Intraoperative complications during gender-affirming laparoscopic hysterectomy in transgender men receiving testosterone: a case series

During the study period,2017 to 2025, a total of 149 gender-affirming laparoscopic hysterectomies were performed at our tertiary referral center. All procedures were performed by an experienced minimally invasive gynecologic surgeon with expertise in advanced laparoscopic surgery and endometriosis. An 18-year-old nulliparous transgender man with three years of testosterone therapy and secondary amenorrhea underwent total laparoscopic hysterectomy. There was no prior abdominopelvic surgical history. On pelvic examination under anesthesia, the hymen was intact, and vaginal and cervical mucosa were atrophic with a pinpoint cervical os. A hymenotomy was required to allow access to the vaginal canal. Preoperative cervical priming included sublingual misoprostol 400 mcg administered the night before and the morning of surgery. Hegar dilatators were used to achieve dilation up to size 9 to allow insertion of a Hohl uterine manipulator. During insertion of the uterine manipulator, perforation of the posterior cul-de-sac occurred. Laparoscopy was initiated, revealing no damage to bowel or other pelvic structures. The manipulator was removed under direct visualization. A uterine dilator was then used to reorient the uterus, and the defect was repaired using continuous 0-Vicryl sutures. The procedure was completed uneventfully, and the patient was discharged on postoperative day three (Fig. 1 ). Fig. 1 Perforated the posterior cul-de-sac Perforated the posterior cul-de-sac A 23-year-old virgin transgender man on three years of testosterone therapy was scheduled for laparoscopic hysterectomy. Cervical preparation mirrored Case 1. Examination revealed an atrophic cervix and intact hymen. Despite preparation, the cervix was too fragile to support tenaculum traction. Attempts to place a uterine manipulator failed due to tearing of the cervix, which eventually avulsed completely. With no viable site for safe manipulation, the surgical team converted to laparotomy. The procedure was completed successfully. Although there were no physical complications, the patient expressed significant dissatisfaction with the resulting abdominal scar (Fig. 2 ). Fig. 2 Atrophic cervix in case 2 Atrophic cervix in case 2 A 21-year-old virgin transgender man with a BMI of 16.3 and 2.5 years of testosterone therapy underwent laparoscopic hysterectomy. Bimanual examination revealed a small uterus. Due to cervical stenosis, a spiral thread was used for uterine manipulation, and the smallest cervical cup was inserted, though the fit remained suboptimal. Upon laparoscopic entry, minor bleeding from a right iliac mesentery laceration was noted. A vascular surgeon was consulted intraoperatively and, upon assessing the hematoma as self-limiting, advised continuation of the procedure with periodic monitoring. Later in the surgery, Intraoperative hematuria was noted in the urinary catheter. Upon further dissection, a 2 × 1 cm bladder dome incision was identified, distal to the anterior vaginal fornix. Due to severe atrophy of the cervical canal, the manipulator likely perforated the attenuated anterior cervical wall of the cervical canal, causing bladder injury during uterine positioning. Primary bladder repair was performed after refreshing the bladder edges. The patient was catheterized for two weeks, with successful healing confirmed via cystography (Fig. 3 ). Fig. 3 Atrophic cervical canal abrasion due to the manipulator Atrophic cervical canal abrasion due to the manipulator An 18-year-old virgin transgender man with three years of testosterone therapy and no surgical history underwent a total laparoscopic hysterectomy. The hymen was thick and required hymenotomy. The cervix and vaginal walls were atrophic. Despite gentle dilation with Hegar dilators up to size 9, insertion of the smallest Hohl cup led to deep bilateral vaginal wall lacerations. Vaginal packing controlled bleeding, and the laparoscopic hysterectomy proceeded without further incident. Following the removal of the uterus and adnexa, the lacerations were repaired with 0-Rapid Vicryl sutures. The tampon was removed on the first postoperative day, and the patient was discharged on day two. Three additional patients experienced similar injuries, all successfully managed. Table 1 Summary of intraoperative findings and complications Case No. Age (years) BMI Testosterone Duration Intraoperative Complication Management Outcome 1 18 22.4 3 years Posterior cul-de-sac perforation due to manipulator insertion Laparoscopic repair uneventful completion 2 23 28 3 years Cervical avulsion; failure of manipulator insertion Conversion to laparotomy patient dissatisfaction with scar 3 21 16.3 2.5 years Minor iliac mesentery injury and inadvertent bladder dome incision Bladder repair catheterization for 2 weeks 4 18 21 3 years Bilateral deep vaginal wall lacerations from manipulator cup Surgical repair tampon removal on POD1; discharge on POD2 Summary of intraoperative findings and complications tampon removal on POD1; discharge on POD2

Laparoscopic hysterectomy in transgender men presents specific intraoperative challenges related to testosterone-induced anatomic changes, including cervical and vaginal atrophy, stenosis, and tissue fragility. This case series highlights complications such as cervical avulsion, vaginal lacerations, and bladder injury. Preoperative counseling, careful manipulation, and consideration of customized instrumentation are essential. Further research and tool development tailored to this population may reduce complication rates and improve outcomes.

Laparoscopic hysterectomy is considered a safe and effective component of gender-affirming care for transgender men to improve gender dysphoria, psychological well-being, and quality of life; however, several technical challenges specific to this population may complicate the procedure. This case series highlights several complications encountered during laparoscopic hysterectomy in transgender men receiving prolonged testosterone therapy and emphasizes the anatomical factors that may contribute to surgical difficulty. The anatomical changes observed in transgender men receiving long-term testosterone therapy resemble those encountered in postmenopausal women with severe hypoestrogenism. Previous gynecologic literature in postmenopausal patients has demonstrated that cervical stenosis, vaginal narrowing, and tissue fragility may increase the technical difficulty of hysterectomy and the risk of genital tract injury during instrumentation. Similar mechanisms may explain the complications observed in our patients [ 9 , 12 , 13 ]. Testosterone-induced anatomical changes may lead to cervical stenosis, reduced vaginal elasticity, and increased susceptibility to tissue tearing during surgical manipulation. In our series, all patients were nulliparous and had intact hymens with severe cervical and vaginal atrophy, which significantly complicated cervical dilation and uterine manipulator placement. Uterine manipulators are widely used during laparoscopic hysterectomy because they improve visualization, facilitate uterine mobilization, and help delineate the vaginal fornices during colpotomy. However, their use may be challenging in transgender men due to narrow vaginal canals, cervical stenosis, and fragile cervical tissue [ 14 ]. In our cases, manipulator insertion resulted in several complications, including posterior cul-de-sac perforation, cervical avulsion, and deep vaginal lacerations. Similar difficulties have been reported in patients with severe genital atrophy or hypoplastic cervices, where standard manipulators may exert excessive pressure on fragile tissues [ 14 – 16 ]. One particularly important complication in our series was cervical avulsion, which required conversion to laparotomy due to the absence of a secure point for uterine manipulation. This finding highlights the importance of careful cervical traction and the potential need for alternative surgical strategies when tissue integrity is compromised. In addition, the bladder injury observed in one patient may have been related to altered pelvic anatomy and inadequate positioning of the uterine manipulator within a stenotic cervical canal. These findings suggest that distorted anatomical relationships and fragile tissues may increase the risk of injury to adjacent organs during manipulation placement. Recent studies evaluating gender-affirming hysterectomy have generally reported favorable surgical outcomes with relatively low rates of major intraoperative complications. Pando et al. described operative outcomes and practice considerations in transgender patients receiving testosterone therapy, while Alder et al. reported surgical outcomes in a consecutive series of 72 gender-affirming hysterectomies [ 17 , 18 ]. Neither study reported complications such as cervical avulsion, posterior cul-de-sac perforation, or severe vaginal wall lacerations related to uterine manipulator placement. The absence of these findings in previous reports highlights the uncommon and potentially under recognized nature of the complications observed in our series. Several preventative technical modifications may reduce complication risk in transgender patients with severe genital atrophy. These include gradual and gentle cervical dilation, preoperative cervical ripening, insertion of uterine manipulators under direct laparoscopic visualization, use of smaller or flexible manipulators, minimizing excessive traction on the cervix, and careful assessment of cervical integrity before manipulator placement. In selected cases with severe stenosis or cervical fragility, laparoscopic hysterectomy without a uterine manipulator may be considered. Potential advantages of manipulator-free laparoscopic hysterectomy include avoidance of cervical trauma, vaginal laceration, and uterine perforation. However, the absence of a manipulator may reduce visualization of surgical planes, limit uterine mobility, and increase technical difficulty during colpotomy and ureteral identification [ 5 , 19 ]. These complications may partly reflect a learning curve in this specific population, and that standard gynecologic instruments are designed for cisgender anatomy. Standard uterine manipulators were originally developed for cisgender gynecologic anatomy and may not be ideally suited for transgender men with severe testosterone-associated genital atrophy. Development of customized instruments for this population may improve surgical safety. Another important aspect of care is thorough preoperative counseling. Although laparoscopic hysterectomy is generally considered safe, patients should be informed about the possibility of intraoperative complications and the potential need for conversion to laparotomy. This is particularly relevant in transgender patients, for whom postoperative body image and scar appearance may have significant psychological implications. In our series, one patient expressed dissatisfaction with the abdominal scar following conversion to laparotomy, underscoring the importance of discussing such possibilities before surgery. Multidisciplinary preparedness, including the availability of urology and vascular surgery support, may also enhance the management of intraoperative injuries when they occur [ 13 ]. Early recognition and prompt management of such complications are essential to ensure favorable outcomes.

Transgender men assigned female at birth who identify as male represent an estimated 0.3% to 0.5% of the population [ 1 , 2 ]. Many pursue gender-affirming surgical procedures, including hysterectomy, which is associated with improved mental health and quality of life [ 3 – 6 ]. Approximately 21% of transgender men undergo hysterectomy [ 7 ]. Laparoscopic hysterectomy with bilateral salpingo-oophorectomy (BSO) is considered a safe, minimally invasive approach, offering benefits such as reduced blood loss, postoperative pain, and shorter hospital stays [ 8 – 11 ]. However, complication rates vary (4% to 41%) due to differences in study design and reporting [ 9 , 12 ]. Testosterone therapy in transgender men can induce genital atrophy, nulliparity, and virginal anatomy. These changes, including cervical stenosis, thinning of the vaginal epithelium, and reduced estrogen receptor expression, resemble a postmenopausal state and pose unique technical challenges during surgery [ 9 , 13 , 14 ]. Uterine manipulators, like the Hohl device, are typically used to facilitate laparoscopic hysterectomy by improving surgical field exposure and reducing ureteral injury risk [ 14 ]. However, in transgender men, their use may be complicated by anatomical constraints such as narrow vaginal canals and stenotic cervices. Despite the increasing number of gender-affirming hysterectomies performed worldwide, limited data are available regarding intraoperative complications related to testosterone-induced anatomical changes in transgender men. This case series describes intraoperative complications (Table  1 ) encountered during laparoscopic hysterectomy in transgender men receiving long-term testosterone therapy and discusses potential strategies for their prevention. The study protocol received approval from the Ethics Committee of the Iran University of Medical Sciences (Approval Code: IR.IUMS.REC.1404.171), and written informed consent was obtained from all participants before enrollment.

Supplementary Material 1. Supplementary Material 1.