Surgical Outcomes by Route of Gender-Affirming Hysterectomy [ID 3783]

INTRODUCTION: There is no established recommendation for the optimal surgical route for patients undergoing hysterectomy for gender affirmation. To evaluate conventional beliefs around the feasibility of the vaginal approach, this study compares outcomes between vaginal and laparoscopic hysterectomy to guide shared decision-making and improve evidence-based surgical care for transgender and gender-diverse patients. METHODS: We conducted a retrospective chart review of patients undergoing gender-affirming hysterectomy at the University of California, San Francisco, from 2015 to 2025. Demographic variables, including uterine weight, testosterone use, and insurance type, were analyzed alongside outcomes, including operative time, estimated blood loss, and perioperative complications. Fisher’s exact test and Kruskal–Wallis test were used to compare outcomes between vaginal and laparoscopic hysterectomy groups. RESULTS: Of 230 patients, 112 (48.7%) underwent vaginal hysterectomy, and 118 (51.3%) underwent laparoscopic hysterectomy. The overall complication rate was 13.9% (n=32). No statistically significant differences were found between approaches in complication rates, 30-day readmissions, or emergency department visits. Operative times were longer for laparoscopic hysterectomy (mean 117.8±35.2 minutes) compared to vaginal hysterectomy (mean 80±26.6 minutes), while estimated blood loss was lower in the laparoscopic group (mean 81.7±99.6 versus 109±103.1 mL). CONCLUSIONS/IMPLICATIONS: Vaginal and laparoscopic approaches demonstrate comparable outcomes in gender-affirming hysterectomy, with differences in operative time and estimated blood loss that may inform individualized surgical decision-making. The vaginal approach is a safe and effective choice, supporting expanded surgical options for transgender and gender-diverse patients.