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

Background Laparoscopic hysterectomy is a core component of gender-affirming care for transgender men. However, long-term testosterone therapy can lead to anatomical and tissue changes that increase the complexity of pelvic surgery.

To describe the intraoperative complications encountered during gender-affirming laparoscopic hysterectomy in transgender men receiving testosterone therapy and discuss strategies for mitigation.

This retrospective case series includes four transgender men undergoing total laparoscopic hysterectomy at a tertiary academic center. All patients were nulliparous virgins with ≥ 2.5 years of testosterone therapy. Clinical data, intraoperative events, and management strategies were analyzed.

Intraoperative complications included posterior cul-de-sac perforation (n = 1), cervical avulsion requiring conversion to laparotomy (n = 1), bladder dome injury (n = 1), and deep vaginal lacerations (n = 4). Contributing factors were cervical atrophy, stenosis, and limited vaginal elasticity due to long-term testosterone exposure. Multidisciplinary support was required in two cases (urology and vascular surgery). All patients recovered without long-term sequelae, although one expressed dissatisfaction with abdominal scarring.

Gender-affirming hysterectomy in transgender men presents unique challenges related to testosterone-induced anatomic changes. Preoperative planning, gentle tissue handling, customized instrumentation, and patient counseling are critical to reduce risk and optimize outcomes. Similar content being viewed by others

We are most grateful to Iran University of Medical Sciences for conducting this research. Funding NA. Author information Authors and Affiliations Corresponding authors Ethics declarations Ethics approval and consent to participate The study protocol received approval from the Ethics Committee of the Iran University of Medical Sciences (Approval Code: IR.IUMS.REC.1404.171. Written informed consent for publication of clinical details and any accompanying images was obtained from all individual patients included in the case series. The cases were fully anonymized with no identifying images or clinical details relating to an individual person in the manuscript. Consent for publication All authors consent to the publication of this study. Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This study demonstrates that testosterone use preoperatively may increase risk of intraoperative vaginal laceration requiring repair. Testosterone use also correlates with increased reports of vaginal bleeding through EMR message, phone call, and clinic visit. These results contribute new evidence to include in preoperative counseling and support existing evidence surrounding the safety of gender-affirming hysterectomy 16. Our findings support the safety and feasibility of gender-affirming hysterectomies, particularly when performed laparoscopically, with very few severe complications 17. Supplementary Information Rights and permissions Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. About this article Cite this article Rokhgireh, S., Norouzi, S., Derakhshan, R. et al. Intraoperative complications during gender-affirming laparoscopic hysterectomy in transgender men receiving testosterone: a case series. BMC Surg (2026). https://doi.org/10.1186/s12893-026-03869-1 Received: Accepted: Published: DOI: https://doi.org/10.1186/s12893-026-03869-1