Does Trainee Involvement in Genital Gender Affirmation Surgery Affect Surgical Outcomes?

INTRODUCTION: Very few opportunities for fellowship training in gender affirmation surgery exist for gynecology-trained surgeons. Very little is known about patient outcomes when trainees are participating in these types of surgeries as there are no published reports in any specialty. OBJECTIVE: The objective of this study was to describe and compare patient outcomes following feminizing genital gender affirmation surgery (FgGAS) between a cohort of patients preceding and following the start of a gynecology-focused fellowship program. METHODS: This was a retrospective cohort study from a single tertiary care referral center. Patients who underwent FgGAS between 2015 and 2023 who had at least 12 months of postoperative in-office follow-up were included in the study. Cases occurring before the fellowship was started (December 2015 to August 2020) were compared to cases occurring after the fellowship began (September 2020 to August 2023). Three fellows were trained during the study period and all three completed a 12-month fellowship. A graduated surgical model was used to train all three fellows. RESULTS: A total of 350 patients underwent FgGAS during the study period and met inclusion criteria: 165 patients undergoing surgery preceding the fellowship and 185 patients following the commencement of the program. The mean (SD) age and BMI of the cohort were 38 (15) years and 26.4 (5.0) kg/m2, respectively. Patients who underwent surgery following the start of the fellowship were younger (35 vs 40 years, p=0.002) and had lower BMI (25.9 vs 26.9 kg/m2, p=0.04) than those who underwent surgery preceding the integration of fellows. Otherwise, the cohorts were similar. Of the entire cohort, 216 (61.1%) underwent either vulvoplasty alone (n=32) or vulvoplasty with vaginoplasty (n=184), 78 (22.3%) underwent a secondary revision surgery following an index vulvoplasty/vaginoplasty, and 58 (16.6%) underwent a bilateral orchiectomy. The median (range) surgical time for all patients was 168 (31–217) minutes and did not differ statistically between the groups. There were also no differences in intraoperative or postoperative complications. Postoperative wound dehiscence did occur more frequently in the fellowship cohort; however, this was not statistically significant (17.8% vs 9.0%, p=0.09). Patients who had vulvoplasty/vaginoplasty surgery with fellow involvement were more likely to undergo subsequent revision surgery 6 to 12 months following their index procedure, 20.0% vs 15.1%, p=0.04. This finding remained statistically significant once age, BMI and incidence of postoperative wound dehiscence were controlled for: adjOR 3.3 95% CI 1.0,11.6, p=0.04. CONCLUSIONS: Integrating gynecologic fellows into the surgical care of patients undergoing feminizing genital gender affirmation surgery does not increase intraoperative or postoperative complications. Fellows, however, are associated with a higher incidence of subsequent revision surgery, which speaks to the need to ensure good supervision of trainees participating in the cosmetic aspects of these surgeries.