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Comparison of Surgical Complication Rates in Combined Hysterectomy and Masculinizing Gender Affirming Bottom Surgery Versus Staged Approach: A National Analysis
Marissa Kent, MD, Oluwaseun Adebagbo, BS, John Park, PharmD, Macie Gettings, BS, Sasha Nickman, BS, Benjamin Rahmani, BS, Ryan Cauley, MD, PhD
Beth Israel Deaconess Medical Center, Boston, MA, USA
Background: Hysterectomy is one of the most commonly performed genital gender affirmation surgeries in transmasculine and nonbinary patients, and can be performed in a staged manner or at the time of masculinizing genital surgery (1, 2). Prior studies have suggested that adopting a combined approach carries an increased likelihood of complications (3, 4). However, relatively small patient cohorts with varying results were included. The aims of this study were to (1) define the cohorts of patients undergoing gender affirming masculinizing genital surgery with and without concurrent hysterectomy and (2) to determine the additive risks of concurrent procedures.
Methods: Patients with a diagnosis of gender dysphoria who underwent masculinizing gender-affirming bottom surgery (GABS) from 2012 to 2022 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The following principal Current Procedural Terminology (CPT) codes: 55980 (metoidioplasty), 55175, 55180 (scrotoplasty, simple or complex) or 56805 (clitoroplasty) were included. Patients were stratified by having a concurrent hysterectomy. Univariate analysis was done to compare the wound, mild systemic, severe systemic and all-cause complication rates between a single GABS and joint procedure with hysterectomy of any approach.
Results: A total of 179 patients were included. Patients who had concurrent hysterectomy were, on average, seven years younger than patients who had single GABS (p<0.01). The two groups were similar in comorbid conditions, such as obesity classification, diabetes, and smoking status. The median total operative time nearly doubled in patients who had a combined hysterectomy (p<0.01). There were no differences in wound, mild, severe systemic, or all-cause complications between the two groups.Conclusion: Our study’s results suggest that hysterectomy at the time of masculinizing GABS can be safe when performed in appropriately selected patients. While these combined procedures take longer, as expected, their complication rates are similar. These findings can inform preoperative counseling, while also offering reassurance to surgeons. A combined approach can improve efficiency, access to care, and improve patient satisfaction.
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| TABLE 1. Patient Characteristics by Combined Bottom GAS |
| Single Bottom GAS | Concurrent Hysterectomy | p-value |
| n = 179 | 159 | 20 | - |
| Age, mean ± SD | 39.26 ± 13.68 | 32 ± 11.98 | 0.01 |
| Sex/Gender, n (%) |
| Female | 39 (24.53) | 6 (30.00) | 0.73 |
| Male | 117 (73.58) | 14 (70.00) | |
| Non Binary | 3 (1.89) | 0 (0.00) | |
| Race/Ethnicity |
| | | |
| | | |
| White | 100 (62.89) | 7 (35.00) | 0.01 |
| Black/ African American | 24 (15.09) | 5 (25.00) | |
| Asian | 8 (5.03) | 3 (15.00) | |
| Non-White Hispanic | 16 (10.06) | 3 (15.00) | |
| American Indian/ Alaska Native | 0 (0.00) | 1 (5.00) | |
| Unknown | 11 (10.06) | 1 (5.00) | |
| BMI Classification, n (%) |
| Normal - Overweight (<30) | 100 (64.10) | 13 (65.00) | 0.89 |
| Class I Obesity (30-35) | 35 (22.44) | 5 (25.00) | |
| Class II Obesity (≥35) | 21 (13.46) | 2 (10.00) | |
| ASA Classification, n (%) |
| 1-No Disturb/2-Mild Disturb | 23 (14.56) | 10 (50.00) | 0.0004 |
| 3-Severe Disturb | 101 (63.92) | 9 (45.00) | |
| 4-Life Threat/5-Moribund | 34 (21.52) | 1 (5.00) | |
| Preoperative Comorbidities, n (%) |
| Diabetes | 10 (6.29) | 0 (0.00) | 0.25 |
| Hypertension | 25 (15.72) | 2 (10.00) | 0.50 |
| Smoker | 20 (12.58) | 0 (0.00) | 0.09 |
| COPD | 4 (2.52) | 0 (0.00) | 0.47 |
| Surgical Specialty, n (%) |
| Urology | 47 (29.56) | 0 (0.00) | 0.04 |
| Plastic Surgery | 107 (67.30) | 19 (95.00) | |
| Gynecology | 4 (2.52) | 1 (5.00) | |
| General Surgery | 1 (0.63) | 0 (0.00) | |
| Elective Case | 154 (96.86) | 20 (100.00) | 0.42 |
| Principal Procedure, n (%) |
| Metoidioplasty [55980] | 78 (49.06) | 19 (95.00) | 0.002 |
| Clitoroplasty [56805] | 31 (19.50) | 1 (5.00) | |
| Scrotoplasty; Simple [55175] | 26 (16.35) | 0 (0.00) | |
| Scrotoplasty; Complicated[55180] | 24 (15.09) | 0 (0.00) | |
|
| | | |
| Concurrent Procedure, n (%) |
| Vaginoplasty | 3 (1.89) | 0 (0.00) | 0.54 |
| Urethroplasty (any code) | 36 (22.64) | 9 (45.00) | 0.03 |
| Vaginectomy or Vulvectomy | 14 (8.81) | 11 (55.00) | <0.0001 |
| Muscle Flap/Tissue Rearrangement | 19 (11.95) | 2 (10.00) | 0.79 |
| Intra/Perioperative Course |
| Operative Time, min, (median, IQR) | 154 [85, 350] | 305.5 [265.5, 340.75] | 0.003 |
| Postoperative Course |
| Hospital LOS, days (median, IQR) | 1 [0, 6] | 2 [1, 2.75] | 0.25 |
| Still in Hospital >30 days | 2 (1.26) | 0 (0.00) | 0.61 |
| Readmission (within 30 days) | 8 (5.03) | 0 (0.00) | 0.30 |
| Return to OR | 13 (8.18) | 0 (0.00) | 0.18 |
| Abbreviations: BMI: body mass index; ASA: American Society of Anesthesiologists; mFI-5: 5-factor modified frailty index; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease. * Hispanic included those reported as white or unknown/not reported under race, **Other races include Asian, Asian, Native Hawaiian or Pacific Islander, and Native Hawaiian or Other Pacific Islander. n, frequency; SD, standard deviation; %, percentage; A p-value of <0.05 was considered statistically significant. |
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| TABLE 2. 30-day Perioperative Variables by Combined Bottom GAS |
| Single Bottom GAS | Concurrent Hysterectomy | p-value |
| n = 179 | 159 | 20 | - |
| Wound complications† | 23 (14.47) | 0 (0.00) | 0.07 |
| Superficial SSI | | | |
| Deep SSI | | | |
| Organ Space SSI | | | |
| Dehiscence | | | |
| Mild systemic complications‡ | 10 (6.29) | 2 (10.00) | 0.53 |
| Bleeding requiring transfusion | | | |
| Sepsis | | | |
| DVT | | | |
| Severe systemic complications§ | 1 (0.63) | 0 (0.00) | 0.72 |
| All-cause complications* | 29 (18.24) | 2 (10.00) | 0.36 |
| †Wound complications | Superficial surgical-site infection (SSI), deep SSI, organ/space SSI and wound dehiscence. ‡Mild systemic complications | Pneumonia, bleeding requiring transfusion, DVT requiring therapy, sepsis, urinary tract infection, renal insufficiency; §Severe systemic complications | Pulmonary embolism, unplanned intubation, ventilator support for greater than 48 h, renal failure requiring dialysis, cerebrovascular accident, cardiac arrest, myocardial infarction, septic shock and death |
| | | |
| within 30 days. All-cause complications | all of the variables included in wound, mild systemic and severe systemic complications. n, frequency; SD, standard deviation; %, percentage; A p-value of <0.05 was considered statistically significant. |
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