medicina

Systematic Review
Which Is the Best Surgical Approach for Female-to-Male
Sexual Reassignment? A Systematic Review of Hysterectomy
and Salpingo-Oophorectomy Options from the
Gynecological Perspective
Mattia Dominoni 1,2, * , Andrea Gritti 1,2 , Martina Rita Pano 1,2 , Lucia Sandullo 3 , Rossella Papa 3 , Marco Torella 3
and Barbara Gardella 1,2

1 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
[email protected] (A.G.); [email protected] (M.R.P.);
[email protected] (B.G.)
2 Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
3 Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery,
University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy; [email protected] (L.S.);
[email protected] (R.P.); [email protected] (M.T.)
* Correspondence: [email protected] or [email protected]; Tel.: +39-038-250-3720

Abstract: Background and Objectives: Transgender people are defined as individuals whose gender
identity does not entirely match their sex assigned at birth. Gender surgery typically represents
the conclusive and irreversible step in the therapeutic process, especially for the impact on the
reproductive sphere. The increased awareness of gender dysphoria and the expanding array of
medical and surgical options, including minimally invasive techniques, contribute to the gradual
increase in the social impact of transgender surgery. There are several surgical techniques for “gender
assignment”, such as vaginal, laparotomic, laparoscopic, and robotic, and the novel approach of
Citation: Dominoni, M.; Gritti, A.; vaginal natural orifice transluminal endoscopic surgery to perform a hysterectomy and bilateral
Pano, M.R.; Sandullo, L.; Papa, R.; salpingo-oophorectomy (BSO). The purpose of this review is to assess the various surgical approaches
Torella, M.; Gardella, B. Which Is the (hysterectomy and salpingo-oophorectomy) for gender reassignment in order to determine the best
Best Surgical Approach for option in clinical practice for the female-to-male population in terms of surgical outcomes such as
Female-to-Male Sexual Reassignment?
operative time, surgical complication, hospital discharge, postoperative pain, and bleeding. Materials
A Systematic Review of Hysterectomy
and Methods: This systematic review includes studies from 2007 to 2024. Special consideration was
and Salpingo-Oophorectomy Options
given to articles documenting the characteristics and management of female-to-male reassignment
from the Gynecological Perspective.
surgery. Finally, eight papers were included in this review. Results: The literature analysis considered
Medicina 2024, 60, 1095. https://
doi.org/10.3390/medicina60071095
surgical techniques ranging from traditional surgery to innovative methods like vaginal natural
orifice transluminal endoscopic surgery and robotic-assisted laparoscopic hysterectomy. Vaginal
Academic Editor: Masafumi
natural orifice transluminal endoscopic surgery and the robotic approach offer potential benefits such
Koshiyama
as reduced postoperative pain and shorter hospital stays. While vaginal natural orifice transluminal
Received: 18 May 2024 endoscopic surgery may encounter challenges due to narrow access and smaller vaginal dimen-
Revised: 22 June 2024 sions, robotic single-site hysterectomy may face instrument conflict. Conclusions: The conventional
Accepted: 1 July 2024 laparoscopic approach remains widely used, demonstrating safety and efficacy. Overall, this review
Published: 4 July 2024 underscores the evolving landscape of surgical techniques for gender affirmation and emphasizes the
necessity for personalized approaches to meet the specific needs of transgender patients.

Keywords: sexual reassignment; v-NOTES; laparoscopy; robotic surgery; single-site

Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
1. Introduction
Attribution (CC BY) license (https:// Transgender people are defined as individuals whose gender identity does not entirely
creativecommons.org/licenses/by/ match the sex assigned to them at birth. Gender dysphoria is characterized by discom-
4.0/). fort due to the disparity between gender identity and the assigned sex at birth [1]. The

Medicina 2024, 60, 1095. https://doi.org/10.3390/medicina60071095 https://www.mdpi.com/journal/medicina

Medicina 2024, 60, 1095 2 of 15

frequency ranges from 1 in 30.400 to 1 in 200.000, although some recent studies suggest a
higher occurrence [2]. For these individuals, psychological counseling is often the first step
to facing daily challenges and finding harmony between body and mind [3]. Medical and
surgical interventions are justified only if they aim to alleviate or resolve suffering. Effec-
tive collaboration across various disciplines becomes crucial for transgender individuals.
Gender surgery typically represents the conclusive and irreversible step in the therapeutic
process, especially for the impact on the reproductive sphere. Prior to considering a surgical
approach, measures like psychotherapy and hormone therapy are implemented to reach
the desired phenotypic aspect [4]. Since gender-confirming surgeries can encompass a
broad range of demolitive and reconstructive procedures, not all transgender individu-
als opt for surgery [5]. Surgery is often the final step in addressing gender dysphoria,
especially for female-to-male (FTM) patients [6]. The specific surgeries for transitioning
from female to male include a subcutaneous mastectomy to create a male-type chest, a
hysterectomy or ovariectomy, and a vaginectomy. These procedures can be performed
alongside metoidioplasty or phalloplasty, using either a pedunculated or free vascular-
ized flap [7]. The increased awareness of gender dysphoria and the expanding array of
medical and surgical options, including minimally invasive techniques, contribute to the
gradual increase in the social impact of transgender surgery [4]. There are various surgi-
cal techniques for “gender assignment,” such as vaginal, laparotomic, laparoscopic, and
robotic, and the novel approach of vaginal natural orifice transluminal endoscopic surgery
(v-NOTES) to perform hysterectomy and bilateral salpingo-oophorectomy (BSO). Even if
some patients do not desire surgery because they are satisfied only with hormonal therapy,
others prefer undergoing surgery to prevent malignancy due to testosterone therapy [8]. In
addition, transgender patients may experience emotional distress during a gynecological
examination, so surgery represents a possible way to avoid such discomfort [9]. The desire
for additional genital surgery such as phalloplasty is even rarer; only a small number of
patients actually proceed with it. This kind of surgery has high complication rates and a
need for reoperation [10]. That is because the majority of transmen are satisfied with just
clitoral hypertrophy and have a fulfilling sexual life, avoiding reconstructive surgery. More
frequently, transgender men just ask for hysterectomy or BSO procedures, with the most
common request being colpectomy (the removal of vaginal epithelium). Hormonal therapy,
hysterectomy alone, and BSO procedures are associated with an increased quality of life
for these patients. Some studies have indeed demonstrated that socioeconomic status and
mental health are significantly ameliorated by the new patient condition [11].
The purpose of this review is to assess the various surgical approaches (hysterectomy
and salpingo-oophorectomy) for gender reassignment in order to determine the best option
in clinical practice for the FTM population in terms of surgical outcomes such as operative
time, surgical complication, hospital discharge, postoperative pain, and bleeding.

2. Materials and Methods

2.1. Research Strategy
The Population, Intervention, Control, and Outcome (PICO) design approach was
used to divide the main problem into four questions [12,13]. The following keywords
combined with the queries reported in Table 1 were used in a literature search considering
publications from November 2007 to March 2024, in the PubMed, Web of Science, and
Embase databases: “sex reassignment procedures”, “sexual reassignment”, “gender reas-
signment”, “transgender”, “female-to-male”, “FTM”, “transgender men”, “trans men”,
“hysterectomy”, and “salpingo-oophorectomy” along with pluralization, spelling variants
between U.S. and U.K. English, and suffixes and prefixes. Using the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) literature selection procedure
(Figure 1), we carried out a systematic search [14]. To combine the literature search, two
authors independently looked through the reviewed manuscripts’ reference lists. The
research strategy is reported in Supplementary S1. This research started on 6 March 2024,
Medicina 2024, 60, 1095 3 of 15

and this systematic review concluded on 31 March. This systematic review was registered
in PROSPERO on the 3 of May with the number CRD42024538535.

Table 1. Research queries according to PICO criteria.

Query Population Intervention Comparison Outcomes

Hysterectomy and v-NOTES/vaginal surgery reduces
1 female-to-male none
salpingo-oophorectomy operative time
Hysterectomy and Laparoscopic/robotic surgery reduce
2 female-to-male none
salpingo-oophorectomy operative time
Hysterectomy and v-NOTES/vaginal surgery reduces
3 female-to-male none
salpingo-oophorectomy intra and postoperative complications
Hysterectomy and Laparoscopic/robotic surgery reduces
4 female-to-male none
salpingo-oophorectomy intra- and postoperative complications
Hysterectomy and v-NOTES/vaginal surgery reduces
5 female-to-male none
salpingo-oophorectomy postoperative pain
Hysterectomy and Laparoscopic/robotic surgery reduces
6 female-to-male none
salpingo-oophorectomy postoperative pain
Hysterectomy and v-NOTES/vaginal surgery reduces
7 female-to-male none
salpingo-oophorectomy hospital stay
Hysterectomy and Laparoscopic/robotic surgery reduces
8 female-to male none
salpingo-oophorectomy hospital stay

2.2. Selection Criteria for Full-Text Article Review

Articles documenting the characteristics and management of female-to-male reas-
signment surgery were given special consideration. Studies were considered eligible and
included in the analysis if they fulfilled the following criteria: (I) female-to-male sexual
reassignment procedures; (II) characteristics of sexual reassignment surgery; and (III) sur-
gical management of sexual reassignment surgery. Case series, literature reviews, and
prospective and retrospective trials were taken into consideration in this review. The ex-
clusion criteria included the following: single case reports, Conference Proceedings, and
Abstracts. In addition, publications written in a language other than English were excluded.
We considered articles about the gynecological pertinence of transition excluding urological
“reconstructive” surgery. We also excluded studies that analyzed vaginectomy procedures
because they are not usually performed during this kind of surgery.

2.3. Outcome Measures

The following outcome measures of at least three items (containing three items) had
to be reported in the reviewed articles: (I) surgical procedure performed to complete hys-
terectomy and salpingo-oophorectomy for female-to-male sexual reassignment; (II) blood
loss; (III) operative time required to complete the procedures; (IV) hospital stay; (V) post-
operative pain using the visual analog scale (VAS); and (VI) the total intra-operative and
postoperative adverse events related to each surgical approach.

2.4. Risk of Bias

The risk of bias (ROB) of individual studies was assessed by the Revised Cochrane
risk-of-bias tool for randomized trials (RoB 2) [15] by two authors (M.R.P. and A.G.) and
supervised by two senior authors (M.D. and B.G.). Any disagreements were resolved
through discussion with the other authors to reach concordance. Supplementary S2 reports
both the graphical and analytical classification of the ROB for each included study.
Medicina 2024, 60, 1095 4 of 15

2.5. Data Collection

Two authors verified the data extraction form, and they each extracted data individu-
ally (R.P. and L.S.).

2.6. Novel Surgical Techniques

While vaginal surgery and laparoscopy have been around for a while, it is worth
describing the single-site procedure and v-NOTES surgery to provide the reader with
a concept of novel surgical approaches that can also be used for female-to-male sexual
reassignment.
Natural orifice transluminal endoscopic surgery (NOTES) is generally employed
for several types of procedures and in different settings of patients. It represents a new
surgical approach that reassumes and integrates several existing techniques. Specifically,
vaginal natural orifice transluminal endoscopic surgery (v-NOTES) can be performed
by positioning a v-NOTES port at the introitus, and then a complete hysterectomy and,
eventually, salpingo-oophorectomy are carried out transvaginally through endoscopic
instruments. This technique is called total vaginal NOTES hysterectomy (TVNH). The
v-NOTES port may be created from a size eight nonpowdered sterile glove, a size 50 pes-
sary, and three trocars of 5 mm. A circumferential colpotomy is performed, and the
pelvic cavity is reached [16]. Alternatively, an Alexis wound retractor may be positioned,
after colpotomy, between the deeper part of the vagina and the perineum, where it is
used to induce a pneumoperitoneum and to seal a surgical glove in which trocars may
be inserted20. However, nowadays, commercial ports are also available [17]. The endo-
scope is put through one of the holes in the fingertips of the glove previously created,
and it consents visualization of the anatomical structures, while other specific instru-
ments are used to seal and cut the uterosacral ligaments, bilateral cardinal ligaments,
transverse cervical fascia, uterine vessels, and ligamentum ovarii. Finally, the uterus
is completely detached, and the surgeon proceeds to remove the adnexal structures.
All specimens are pulled out through the vagina, which is finally closed forming the
vaginal cuff [16,18].
Another technique to perform hysterectomy and bilateral salpingo-oophorectomy is
represented by a robotic single-site procedure. After positioning the uterine manipulation
device, a first incision at the umbilical level allows for single-site port placement [19]. This
is made up of a target anatomy arrow indicator, a room for 4 cannulae, and an insufflation
valve. Two of the four cannulae are curved cannulae, whereas two are straight (one for the
endoscope and one for the bedside assistant surgeon port). Then, pneumoperitoneum is
achieved, and the patient is positioned in the Trendelenburg position, while the da Vinci
robot is appropriately situated. A trocar for the robotic endoscope and two trocars for
the robotic instruments are positioned in a triangular way. In particular, the monopolar
cautery is placed in the second arm, the curved scissor in the first arm, and an assistant’s
accessory cannula is used as access for suction/irrigator, for a multifunctional versatile
laparoscopic device. Surgical steps consist of transection of the round ligament and incision
of the retroperitoneum up to retroperitoneal spaces. Then, ureters are closed off, and the
ovarian pedicles are resected. Further steps consist of a total hysterectomy and the removal
of the uterus and adnexa through the vagina. Lastly, the vaginal cuff and access port
are closed [19]. Generally, the robotic single-port hysterectomy causes only a single scar
because it uses a single transumbilical entry point. The robotic multiport technique differs
because it has four accesses. Particularly, a Veress needle is inserted to insufflate CO2
and to create pneumoperitoneum. Then, four different trocars are put in the abdominal
cavity, one in the umbilical, two positioned about 10 cm from the optical trocar on the
transverse umbilical line, and the last positioned between the optical trocar and the right
hypochondrium [20].
 Medicina 2024, 60, 1095 5 of 15

2.7. Statistical Analysis

Categorical data are provided as counts and percentages, while continuous variables
are provided as the mean ± standard deviation or as the median (interquartile range [IQR]).

3. Results
We collected 204 papers from the preliminary bibliographic search, as reported in
Medicina 2024, 60, x FOR PEER REVIEW 6 of 16
Figure 1. A total of 15 articles were found after eliminating duplicated papers and unrelated
records (Figure 1).

Figure 1. PRISMA
Figure 1. PRISMAFlow
Flowchart
chart related
related totoResearch
Research strategy.
strategy.

Five articles were excluded since they were outside the aim of this study, dealing
with urological reconstructive procedures. Two additional studies were excluded because
they described surgical interventions not usually performed after hysterectomy and sal-
pingo-oophorectomy (i.e., colpectomy), given the potentially serious complications (ex-
tensive blood loss, vescico-vaginal, or recto-vaginal fistula). We finally considered eight
Medicina 2024, 60, 1095 6 of 15

Five articles were excluded since they were outside the aim of this study, dealing with
urological reconstructive procedures. Two additional studies were excluded because they
described surgical interventions not usually performed after hysterectomy and salpingo-
oophorectomy (i.e., colpectomy), given the potentially serious complications (extensive
blood loss, vescico-vaginal, or recto-vaginal fistula). We finally considered eight articles for
this review. The results of this research are summarized in Tables 2 and 3, where the most
significant results of the articles are reported.

Table 2. Demographic characteristics of the enrolled patients.

Origin of Patients Age BMI Parity Uterine Weight

Study and Year
Study Enrolled (Mean ± SD) (Mean ± SD) (N, %) (Mean ± SD) g

Bogliolo et al.,
Italy 10 TM 28 ± 5.7 22 ± 1.7 0 Not reported
2014 [19]

Gardella et al.,
2021 Italy 60 TM 30.62 ± 7.93 23.52 ± 4.26 0 Nor reported
[21]

Giampaolino
Median: 23.5 Median: 22.5
et al., 2021 Italy 20 TM Not reported
(19.5–28.4) (range: 21–24.7)
[20]

Obedin-Maliver,
2017 USA 33 TM 35.2 ± 69.9 27.9 ± 65.4 2 (6.1) Not reported
[22]

Jeftovic et al.,
2018 Serbia 124 TM Not reported Not reported Not reported Not reported
[23]

O’Hanlan et al.,
2007 USA 31.76 ± 7.4 27.36 ± 5.8 2 (4.9) 118.02 ± 115.6
[24]

v-NOTES: v-NOTES:
Donmez et al.,
27.57 ± 3.9 22.9 ± 2.8
2024 Turkey 83 TM Not reported Not reported
TLH: TLH:
[16]
26.6 ± 4.8 24.8 ± 4.4

VH: 29.3 ± 6.4 VH: 23.7 ± 4.4 VH: not reported

Lee et al., 2018 VH:0
Taiwan 56 TM v-NOTES: v-NOTES: v-NOTES: not
[18] v-NOTES:0
28.8 ± 7.3 24.3 ± 5.0 reported
Legend: standard deviation: SD; transgender men: TM; total laparoscopic hysterectomy: TLH; vaginal hysterec-
tomy: VH; vaginal natural orifice transluminal endoscopic surgery: v-NOTES.
Medicina 2024, 60, 1095 7 of 15

Table 3. Main results of the studies included in this review.

Intra- and
Study Patients Blood Loss, Hospital Stay, Visual Postoperative
Study and Year Procedure Operative Time
Design Enrolled mL Days Analog Scale (VAS) Complications,
n (%)
Mean ± SD minutes Mean
RSSH and Operative time: VAS: 1 (interquartile 0–3
Bogliolo et al., Retrospective Mean ± SD 30 ± Mean ± SD days
10 TM mean ± SD minutes 137 ± 32. at 1 h after surgery) 1 (10)
2014 [19] study 24 mL 2.4 ± 0.9
BSO Console time:79 ± 15. VAS: 0 (interquartile 0–0)
Docking time: 9 ± 2 m. at 24 h after surgery
Mean ± SD
Total surgical time:
Mean ± SD
Gardella et al., Prospective 143.77 ± 40.39.
Hb drop mean ± SD: VAS: 4.53 ± 1.73 at 1 h
2021 monocentric 60 TM RSSH and BSO Console time: 3.85 ± 1.26 3 (4.83)
1.1 ± 0.46 after surgery
[21] study 100.73 ± 32.26.
VAS: 2.35 ± 1.96
Docking time:
7.72 ± 2.61.
Median
Median
Operation time: 90
Median VAS: 5 (interquartile 3–8)
(interquartile 65–150).
90 (interquartile score in the immediate
Giampaolino Single-center Docking time: 15 Median
150–30) mL postoperative period.
et al., 2021 retrospective 20 TM RH and BSO (interquartile 10–25) 2.5 (interquartile Not reported
Decrease in VAS: 3 (interquartile 1–6)
[20] study minutes. 2–4)
hemoglobin levels (%): at 24 h after surgery.
Time spent in the
8 (4–16) VAS: 2 (interquartile 0–5)
operating room: 140
at 28 h after surgery.
(90–180).
Median
14 TM: TLH and 13 TLH and BSO:175
BSO (one subject (interquartile 110–30).
Obedin-Maliver, Single-center
only adnexal VH and BSO: 250
2017 retrospective 33 TM Not reported Not reported Not reported 9 (27.3)
surgery). (interquartile 175–400).
[22] cohort study
8 TM: VH and BSO. AH and BSO: 225
11 TM: AH and BSO. (interquartile
200–250).
Medicina 2024, 60, 1095 8 of 15

Table 3. Cont.

Intra- and
Study Patients Blood Loss, Hospital Stay, Visual Postoperative
Study and Year Procedure Operative Time
Design Enrolled mL Days Analog Scale (VAS) Complications,
n (%)
Mean
Mean VH: 4
Jeftovic et al., 92 TM: VH and BSO VH:51 (interquartile (interquartile
Retrospective VH: 1 (1%)
2018 124 TM 32 TM: TLH and 46–72) Not reported 3–6) Not reported
study TLH: 1 (3%)
[23] BSO TLH: 76 (interquartile TLH 4
68–90) (interquartile
3–6)
O’Hanlan et al.,
Retrospective Mean ± SD Mean ± SD Mean ± SD
2007 41 TM THL and BSO Not reported 5 (12.2)
study 74.08 ± 35.4 26.88 ± 27.7 1.07 ± 0.3
[24]
Postoperative pain second
hour after surgery,
Postoperative median ± SD
Hemoglobin drop,
21 TM: v-NOTES hospital stay, v-NOTES: 5 ± 1.56
Donmez et al., mean ± SD: mean ± SD
Retrospective and BSO days: TLH: 8 ± 1.11
2024 83 TM v-NOTES: 126.1 ± 37.9 v-NOTES: 1.5 ± 0.9 0
cohort study 62 TM: TLH and v-NOTES: Postoperative 24th hour
[16] TLH: 76.1 ± 33.9 In TLH: 1.5 ± 0.9
BSO 1.6 ± 1.01 after surgery, median ±
(0.1–3.4)
TLH: 2.9 ± 0.5 SD
TVNH: 1 ± 0.62
TLH: 2 ± 0.9
VAS at 2 h and 72 h,
median mean ± SD:
mean ± SD
42 TM: VH and BSO mean ± SD: v-NOTES: 200 v-NOTES: v-NOTES 1
Lee et al., 2018 Retrospective v-NOTES: 7.7 ±
56 TM 14: v-NOTES and v-NOTES: 144.3 ± 51.7 (interquartile 100–388) 4.9 ± 3.0 and 1.7 ± 1.0 (0.025)
[18] study 2.4
BSO VH: 149.2 ± 47.1 VH:150 mL (n = 12) VH: 5 (11.9)
VH: 7.1 ± 3.1
(interquartile 100–350) VH: 7.1 ± 1.4 (n = 42) and
2.7 ± 1.1 (n = 34)
Legend: standard deviation: SD; robotic-assisted single-site laparoscopic hysterectomy: RSSH; multiport robotic-assisted laparoscopic hysterectomy: RH; abdominal hysterectomy: AH;
bilateral salpingo-oophorectomy: BSO; transgender men: TM; total laparoscopic hysterectomy: TLH; vaginal hysterectomy: VH; vaginal natural orifice transluminal endoscopic surgery:
v-NOTES; VAS: visual analog scale; Hb: hemoglobin.
Medicina 2024, 60, 1095 9 of 15

3.1. Population
Eight retrospective cohort studies published between 2007 and 2024 were included.
A total of 425 trans-sexual men who underwent hysterectomy and bilateral salpingo-
oophorectomy for sexual reassignment were included in the studies. Regarding geograph-
ical distribution, three trials were conducted in Italy [19–21], one in Serbia [23], two in
the USA [22,24], one in Turkey [16], and one in Taiwan [18]. Table 2 also reports the
demographic characteristics of patients enrolled.

3.2. Intervention
Two studies [18,21] reported the application of robotic single-site assisted laparoscopy
for hysterectomy and salpigo-oophorectomy in 66 transgender men (TM) (15.52%). One
study [20] evaluated the application of multiport-robotic-assisted laparoscopy for sexual
reassignment procedures in 20 TM (4.7%). Total laparoscopic hysterectomy and salpingo-
oophorectomy were investigated in four studies [16,22–24] for a total of 149 subjects
(35.05%), while vaginal hysterectomy and salpingo-oophorectomy were performed in
three trials [18,22,23] in 142 (33.41) TM. Considering the Obedin-Maliver study [22], 13 out
of 14 subjects underwent bilateral salpingo-oophorectomy, while only 1 subject underwent
adnexal surgery. Finally, v-NOTES was performed in 35 TMs (8.23%) in two studies [16,18].
In only one paper, abdominal hysterectomy and salpingo-oophorectomy were performed
for the surgical procedure of sexual reassignment in 11 TM (2.58%) [22].

3.3. Comparison
No randomized clinical trial about the different surgical techniques applied to sexual
reassignment surgery is available.

3.4. Outcomes
Regarding operative time, robotic single-site procedures required a mean of 140.38 min
for hysterectomy and salpingo-oophorectomy [19,21] while multiport robotic surgery
required a median of 90 min [20]. In addition, the console time for robotic single-site
hysterectomy (RSSH) had a mean of 89.91 min. Docking time required a mean of 8.36 min
for a single-site procedure and a median of 15 min for robotic hysterectomy (RH). Three
papers [22–24] reported a mean of 75.39 min for traditional total laparoscopic surgery (TLH
and BSO), and one paper did not report the operative time in minutes [22]. Operative time
was not reported for abdominal procedures [22]. Finally, considering vaginal approaches,
traditional vaginal surgery required a mean of 100.2 min [18,22,23], but one trial did not
analyze operative time. On the other hand, two studies [16,18] reported operative time for
v-NOTES (mean of 270.4 min).
Analyzing blood loss, in one study, a robotic single-site procedure reported a mean of
30 mL, and a mean Hb drop of 1.1 g/dL was reported in another study [19,21]. Multiport
robotic surgery had a median of 90 mL [20]. One paper [22] reported a median of 175 mL
and another paper [24] reported a mean of 26.88 mL for traditional laparoscopic surgery; in
addition, one paper [16] reported a mean Hb drop of 1.5. One paper did not report blood
loss [23]. One paper reported a median blood loss of 225 mL for abdominal procedures [22].
Finally, considering vaginal surgery, two articles [18,23] reported a mean blood loss of
200 mL for the traditional vaginal approach, while one paper did not report the value of
blood loss. Two studies [16,18] reported blood loss for v-NOTES as follows: a median of
200 mL in one study [18], and a mean Hb drop of 1.5 in the other paper [16].
Two studies [19,21] reported a hospitalization of 3.15 days for the robotic single-site
approach, while RH had a median of 2.5 days [20]. Hospital stay was not reported for
the abdominal approach [22]. Three studies [16,23,24] reported a mean hospitalization
of 2.65 days for laparoscopic surgery, while one paper did not report any data [22]. Two
papers [18,23] reported a mean of 5.55 days for transvaginal surgery, and one paper did not
analyze hospitalization [22]. In the case of v-NOTES, the mean was 4.65 days, as reported
Medicina 2024, 60, 1095 10 of 15

in two trials [16,18]. In overall vaginal approaches, there were several discrepancies among
the values reported.
Three papers did not report any data about the visual analog scale (VAS) in postopera-
tive time [22–24]. Analyzing the values of the VAS in the papers considered, there were
differences in the time of VAS measurement in all the works reported in Table 2. Analyzing
the general trend in the VAS, it was clear that in all the surgical procedures, there was a
decrease in postoperative pain.
Finally, considering the overall complications (intra-operative and postoperative), the
results were the following: two papers [19,21] reported a mean of two complications for
RSSH, while one paper [20] did not report if any complications occurred for RH. For the
laparoscopic group, the mean number of complications was two in three papers [16,23,24],
while for the vaginal procedure, it was three in two papers [18,22,23]. It is important to
mention that in one paper [22], the number of complications was not differentiated among
TLH, vaginal hysterectomy (VH), and abdominal hysterectomy (AH); for this reason, it
was not computed in the previous mean evaluation. Finally, considering v-NOTES, the
mean number of complications was 0.5 (in two papers) [16,18].

4. Discussion
This study highlights the use of various surgical techniques, including laparoscopic,
robotic-assisted, transvaginal, and v-NOTES (which can be total or vaginal-assisted) hys-
terectomy and salpingo-oophorectomy. Surgical procedures vary from traditional ap-
proaches such as laparotomy, laparoscopy, or the vaginal route to more recent approaches
like v-NOTES or robotic surgery. Prior research has examined how gender affirmation
surgery affects the psycho-social and sexual functioning of transgender subjects. How-
ever, little is known about the prevalence of hysterectomy and related perioperative
adverse events in transgender patients pursuing gender affirmation treatment. In the
TM population, Bretschneider’s cross-sectional population-based survey reported that
laparoscopic hysterectomy was the most common procedure performed (57.2%), followed
by laparoscopic-assisted vaginal (20%), abdominal (15.2%), and vaginal hysterectomy
(7.7%) [25].
The inclusion of novel techniques such as v-NOTES and robotic-assisted single-site
laparoscopic hysterectomy reflects advancements in minimally invasive surgery, offering
potential benefits such as reduced postoperative pain and shorter hospital stays. Both
appear to be indicated for patients undergoing female-to-male transition surgery.
Regarding the main outcomes of this review, operation time in trans-sexual sub-
jects who underwent v-NOTES and the vaginal approach was greater with respect to
laparoscopy; in addition, also in the case of robotic surgery, the operation time was higher
than in the case of laparoscopy. On the other hand, blood loss appeared to be higher
in vaginal surgery (VH and v-NOTES) than in the laparoscopic approach (traditional la-
paroscopy and robotic surgery). As Gardella et al. suggested for the TM group, the absence
of adhesions at the abdominal wall and viscera may be an important factor in reducing
operative times. In addition, TM patients had a smaller uterus, which simplified the dissec-
tion of the anatomical planes. On the contrary, the extraction of surgical specimens may be
more difficult because of the atrophy of the vaginal wall and the narrow space [21]. The
differences in total operative time are probably derived from the different skills of surgeons,
the comorbidity of patients, and the time request for instrument organization, especially in
the case of robotic surgery and v-NOTES. v-NOTES offers a minimally invasive approach
with no visible scars, but it may be challenging because of limited access and smaller
vaginal dimensions and atrophy in transgender male patients, mainly due to the use of
androgen-based therapies. The most critical factor is the conflict among instruments, given
the narrow route of access. This can be avoided using proper endoscope selection. The
trans-sexual male vagina is often smaller because of virginity and nulliparity, and it is
atrophic because of hormonal therapy [19]. However, trans-sexual males tend to have
smaller uterine weight, length, width, and depth [24]. In addition, the v-NOTES technique
Medicina 2024, 60, 1095 11 of 15

represents a more feasible route to perform BSO compared with traditional vaginal proce-
dures when removing ovaries regardless of their position in the pelvic cavity and even in
the presence of adhesions.
Concerning the single-site approach, BMI had no negative impact on surgical out-
comes, and obesity did not appear to be a barrier to the single-site strategy. In contrast to
other traditional types of surgery, age and BMI did not appear to influence the operating
length or outcomes of patients undergoing RSSH. Gupta et al. found that younger individ-
uals with a lower BMI were more likely to have standard laparoscopy or RSSH [26]. The
single-site approach necessitates surgical experience because the movements are forced and
vision is limited. The literature data show that the reduction in operative time is correlated
to surgeon experience, and surgical skill influences all operative times, regardless of the
complexity of surgical cases [26].
Nowadays, the introduction of vaginal surgery has resulted in a longer hospital stay
than both laparoscopic and robotic surgery, with the latter having the shortest value. On
the other hand, laparoscopic, robotic, and conventional vaginal surgery are procedures
associated with the highest average number of problems after v-NOTES surgery. On
the other hand, robotic surgery is an expensive surgical procedure, but Bogliolo et al.
showed that, for benign indications, the robotic single-site technique is less expensive
than the multiport approach, saving between USD 1500 and USD 2000 for each single-site
procedure [27].
Because the articles’ various times of consideration prevented a comparison, our
review’s assessment of postoperative pain using the VAS was not comprehensive. Nev-
ertheless, research has shown that FTM tend to have lower VAS scores following surgery
compared with laparoscopy, and they also tend to report reduced postoperative pain when
using the v-NOTES approach. Assessing the complication rate, no difference was found
between the two groups [16]. Additionally, comparing VH and v-NOTES, the latter is
associated with less postoperative pain [18].
Regarding the possible benefits of minimally invasive surgery in FTM, particular
attention was paid to scar-less surgery, especially considering the psychological well-being
of TM. Furthermore, patients who underwent single-site surgery reported a considerable
improvement in their well-being because the operation had less of an impact on their view
of their bodies, as well as a large rise in personal satisfaction with the quality of the surgical
scar. Not only does the presence of a single scar improve cosmetic results, but it may reduce
the risk of inferior epigastric or circumflex ileac artery transection, which is important in
eventual reconstructive surgery [19,28]. The multiport robotic technique constitutes a viable
alternative surgery for TM patients for several reasons such as better triangulation and a
higher range of movements because of the greater distance between laparoscopic accesses;
however, it does not obtain the same cosmetic result as single-port surgery because of the
greater number of accesses, which are also causes of major pain and recognizable signs
of surgery [20]. Nowadays, v-NOTES is a possible scar-less approach that may reduce
the need to resort to abdominal surgery, preserve the integrity of the abdominal wall,
avoid useless scars, and ensure a good cosmetic result. This surgical technique combines
the benefits of laparoscopic surgery and the cosmetic outcomes, using the advantages of
vaginal surgery [28]. As surgical options continue to evolve, personalized approaches
adapted to individual needs will be crucial in optimizing outcomes and improving the
overall quality of care for transgender patients undergoing gender reassignment surgeries.
It is of paramount importance that surgeons have significant experience with tradi-
tional laparoscopy in order to navigate the learning curve for laparoscopy; nevertheless, the
robotic technique appears to be easier because of its enhanced dexterity, wristed equipment,
and enlarged three-dimensional vision. For this reason, younger surgeons can manage
the learning curve associated with the robotic single-site method. Furthermore, from a
future perspective, young surgeons may find the application of the vaginal approach to be
more common from a minimally invasive standpoint by using the v-NOTES technique in
conjunction with a minimally invasive laparoscopic approach.
Medicina 2024, 60, 1095 12 of 15

In addition, it is interesting to evaluate the minimally invasive approach proposed for

TM also in cisgender women (CW), in order to evaluate the possible difference or benefit
between the laparoscopic and vaginal routes. In our previous study [21], we compared
single-site and multiport robotic surgery in TM and CW. The surgical times for TM and
CW differed statistically (total operative time = 0.0152, docking time = 0.0011, console
time = 0.0001, anesthetic time = 0.0061). There was also a significant difference in the body
mass index (p = 0.0169), uterine volume (p = 0.0001), and prior comorbidity (p = 0.0001)
aside from TM. The two groups did not differ in terms of conversion rate, reduction in
hemoglobin and blood loss, length of hospital stay, or intra- and postoperative problems.
When compared with other purposes for benign disease, RSSH for sex reassignment looks
to be a safe, practical, and affordable choice with a significant reduction in surgery time.
Furthermore, it seems that the advantages of this scar-lees surgical technique are more
noticeable in TM. Similarly, Chen et al. reported that TM had a much shorter operat-
ing duration than CW with menstrual problems, although they used a different surgical
technique [29].
Analyzing the traditional laparoscopic approach between TM and CW, O’Hanlan
et al. [24] reported that the operating times for TM surgeries were shorter (mean 74 min
versus 120 min, median 57.5 min versus 116 min, p < 0.001), there was less blood loss (mean
27 mL versus 107 mL, median 20 mL versus 50 mL, p < 0.001), and the uterine weight
was lower (mean 118 g versus 167 g, median 89 g versus 140.5 g, p < 0.001). Both the
overall (12.2% vs. 8.3%) and re-operative (4.9% vs. 4.3%) complication rates did not differ
statistically from one another. Because of this, patients who identify as trans-sexual can
have satisfactory surgical outcomes with a total laparoscopic hysterectomy.
In addition, analyzing hysterectomies performed by the traditional vaginal route or by
v-NOTES in CW, Merlier et al. [30] reported that v-NOTES can be carried out as a suitable
and safe substitute for VH. Except for the rate of salpingectomies or adnexectomies, which
was significantly higher in the v-NOTES group (with 100% of patients undergoing one of
these procedures compared with 60% in the vaginal route group; p < 0.001), there was no
difference in the surgical outcomes between the two groups in CW. To our knowledge, no
paper has reported a comparison between TM and CW with the v-NOTES approach. On the
other hand, a previous paper compared the vaginal route for hysterectomy in TM and CW.
In total, 42% of cisgender women and 24% of transgender men had vaginal hysterectomies.
The estimated blood loss was lower in TM (P5.002), but the difference between the gender
groups was no longer significant when uterine size and hysterectomy route were taken
into account. The number of patients reporting problems did not differ between the groups.
Vaginal hysterectomy should be taken into consideration when planning surgery for TM
because it is a feasible operation for this demographic, as the authors of [22] attested.
Finally, the surgical approaches involved in FTM sexual reassignment may involve
pelvic floor structures. Nowadays, the literature data about the role of surgery in the risk of
developing pelvic floor dysfunction in TM is poor and not complete or decisive. Pelvic floor
dysfunction is becoming a more significant problem in transgender persons. This increasing
prevalence could be caused by a variety of factors, including comorbidities, socioeconomic
level, and hormone medication, which may have an effect on the organization of connective
and adipose tissue, pelvic organ support systems, and pelvic floor muscle mass. Surgery
for sexual reassignment may affect the pelvic floor and result in pelvic floor dysfunction,
which may lead to prolapse of the pelvic organs, urine incontinence, problems with sexual
pleasure, or problems with overall wellness [25,31,32]. Furthermore, androgen therapy
produces epithelial thinning and suppresses estrogens in a manner similar to that of
estrogen deprivation. This leads to anatomical changes in the vulvar, urethral, vaginal
wall, and bladder tissues, which cause genital dryness, friable vaginal epithelium, frequent
urination, and urgency [33,34].
Medicina 2024, 60, 1095 13 of 15

Limitations and Strengths

The main limitation of this study was the small number of articles selected. In addition,
the analyzed data were derived from retrospective works, and a comparison was difficult
because of the different measurement and analysis methods. However, the number of trans-
gender male patients who undergo hysterectomy and BSO is now increasing, which will
lead to a greater number of studies available in the future. Another potential drawback was
the inability to take into account the lifestyle choices, hormonal therapy, and demographic
traits that could play a major role in determining the surgical strategy. Furthermore, this
review did not address the psychological effects of surgery or the aesthetic result for the
TM who underwent it.
This research was the first to examine the potential surgical options for gender reas-
signment surgery in terms of surgical results and comorbidities. This analysis provides
us with a broad overview of the options that are currently available to ensure that the
FTM population has a customized and trustworthy approach that is based on the unique
characteristics of each subject.

5. Conclusions
This review highlights the different gynecological surgical techniques available for
sexual reassignment procedures, from traditional approaches to innovative methods like
v-NOTES and robotic-assisted procedures. This review clarifies that laparoscopic surgery
results in shorter operating times, less blood loss, and shorter hospital stays. Nonetheless,
the risk of surgical complications is significantly decreased by vaginal surgery, particularly
v-NOTES. In order to ensure excellent surgical success, high quality of life, and psycho-
social well-being, new techniques like v-NOTES in gender reassignment surgery will likely
enable us to combine the advantages of the laparoscopic technique with the benefits of
vaginal surgery and an aesthetic outcome.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/medicina60071095/s1, S1: Research strategy link. S2: Risk of bias
in the included studies.
Author Contributions: Conceptualization: M.D. and B.G.; methodology, L.S. and R.P.; investigation,
A.G. and M.R.P.; writing—original draft preparation A.G. and M.R.P.; writing—review and editing,
M.D. and M.T. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflicts of interest.

References
1. Davis, L.C.; Diianni, A.T.; Drumheller, S.R.; Elansary, N.N.; D’ambrozio, G.N.; Herrawi, F.; Piper, B.J.; Cosgrove, L. Undisclosed
financial conflicts of interest in DSM-5-TR: Cross sectional analysis. BMJ 2024, 384, e076902. [CrossRef]
2. Meier, S.C.; Labuski, C.M. The demographics of the transgender population. In International Handbook on the Demography of
Sexuality; Baumle, A.K., Ed.; Springer Science + Business Media: Dordrecht, The Netherlands, 2013; pp. 289–327.
3. Ghiasi, Z.; Khazaei, F.; Khosravi, M.; Rezaee, N. Physical and psychosocial challenges of people with gender dysphoria: A content
analysis study. BMC Public Health 2024, 24, 16. [CrossRef] [PubMed]
4. Coleman, E.; Radix, A.E.; Bouman, W.P.; Brown, G.R.; de Vries, A.L.C.; Deutsch, M.B.; Ettner, R.; Fraser, L.; Goodman, M.; Green,
J.; et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int. J. Transgender Health 2022, 23
(Suppl. 1), S1–S259. [CrossRef] [PubMed]
5. Schechter, L.S. Gender Confirmation Surgery: An Update for the Primary Care Provider. Transgender Health 2016, 1, 32–40.
[CrossRef] [PubMed]
Medicina 2024, 60, 1095 14 of 15

6. Manrique, O.J.M.; Bustos, S.S.; Bustos, V.P.; Mascaro, A.A.; Ciudad, P.; Forte, A.J.; Del Corral, G.; Kim, E.A.M.; Langstein, H.N.
Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned. Plast. Reconstr. Surg.—Glob. Open
2021, 9, e3478. [CrossRef]
7. Monstrey, S.; Ceulemans, P.; Hoebeke, P. Sex Reassignment Surgery in the female-to male Transsexual. Semin. Plast. Surg. 2011,
25, 229–244. [CrossRef] [PubMed]
8. Braun, H.; Nash, R.; Tangpricha, V.; Brockman, J.; Ward, K.; Goodman, M. Cancer in Transgender People: Evidence and
Methodological Considerations. Epidemiol. Rev. 2017, 39, 93–107. [CrossRef] [PubMed]
9. Dutton, L.; Koenig, K.; Fennie, K. Gynecologic Care of the Female-to-Male Transgender Man. J. Midwifery Womens Health 2008, 53,
331–337. [CrossRef]
10. Kang, A.; Aizen, J.M.; Cohen, A.J.; Bales, G.T.; Pariser, J.J. Techniques and considerations of prosthetic surgery after phalloplasty
in the transgender male. Transl. Androl. Urol. 2019, 8, 273–282. [CrossRef] [PubMed]
11. Kilmer, L.H.; Chou, J.; Campbell, C.A.; DeGeorge, B.R.; Stranix, J.T. Gender-Affirming Surgery Improves Mental Health Outcomes
and Decreases Anti-Depressant Use in Patients with Gender Dysphoria. Plast. Reconstr. Surg. 2023, 11 (Suppl. 6), 1. [CrossRef]
12. Methley, A.M.; Campbell, S.; Chew-Graham, C.; McNally, R.; Cheraghi-Sohi, S. PICO, PICOS and SPIDER: A comparison study of
specifcity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv. Res. 2014, 14, 579. [CrossRef]
[PubMed]
13. Aslam, S.; Emmanuel, P. Formulating a researchable question: A critical step for facilitating good clinical research. Indian J. Sex.
Transm. Dis. AIDS 2010, 31, 47–50. [CrossRef] [PubMed]
14. Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The
PRISMA Statement. J. Clin. Epidemiol. 2009, 62, 1006–1012. [CrossRef]
15. Higgins, J.P.; Altman, D.G.; Gøtzsche, P.C.; Jüni, P.; Moher, D.; Oxman, A.D.; Savovic, J.; Schulz, K.F.; Weeks, L.; Sterne, J.A.; et al.
The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011, 343, d5928. [CrossRef] [PubMed]
16. Donmez, E.E.; Elci, E.; Elci, G. Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin
transgender men. Minim. Invasive Ther. Allied Technol. 2024, 33, 163–170. [CrossRef]
17. Lerner, V.T.; May, G.; Iglesia, C.B. Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in
Gynecologic Minimally Invasive Surgery. JSLS 2023, 27, e2022.00082. [CrossRef] [PubMed]
18. Lee, Y.L.; Hsu, T.F.; Jiang, L.Y.; Chao, H.T.; Wang, P.H.; Chen, Y.J. Transvaginal Natural Orifice Transluminal Endoscopic Surgery
for female-to male Transgender Men. J. Minim. Invasive Gynecol. 2019, 26, 135–142. [CrossRef] [PubMed]
19. Bogliolo, S.; Cassani, C.; Babilonti, L.; Gardella, B.; Zanellini, F.; Dominoni, M.; Santamaria, V.; Nappi, R.E.; Spinillo, A. Robotic
Single-Site Surgery for female-to male Transsexuals: Preliminary Experience. Sci. World J. 2014, 2014, 674579. [CrossRef]
20. Giampaolino, P.; Della Corte, L.; Improda, F.P.; Perna, L.; Granata, M.; Sardo, A.D.S.; Bifulco, G. Robotic Hysterectomy as a Step
of Gender Affirmative Surgery in female-to male Patients. J. Investig. Surg. 2021, 34, 645–650. [CrossRef] [PubMed]
21. Gardella, B.; Dominoni, M.; Bogliolo, S.; Spinillo, A. Surgical outcome for robotic-assisted single-site hysterectomy (RSSH) in
female-to male reassignment compared to its use in benign gynecological disease: A single center experience. J. Robot. Surg. 2021,
15, 579–584. [CrossRef]
22. Obedin-Maliver, J.; Light, A.; De Haan, G.; Jackson, R.A. Feasibility of Vaginal Hysterectomy for female-to male Transgender
Men. Obstet. Gynecol. 2017, 129, 457–463. [CrossRef]
23. Jeftovic, M.; Stojanovic, B.; Bizic, M.; Stanojevic, D.; Kisic, J.; Bencic, M.; Djordjevic, M.L. Hysterectomy with Bilateral Salpingo-
Oophorectomy in female-to male Gender Affirmation Surgery: Comparison of Two Methods. BioMed Res. Int. 2018, 2018, 3472471.
[CrossRef] [PubMed]
24. O’Hanlan, K.A.; Dibble, S.L.; Young-Spint, M. Total Laparoscopic Hysterectomy for female-to male Transsexuals. Obstet. Gynecol.
2007, 110, 1096–1101. [CrossRef] [PubMed]
25. Bretschneider, C.E.; Sheyn, D.; Pollard, R.; Ferrando, C.A. Complication rates and outcomes after hysterectomy in transgender
men. Obstet. Gynecol. 2018, 132, 1265–1273. [CrossRef]
26. Gupta, N.; Blevins, M.; Holcombe, J.; Furr, R.S. A Comparison of Surgical Outcomes between Single-Site Robotic, Multiport
Robotic and Conventional Laparoscopic Techniques in Performing Hysterectomy for Benign Indications. Gynecol. Minim. Invasive
Ther. 2020, 9, 59–63. [CrossRef]
27. Bogliolo, S.; Ferrero, S.; Cassani, C.; Musacchi, V.; Zanellini, F.; Dominoni, M.; Spinillo, A.; Gardella, B. Single-site versus multiport
robotic hysterectomy in benign gynecologic diseases: A retrospective evaluation of surgical outcomes and cost analysis. J. Minim.
Invasive Gynecol. 2016, 23, 603–609. [CrossRef]
28. Jallad, K.; Siff, L.; Thomas, T.; Paraiso, M.F.R. Salpingo-Oophorectomy by Transvaginal Natural Orifice Transluminal Endoscopic
Surgery. Obstet. Gynecol. 2016, 128, 24. [CrossRef]
29. Chen, I.; Nguyen, V.; Hodge, M.; Mallick, R.; Gagné, H.; Singh, S.S.; Choudhry, A.J.; Xie, R.; Liao, Y.; Wen, S.W. Surgical outcomes
for transgender men undergoing hysterectomy. J. Obstet. Gynaecol. Can. 2020, 42, 25–30. [CrossRef] [PubMed]
30. Merlier, M.; Collinet, P.; Pierache, A.; Vandendriessche, D.; Delporte, V.; Rubod, C.; Cosson, M.; Giraudet, G. Is V-NOTES
Hysterectomy as Safe and Feasible as Outpatient Surgery Compared with Vaginal Hysterectomy? J. Minim. Invasive Gynecol. 2022,
29, 665–672. [CrossRef]
Medicina 2024, 60, 1095 15 of 15

31. Melloni, C.; Melloni, G.; Rossi, M.; Rolle, L.; Carmisciano, M.; Timpano, M.; Falcone, M.; Frea, B.; Cordova, A. Lower Urinary
Tract Symptoms in Male-to-Female Transsexuals: Short Terms Results and Proposal of a New Questionnaire. Plast. Reconstr. Surg.
Glob. Open 2016, 4, e655. [CrossRef]
32. Combaz, N.; Kuhn, A. Long-Term Urogynecological Complications after Sex Reassignment Surgery in Transsexual Patients: A
Retrospective Study of 44 Patients and Diagnostic Algorithm Proposal. Am. J. Urol. Res. 2017, 2, 38–43.
33. Krakowsky, Y.; Potter, E.; Hallarn, J.; Monari, B.; Wilcox, H.; Bauer, G.; Ravel, J.; Prodger, J.L. The effect of gender-affirming
medical care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front. Cell. Infect. Microbiol.
2022, 11, 769950. [CrossRef] [PubMed]
34. Clark, A.L.; Goetsch, M.F. Genitourinary syndrome of menopause: Pathophysiology, clinical presentation, and diferential
diagnosis. Clin. Obstet. Gynecol. 2024, 67, 13–26. [CrossRef] [PubMed]

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