Postoperative complications following gender-affirming vaginoplasty: an acs nsqip study

To describe severe and overall 30-day complications following gender-affirming vaginoplasty using a large multicenter database.

This is a cross-sectional study of transgender individuals who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and CPT codes for male-to-female vaginoplasty (CPT 55970, 57291, 57292, and/or 57335). Cases were excluded if patients were <18 years old, assigned female at birth, had prior surgery within 30 days of the index surgery, did not have general anesthesia, or had an operative time <60 minutes. Surgical procedures were stratified by Clavien Dindo Grade 0-2 or 3-5. Clavien Dindo scores 3-5 included: surgical intervention, life-threatening complication requiring ICU management, or death. We conducted multivariable analysis controlling for age, race, ethnicity, BMI, year of surgery, ASA class, smoking status, diabetes, hypertension, steroid use, preoperative hematocrit, concomitant non-genital surgery, and operative time.

We identified 488 cases eligible for inclusion in this study. The mean age of the cohort was 37.5 (SD) and race distribution was: 71.1% White, 15.2% Black, 5.5% Asian/Pacific Islander, and 8.2% Other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent non-genital surgery was performed in 17% of cases. Median operative time for all cases was 271 (IQR 214-344) minutes. There were no reported deaths in the 30-day period (Clavien Dindo Grade 5) and 5.5% (n=27) of cases had a Clavien Dindo score of 3-4. On multivariate analysis, BMI and higher ASA class were associated with higher odds of having a Clavien Dindo 3-4 complication (adjOR 2.9, CI 1.32-4.21, p=0.01 and adjOR 1.23, CI 0.56-2.57, p=0.05, respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 9% (n=46) of cases. The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: BMI (aOR 9.81, CI 1.77-22.13, p=0.005), higher ASA class (aOR 3.23, CI 1.23-9.03, p=0.003), diabetes (aOR 5.39, CI 1.42-20.45, p=0.006), and hypertension (aOR 3.63, CI 1.26-10.47, p=0.01). The reoperation rate was 4.7% (n=23), with no significant patient factors associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma.

In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications are rare, occurring in 5.5% of patients. The majority of patients experience minor or no complications following surgery.