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

Abstract

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.

Lay Summary: Transgender men are individuals who were assigned female at birth but identify as men. Some choose to undergo surgery to remove the uterus and ovaries as part of their sex-affirming care. This surgery can be performed through the vagina (vaginal total hysterectomy [VTH]) or with the help of laparoscopy (LAVH). We reviewed the records of 132 transgender men who underwent surgery at a major Taiwanese hospital over 10 years. LAVH led to fewer complications such as infections and bleeding (19%) than VTH (37%), and patients reported milder pain shortly after surgery. The trade-off was that LAVH took approximately 30 minutes longer. These findings suggest that LAVH may be a safer option for transgender men.

1. INTRODUCTION

Individuals who are female-to-male (FtM) transgender were assigned female at birth but identify as men. Approximately 0.3% to 0.6% of adults self-identify as transgender globally, and the demand for gender-affirming surgical care continues to increase.^1,2 Taiwan has shown a similar trend; the 1-year prevalence of gender dysphoria among persons assigned female at birth doubled from 1.6 to 3.2 per 100 000 between 2010 and 2019, and 416 FtM gender-change registrations were recorded nationwide between 2002 and 2020.^3–6 Gender-affirming surgery in Taiwan is concentrated in a limited number of tertiary referral centers, and our institution performed 153 FtM gender-affirming hysterectomies during the study period, representing a substantial proportion of the national surgical caseload.^3,4,6,7

Hysterectomy with bilateral salpingo-oophorectomy (BSO), with or without concurrent vaginectomy, is an important component of sex-affirming surgery in individuals who are FtM transgender. It relieves menstrual dysphoria and reduces long-term gynecologic risks associated with prolonged exogenous testosterone exposure.^8–10 For benign disease in cisgender women, the vaginal route is generally preferred over the abdominal route because it is associated with faster recovery, fewer complications, and lower cost.^11–14 In individuals who are FtM transgender, vaginal hysterectomy may offer the additional benefit of preserving a scar-free abdomen. However, testosterone-associated vaginal atrophy and nulliparity may make vaginal total hysterectomy (VTH) technically challenging.^15,16 Laparoscopic-assisted vaginal hysterectomy (LAVH) provides direct pelvic visualization and facilitates adnexal access but requires abdominal port site incisions.^13,14,17

However, data and comparative evidence on these two routes in individuals who are FtM transgender remain limited. Most published single-institution series have included fewer than 60 patients or focused on a single surgical technique.^6,15–20 To our knowledge, no previous study has directly compared VTH and LAVH in an Asian FtM cohort. Therefore, we conducted a 10-year single-center retrospective cohort study to compare the perioperative outcomes, complications, and reoperation rates of VTH and LAVH in individuals who are FtM transgender undergoing gender-affirming hysterectomy with BSO.

2. METHODS

2.1. Study design and setting

This retrospective cohort study was conducted at the Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, a tertiary academic referral center in Taipei, Taiwan. The study was conducted from January 2016 to May 2026. The study protocol was reviewed and approved by the Institutional Review Board of the Taipei Veterans General Hospital (IRB Protocol Number: 2026-03-007CC). The requirement for written informed consent was waived because of the retrospective design and the use of deidentified data.

2.2. Participants

We retrospectively identified all individuals who were FtM transgender and underwent total hysterectomy with BSO for sex-affirming indications during the study period from the institutional surgical database. Eligible patients had a documented and persistent diagnosis of gender dysphoria or transsexualism confirmed by two independent mental health professionals and had received continuous testosterone therapy in accordance with the prevailing World Professional Association for Transgender Health Standards of Care. In total, 153 unique patients who were FtM transgender were screened. Twenty-one patients were excluded: 13 underwent combined sex-affirming procedures, including subcutaneous mastectomy, metoidioplasty, sex reassignment surgery stage I, or fat grafting, during the same operative session; six underwent transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy, which is a distinct minimally invasive technique previously described by our group;⁶ and two underwent vaginectomy only without concurrent hysterectomy. One patient in whom intended VTH was intraoperatively converted to abdominal total hysterectomy was retained in the VTH group and analyzed on an intention-to-treat basis. After applying these criteria, 132 patients were included in the final analysis (Fig. 1).

Fig. 1.

Study flowchart of patient enrollment, exclusions, and group allocation. ATH = abdominal total hysterectomy; BSO = bilateral salpingo-oophorectomy; LAVH = laparoscopic-assisted vaginal hysterectomy; SRS = sex reassignment surgery; vNOTES = vaginal natural orifice transluminal endoscopic surgery; VTH = vaginal total hysterectomy.

2.3. Surgical procedures

All procedures were performed by experienced gynecologic surgeons under general anesthesia with the patient in the Trendelenburg position. First-generation cephalosporins (cefazolin, 1 g) were administered intravenously within 30 minutes of skin incision. A Foley catheter was placed after disinfection before surgery. In the VTH group, hysterectomy and BSO were completed entirely via the vaginal route by sequential transection and ligation of the uterosacral, cardinal, and infundibulopelvic ligaments. In the LAVH group, conventional multiport laparoscopy was used to mobilize the adnexa and seal the upper uterine pedicles under direct visualization, followed by transvaginal hysterectomy and specimen delivery. When planned, concurrent vaginectomy was performed during the same operative session. Postoperative analgesia and antibiotics were administered according to the institutional protocols.

2.4. Data collection and outcome measures

Patient demographics, clinical characteristics, surgical records, pathology reports, and postoperative courses were retrieved from electronic medical records. The baseline variables included age, body weight, height, body mass index (BMI), smoking status, parity, current androgen therapy, history of mastectomy, and history of abdominal surgery.

Operative and perioperative variables included concurrent vaginectomy, total operative time, estimated intraoperative blood loss, uterine dimensions measured on gross pathology examination, length of hospital stay, duration of indwelling Foley catheterization, time to first flatus, postoperative pain scores, and the need for rescue analgesia beyond the standard postoperative order set. Postoperative pain was assessed using a 10-point visual analog scale at 2, 24, and 48 hours after surgery. Uterine volume was calculated using the prolate ellipsoid formula: π/6 × length × width × depth. Estimated blood loss and length of hospital stay were corroborated by the Institutional Clinical Data Warehouse to ensure accuracy.

The primary composite outcome, designated “overall complications,” was defined as the occurrence of any one or more of the following events within 14 days after the index hysterectomy: intraoperative organ injury (bladder, ureter, bowel, or major vascular), intraoperative conversion to laparotomy, intraoperative blood transfusion, postoperative internal bleeding, pelvic abscess, urinary retention requiring prolonged catheterization, rectovaginal fistula, incomplete BSO, unplanned readmission, or secondary surgical intervention. Each patient was counted only once for the overall complication category, regardless of the number of individual events experienced.

2.5. Statistical analysis

Continuous variables were presented as mean ± SD or median with interquartile range, and categorical variables were summarized as frequency and percentage. The normality of continuous variables was assessed using the Shapiro–Wilk test. Intergroup comparisons were performed using the independent t test for normally distributed continuous variables and the Mann–Whitney U test for non-normally distributed continuous or ordinal variables. Categorical variables were compared using the chi-squared test when all expected cell counts were ≥5; otherwise, Fisher’s exact test was used. Statistical significance was defined as a two-sided p values <0.05. All analyses were performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria).

3. RESULTS

3.1. Patient enrollment and baseline characteristics

Between January 2016 and May 2026, 153 individuals who were FtM transgender and underwent gender-affirming gynecologic surgery at our institution were assessed for eligibility. Twenty-one patients were excluded: 13 underwent combined sex-affirming procedures during the same operative session, six underwent hysterectomy via the vNOTES approach, and two underwent vaginectomy only without concurrent hysterectomy. The remaining 132 patients were included in the final analysis and classified into VTH (n = 89) and LAVH (n = 43) groups (Fig. 1). The baseline characteristics are summarized in Table 1. The two groups were comparable in terms of age, height, body weight, smoking status, parity, history of mastectomy, history of abdominal surgery, and current androgen therapy. However, BMI was statistically higher in the LAVH group than in the VTH group (mean, 24.8 ± 4.5 vs 23.2 ± 3.9 kg/m²; median, 24.2 vs 22.3 kg/m²; p = 0.030). The proportions of patients with overweight and obesity were also higher in the LAVH group than in the VTH group: 41.9% vs 19.5% for BMI ≥25 kg/m² and 16.3% vs 6.9% for BMI ≥30 kg/m², respectively.

Table 1.

Characteristics of female-to-male transgender men receiving hysterectomy with bilateral salpingo-oophorectomy.

Characteristics	VTH Group (n = 89)	LAVH Group (n = 43)	p
Age, y	30.8 ± 6.4	31.1 ± 5.7	0.638
Weight, kg	61.3 ± 10.1	64.9 ± 13.7	0.142
Height, cm	162.7 ± 5.2	161.7 ± 4.7	0.276
BMI, kg/m2	23.2 ± 3.9	24.8 ± 4.5	0.030*
Median (IQR)	22.3 (21.0-24.2)	24.2 (21.4-26.1)
Current or ex-smoker	18 (20.2)	9 (20.9)	0.926
Parous	0 (0.0)	0 (0.0)	NA
History of previous mastectomy	81 (91.0)	38 (88.4)	0.504
History of previous abdominal surgery	4 (4.5)	1 (2.3)	0.536
Current androgen therapy	75 (84.3)	40 (93.0)	0.202

Data are presented as mean ± SD or n (%) unless otherwise specified. Continuous variables were assessed for normality using the Shapiro–Wilk test and compared using the independent t test (parametric) or Mann–Whitney U test (nonparametric); categorical variables were compared using the χ² test or Fisher exact test as appropriate. Variables that violated normality (Shapiro–Wilk p < 0.05; BMI) are additionally presented as median (IQR) and were compared with the Mann–Whitney U test; all other continuous variables are presented as mean ± SD and were compared with the independent t test.

BMI = body mass index; IQR = interquartile range; LAVH = laparoscopic-assisted vaginal hysterectomy; NA = not applicable; VTH = vaginal total hysterectomy.

^*p < 0.05 was considered statistically significant.

3.2. Operative and perioperative outcomes

The operative and perioperative outcomes are summarized in Table 2. Surgery lasted significantly longer in the LAVH group than in the VTH group (152.4 ± 78.7 vs 121.2 ± 57.6 minutes; p = 0.024). Concurrent total vaginectomy was performed in 56 patients in the VTH group and 31 in the LAVH group, with no significant difference between the groups (62.9% vs 72.1%; p = 0.290). The estimated intraoperative blood loss did not differ significantly between the VTH and LAVH groups (median, 250 mL [interquartile range {IQR}, 100–362 mL] vs 200 mL [IQR, 100–300 mL]; p = 0.679). Hospital length of stay was also comparable for the groups (4.2 ± 0.8 vs 4.3 ± 0.6 days; p = 0.183), as were Foley catheter duration and time to first flatus. Uterine dimensions were generally similar, although uterine width was significantly greater in the LAVH group (5.2 ± 2.4 vs 4.4 ± 0.9 cm; p = 0.040). The calculated uterine volume did not differ significantly between the groups (median, 64.9 vs 60.7 mL; p = 0.397). Postoperative pain scores were higher in the VTH group at 2 hours after surgery (4.6 ± 1.0 vs 4.1 ± 0.9; p = 0.007). This difference was attenuated by 24 hours (4.2 ± 1.9 vs 3.7 ± 1.3; p = 0.123) and was no longer present at 48 hours (3.1 ± 1.3 vs 3.1 ± 1.0; p = 0.879). The need for additional rescue analgesia did not differ significantly between the two groups (81.8% vs 71.4%; p = 0.263).

Table 2.

Operative and associated outcomes of hysterectomy with bilateral salpingo-oophorectomy in female-to-male transgender men

Outcomes	VTH Group (n = 89)	LAVH Group (n = 43)	p
Concurrent vaginectomy, n (%)	56 (62.9)	31 (72.1)	0.290
Operative time, min	121.2 ± 57.6	152.4 ± 78.7	0.024*
Operative estimated blood loss, mL (median, IQR)	250 (100-362)	200 (100-300)	0.679
Uterine size, cm
Length	7.4 ± 1.1	8.0 ± 2.7	0.167
Width	4.4 ± 0.9	5.2 ± 2.4	0.040*
Depth	3.6 ± 0.8	3.6 ± 1.1	1.000
Uterine volume, mL (median, IQR)	60.7 (45.0-78.9)	64.9 (47.6-88.1)	0.397
Hospital stay, d	4.2 ± 0.8	4.3 ± 0.6	0.183
Foley catheter indwelling, d	2.2 ± 1.3	1.9 ± 0.9	0.377
Time to first flatus, d	1.4 ± 0.6	1.5 ± 0.6	0.311
Visual analog scale for pain (hours after operation)
2 h	4.6 ± 1.0	4.1 ± 0.9	0.007*
24 h	4.2 ± 1.9	3.7 ± 1.3	0.123
48 h	3.1 ± 1.3	3.1 ± 1.0	0.879
Additional postoperative analgesia required, n (%)a	72 (81.8)	30 (71.4)	0.263

IQR = interquartile range; LAVH = laparoscopic-assisted vaginal hysterectomy; VTH = vaginal total hysterectomy.

Data are presented as mean ± SD or n (%) unless otherwise specified. Continuous variables were assessed for normality using the Shapiro–Wilk test and compared using the independent t test (parametric) or Mann–Whitney U test (nonparametric); categorical variables were compared using the χ² test or Fisher exact test as appropriate. Variables that violated normality (Shapiro–Wilk p < 0.05; estimated blood loss and uterine volume) are presented as median (IQR) and were compared with the Mann–Whitney U test; all other continuous variables are presented as mean ± SD and were compared with the independent t test. Uterine volume was calculated as π/6 × length × width × depth (prolate ellipsoid).

^aAdditional postoperative analgesia includes any rescue analgesic administered beyond the standard postoperative order set.

^*p < 0.05 was considered statistically significant.

3.3. Complication

The complications are summarized in Table 3. Overall, complications were significantly less frequent in the LAVH group than in the VTH group (8/43 [18.6%] vs 33/89 [37.1%], respectively, p = 0.032). Intraoperative organ injury was rare and occurred in one patient in the VTH group who sustained a bowel injury, and repair was performed. No bladder, ureteral, or major vascular injuries were observed in either group. Conversion to laparotomy occurred in one patient in the VTH group and in no patients in the LAVH group. Incomplete surgery due to difficulty performing BSO was recorded for one additional VTH patient.

Table 3.

Intraoperative and immediate postoperative complications of hysterectomy with bilateral salpingo-oophorectomy in female-to-male transgender men

Complications, n (%)	VTH Group (n = 89)	LAVH Group (n = 43)	p
Overall complicationsa	33 (37.1)	8 (18.6)	0.032*
Intraoperative
Blood transfusion	6 (6.7)	3 (7.0)	1.000
Bladder injury	0 (0.0)	0 (0.0)	1.000
Ureter injury	0 (0.0)	0 (0.0)	1.000
Bowel injury	1 (1.1)	0 (0.0)	1.000
Major vascular injury	0 (0.0)	0 (0.0)	1.000
Conversion to laparotomy/abdominal operation	1 (1.1)	0 (0.0)	1.000
Postoperative
Internal bleeding	5 (5.6)	0 (0.0)	0.173
Pelvic abscess	15 (16.9)	3 (7.0)	0.121
Urinary retention requiring prolonged catheterization	3 (3.4)	2 (4.7)	0.661
Rectovaginal fistula	1 (1.1)	0 (0.0)	1.000
Incomplete surgery	1 (1.1)	0 (0.0)	1.000
Unplanned readmission within 14 d	10 (11.2)	4 (9.3)	1.000
Secondary surgical intervention within 14 d	6 (6.7)	0 (0.0)	0.177

Data are presented as n (%). Comparisons were made using the χ² test or Fisher exact test as appropriate. The single conversion to laparotomy in the VTH group was an intraoperatively planned conversion to abdominal total hysterectomy and is included in the VTH group on an intention-to-treat basis.

LAVH = laparoscopic-assisted vaginal hysterectomy; VTH = vaginal total hysterectomy.

^aOverall complications represent a composite outcome of any one or more of the listed intraoperative and postoperative complications within 14 d; each patient is counted only once.

^*p < 0.05 was considered statistically significant.

Although the overall complication rate was significantly lower for the LAVH group, no individual complication subtypes were statistically significant. Internal bleeding requiring reoperation occurred in five patients in the VTH group and none in the LAVH group (5.6% vs 0%; p = 0.173). Secondary surgical intervention within 14 days was required for six patients in the VTH group and none in the LAVH group (6.7% vs 0%; p = 0.177). Pelvic abscesses were also more frequent in the VTH group than in the LAVH group (16.9% vs 7.0%; p = 0.121). The rates of blood transfusion, urinary retention, rectovaginal fistula, and unplanned readmission within 14 days did not differ significantly between groups. Unplanned readmission was recorded for 10 patients in the VTH group and four in the LAVH group (11.2% vs 9.3%; p = 1.000).

4. DISCUSSION

In this 10-year, single-center, retrospective cohort study of 132 individuals who were FtM transgender and underwent sex-affirming hysterectomy with BSO, we directly compared two minimally invasive transvaginal routes: conventional VTH and LAVH. Three main findings were observed. First, the overall perioperative complication rate was significantly lower after LAVH than after VTH. Second, LAVH was associated with milder immediate postoperative pain at 2 hours, although this difference was transient and disappeared after 48 hours. Third, LAVH required a longer duration of surgery, whereas the estimated blood loss, length of hospital stay, duration of Foley catheter placement, and time to first flatus were similar for the groups. The lower complication burden observed for the LAVH group was not explained by differences in concurrent vaginectomy or BMI.

The longer duration of surgery associated with LAVH is consistent with previous comparisons between vaginal and laparoscopic hysterectomy in cisgender women and likely reflects the additional steps required for port placement, pneumoperitoneum, laparoscopic assessment, and sealing of the upper uterine and adnexal pedicles.^12,13,20

Despite the additional duration of surgery, LAVH was associated with a lower overall complication rate. This may be attributable to the improved visualization of the deep pelvis, more controlled hemostasis, and easier adnexal access under direct laparoscopic vision.^13–15,21 The significant difference in overall complications was not driven by a single dominant event. Instead, several clinically relevant complications, including internal bleeding requiring reoperation, pelvic abscess, and secondary surgical intervention, were more frequent in the VTH group, although individual comparisons did not reach statistical significance. This pattern suggests a consistent direction of the effect across multiple endpoints, rather than an isolated, complication-specific difference.

The lower 2-hour postoperative pain score of the LAVH group was also noteworthy. Although vaginal hysterectomy is generally considered less invasive because it avoids abdominal incisions, patients who are FtM transgender often present with testosterone-associated vaginal atrophy, nulliparity, and limited uterine descent. These factors may increase the degree of vaginal manipulation and deep pelvic dissection required during VTH.⁶ The lower 2-hour postoperative VAS pain score for the LAVH group reached statistical significance, but the absolute inter-group difference was only 0.5 points on a 10-point scale, which falls below the commonly cited minimal clinically important difference of approximately 1.0 to 1.5 points for acute postoperative pain.^22,23 Furthermore, the difference was attenuated by 24 hours and absent at 48 hours, and the requirement for rescue analgesia did not differ between the groups. The pattern was consistent with the reduced early vaginal manipulation for the LAVH approach, but the clinical relevance of this transient pain difference is likely modest and should not be overinterpreted.

Whether concurrent vaginectomy increases perioperative morbidity remains an important concern for FtM sex-affirming surgery. In our cohort, concurrent vaginectomy was performed for approximately two-thirds of the patients and was not associated with increased rates of overall complications, internal bleeding, reoperation, or readmission. In the VTH group, the reoperation rates were not higher among patients who underwent concurrent vaginectomy, and no reoperation occurred in the LAVH group, regardless of vaginectomy status. These findings suggest that concurrent vaginectomy can be performed with hysterectomy by experienced surgeons without a clear increase in short-term perioperative morbidity.

The BMI was significantly higher in the LAVH group, with a greater proportion of patients with overweight and obesity. This likely reflects the real-world surgical selection; an increased body habitus can make the vaginal route more technically challenging because of limited exposure, restricted retraction, and a deeper operative field. Therefore, surgeons may preferentially select LAVH for patients with more difficult vaginal access. The LAVH group had fewer overall complications despite having a higher BMI. This observation does not eliminate the possibility of residual confounding, but it supports the feasibility and potential advantages of laparoscopic assistance in patients for whom the purely vaginal route is technically constrained.

Our findings add to the growing literature on minimally invasive hysterectomy for individuals who are FtM transgender (Table 4). O’Hanlan et al¹⁷ reported one of the earliest large series of total laparoscopic hysterectomy in 41 patients who were FtM transgender, with a short median duration of surgery, minimal blood loss, and an overall complication rate of 12%. Obedin-Maliver et al¹⁶ analyzed 33 transmasculine patients undergoing surgery with mixed routes and concluded that vaginal hysterectomy is feasible in this population, with uterine size rather than gender identity guiding route selection. Subsequent studies have described newer minimally invasive platforms, including robot-assisted total laparoscopic hysterectomy with laparoscopic colpectomy, reduced-port total laparoscopic hysterectomy, and robotic-assisted single-site hysterectomy.^18–20 From our institution, Lee et al⁶ previously compared transvaginal NOTES with conventional VTH in individuals who are FtM transgender and reported comparable safety and less postoperative pain with the NOTES approach. In this context, the present study represents, to our knowledge, the largest single-center cohort directly comparing VTH and LAVH in individuals who are FtM transgender and the first such comparative study from East Asia.

Table 4.

Comparison of published series of hysterectomy in female-to-male gender-affirming surgery

Study (year)	Country	Design	FtM cases (n)	Surgical route(s)	Operative time	Blood loss (EBL)	Complications	Hospital stay	Clinical value
O’Hanlan et al (2007)17	USA	Retrospective	41	TLH + BSO (4 ports)	Median 57.5 min	Median 20 mL	12.2%; reoperation 4.9%; 1 conversion	Mean 1.07 d	Early large TLH series
Obedin-Maliver et al (2017)16	USA	Retrospective	33	Mixed: VH 24%, LH 42%, AH 33%	Anesthesia median 205 min	Median 200 mL	Acute postop 15.2%; conversion 8.3%	NR	VH feasible despite atrophy; uterine size drives route
Groenman et al (2017)19	The Netherlands	Prospective	36	Robot-assisted TLH + BSO + RaLC (single step)	Median 230 min	Median 75 mL	Major 2.8%; minor 22%; conversion 0%	Median 3 d	Robotic colpectomy is an alternative to vaginal colpectomy
Marfori et al (2018)20	USA	Retrospective	12	2-port reduced-port TLH + BSO	Mean 89 min	Mean 53 mL	No major events; cuff granulation 25%	Same-day discharge	Reduced-port feasibility
Lee et al (2019)6	Taiwan	Retrospective comparative	56 (NOTES 14; VH 42)	Transvaginal NOTES VH + BSO vs conventional VH	144 vs 149 min (NS)	200 vs 150 mL (NS)	NOTES 7% vs conventional 12% (NS)	7.7 vs 7.1 d (NS)	First NOTES series in FtM; less pain
Gardella et al (2021)18	Italy	Retrospective	60	Robotic single-site hysterectomy + BSO	Mean 144 min	Hb drop 1.1 g/dL	Early postop 4.8%; conversion 0%	Mean 3.85 d	Single-site robotic safe and cost-effective
Present study (2026)	Taiwan	Retrospective	132 (VTH 89; LAVH 43)	Conventional VTH vs LAVH ± vaginectomy	121 vs 152 min (p = 0.024)	250 vs 200 mL (NS)	VTH reoperation rate 6.7% vs LAVH 0%, less overall complications in LAVH	4.2 vs 4.3 d (NS)	LAVH is safer, less painful compared with conventional VTH

Values are reported as published.

AH = abdominal hysterectomy; BSO = bilateral salpingo-oophorectomy; EBL = estimated blood loss; FtM = female-to-male; Hb = hemoglobin; LAVH = laparoscopic-assisted vaginal hysterectomy; LH = laparoscopic hysterectomy; NOTES = natural orifice transluminal endoscopic surgery; NR = not reported; NS = not statistically significant; RaLC = robot-assisted laparoscopic colpectomy; TLH = total laparoscopic hysterectomy; VH = vaginal hysterectomy; VTH = vaginal total hysterectomy.

The overall complication rates in our cohort were higher than those reported in recent robotic or reduced-port series. Several factors may explain this discrepancy. First, our study included consecutive patients over a 10-year period and used broad, predefined definitions of perioperative complications, including blood transfusion, infections, and hemorrhagic, urinary, and readmission outcomes, within 14 days. Second, our cohort included a high proportion of concurrent vaginectomies, which may reflect a more complex surgical population, although vaginectomies were not associated with increased morbidity.

This study has several strengths. To the best of our knowledge, this is the largest single-center comparative study of VTH and LAVH in individuals who are FtM transgender from East Asia. As sex-affirming surgery in Taiwan is concentrated in a few tertiary referral centers, our screened cohort likely represents a meaningful proportion of the national FtM hysterectomy caseload.^3,4,7 Compared with large administrative datasets, our chart-based cohort provided real-world perioperative information, including duration of surgery, estimated blood loss, uterine dimensions, pain trajectory, catheter duration, and time to first flatus. Consecutive enrollment over a decade and standardized institutional perioperative protocols further strengthened the internal consistency of the analysis.

This study has limitations. First, this was a retrospective, single-center study, and the surgical route was not randomized. Surgeons at our institution preferentially selected LAVH for patients with a technically more challenging anatomy, including those with a higher BMI and limited vaginal access, which is reflected in the significantly higher BMI in the LAVH group. While we considered multivariable adjustment, the limited number of complication events (n = 41 overall, with most individual subtypes occurring in fewer than 10 patients) precluded a robust adjusted analysis without the risk of overfitting. Second, long-term outcomes, including quality of life assessment, pelvic floor symptoms, and patient-reported satisfaction, were not captured. Third, all procedures were performed at a tertiary academic teaching center by surgeons with different levels of surgical experience, which may limit the generalizability of our findings to other healthcare settings. Therefore, prospective or multicenter studies with propensity-score matching are warranted to confirm these findings.

In conclusion, LAVH was associated with a lower overall perioperative complication rate and less immediate postoperative pain, although it required a longer duration of surgery than VTH in FtM transgender individuals. Improved pelvic visualization and adnexal access may facilitate surgical management and adnexal assessment, particularly when the pelvic anatomy is challenging. Prospective multicenter studies with longer follow-up durations and patient-reported outcomes are warranted to further define the optimal surgical approach to FtM sex-affirming hysterectomies.