Concurrent Vaginectomy at Time of Gender-Affirming Hysterectomy: A NSQIP Study

INTRODUCTION: Patients assigned female at birth may desire a vaginectomy for gender dysphoria or prior to phalloplasty. In either scenario, there is currently no standardized approach for performing vaginectomy concurrently with hysterectomy versus staged. Given that the vagina is accessed at the time of hysterectomy, a concurrent vaginectomy may be opportunistic, although it is unclear if this would result in increased risk of postoperative complications. OBJECTIVE: The objective was to compare postoperative complications between gender-affirming hysterectomies with and without concurrent vaginectomy. METHODS: Utilizing the National Surgical Quality Improvement Program (NSQIP) database from 2019–2022, a retrospective cohort of patients undergoing hysterectomy with and without concurrent vaginectomies with ICD-9/10 diagnosis of gender dysphoria were identified. Demographics, operative data, and perioperative outcomes were collected. The primary outcome measure was a composite of unplanned readmission, unplanned surgery, and major 30-day postoperative complications, as defined by the NSQIP dataset. Univariable and multivariable logistic regression models were applied to evaluate factors associated with the composite outcome. RESULTS: 1371 patients met inclusion criteria. 1351 (98.5%) had hysterectomy alone and 20 (1.5%) with concurrent vaginectomy. Most surgeries were outpatient procedures (79.7%), and the cohort’s mean age was 28.3 years (SD 7.5), mostly White (64.2%) with a mean BMI of 29.5 kg/m2 (SD 7.4). There was no difference in the rates of the composite outcome with 2.9% (n=39) in the hysterectomy group and 0% (n=0) in the concurrent vaginectomy group. Multivariable logistic regression showed that ASA Class 3 had increased odds of postoperative complications/readmissions/reoperation compared to ASA Class 1 (OR 16.61, 95% CI 1.18–1.44, p=0.03). Other factors, including concurrent vaginectomy, age, BMI, race, major medical comorbidities, and total operation time were not significantly associated with increased postoperative complications. CONCLUSIONS: In this NSQIP database, there were no differences in the rates of unplanned hospital readmissions, unplanned operations, and 30-day postoperative complications in patients with gender dysphoria undergoing hysterectomy with and without concurrent vaginectomy. With the small number of concurrent vaginectomies, future research is needed to evaluate the impact of concurrent vaginectomies (Table 1).