the postoperative setting, is understudied [18]. We encountered challenges in our study design, as no instruments specific to patient goals and postoperative anatomy relevant to GAOS existed. To this end, we incorporated questions that are specific to presumed anatomy and function following GAOS into the PROMIS^® Sexual Function and Satisfaction Measures, version 2.0, for example postoperative item #4 regarding tucking (Additional file 1). While the preexisting instrument has demonstrated validity in diverse populations, our modifications to it require validation and review externally.

Further limitations of our study include its retrospective nature and being derived from a single institution’s data, which limits generalizability. While two techniques for GAOS were offered, they were treated interchangeably in terms of postoperative counseling and follow-up, which with further experience in this procedure may not be sufficient. In particular, we have counseled patients against total excision of rugated skin owing to potential wound complications from excessive tension on the closure, unless dysphoria with it is verbalized specifically. Additionally, although we adapted PROMIS^® measures to reflect post-GAOS anatomy, we did not include a validated gender dysphoria scale, which could enhance future assessments of surgical outcomes.

Conclusion

We demonstrate that a subset of TGD patients may seek GAOS, which can address genital dysphoria. Further study of this procedure, access to care, and surgical outcomes, is needed to address the unique needs of TGD populations. We urge surgical training programs and referral networks to become familiar with GAOS as a distinct, patient-centered gender-affirming option.

Abbreviations

AMAB

Assigned male at birth

GAOS

Gender-affirming orchiectomy and scrotectomy

GAS

Gender-affirming surgery

PROMIS

Patient-Reported Outcomes Measurement Information System

TGD

Transgender and gender diverse

USTS

United States Transgender Survey

WPATH

World Professional Association for Transgender Health

Biographies

Kitan Zoltin

is a medical student at Michigan State University College of Osteopathic Medicine with a passion for urology and advancing gender-affirming surgical care. Kitan Zoltin has contributed to the field through presentations aimed at advancing knowledge and understanding of transgender and gender-diverse patients and their unique healthcare needs. Recently accepted as a member of the American Urological Association Diversity, Equity, and Inclusion Committee, Kitan Zoltin continues to advocate for equitable care and representation within urology.

Briar Shannon

is an RN, BSN nurse navigator for gender-affirming surgical services at the Vattikuti Urology Institute, Henry Ford Health, specializing in care coordination and clinical support for transgender and gender-diverse patients.

Ryan Timar

is a urology resident at the Vattikuti Urology Institute with clinical and research interests in genitourinary reconstruction and gender-affirming surgical care.

Gaines Blasdel

is a medical student at the University of Michigan, a researcher, and advocate with expertise in LGBTQIA+ health, gender-affirming care, and policy reform. Gaines Blasdel has contributed to numerous publications and initiatives to improve healthcare access for transgender and gender-diverse individuals.

Nabeel Shakir

serves as the Director of Genitourinary Reconstructive Surgery at the Vattikuti Urology Institute and leads the gender-affirming surgical program at Henry Ford Health. The program was developed from the ground up under Nabeel Shakir, establishing a comprehensive framework for patient-centered care. Research areas of focus for Nabeel Shakir include clinical decision-making aids, surgical education, and patient-centered outcomes, with an emphasis on empowering patients, innovating treatments, and mentoring future leaders in reconstructive urology.

Authors’ contributions

K.Z. conceptualized the study, curated the data, created visualizations, prepared the original draft, and participated in reviewing and editing the manuscript. B.S. contributed to the conceptualization, data curation, investigation, methodology, validation, and visualizations, and participated in reviewing and editing the manuscript. R.T. curated the data, performed formal analyses, contributed visualizations, and reviewed and edited the manuscript. G.B. provided substantial revisions and participated in reviewing and editing the manuscript. N.S. contributed to the conceptualization, formal analysis, investigation, and methodology, and oversaw the project, providing resources, supervision, and validation. N.S. also contributed to writing the original draft, and reviewing and editing the manuscript. All authors read and approved the final manuscript.

Funding

No funding was received for conducting this study.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and the ethical standards of the Institutional Review Board at Henry Ford Health. The Henry Ford Health Institutional Review Board reviewed this study and determined it to be exempt from further review under Department of Health and Human Services regulations for the protection of human subjects (45 CFR 46.111).

All participants provided written informed consent to participate in this study, including consent for the administration of the questionnaire and data collection.

Consent for publication

Participants were informed that anonymized data collected in this study may be published, and all participants provided written informed consent for publication.

Competing interests

The authors declare no competing interests.