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Page 10 of 16 Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11

TM
urethra and vaginal remnant, with the use of Firefly to visualize the cystoscope light within the vaginal
remnant transabdominally. The remnant vagina mucosa is then mobilized off the rectum or bladder and
excised, then the edges closed using a running 3-0 V-loc suture. Finally, a leak test is performed
cystoscopically and the incised perineum closed. There were no complications, including no cases of vaginal
remnant or urethral diverticulum on cystoscopy, at a mean follow-up of 9.4 months.

Robotic gender-affirming hysterectomy ± BSO
Gender-affirming hysterectomy ± BSO may be performed via open abdominal incision or via a minimally-
invasive approach: transvaginal, laparoscopic, robotic, or v-NOTES (Vaginal Natural Orifice Transluminal
Endoscopic Surgery).

Transvaginal hysterectomy was traditionally preferred due to the absence of abdominal scars compared to
open surgery and maintaining continuity of the inferior epigastric vessels and rectus abdominis, which may
[24]
be required for future phalloplasty . As with vaginectomy, transvaginal hysterectomy may be challenging
in this cohort due to the narrowed vagina under the influence of testosterone and in context of most
transmasculine patients being nulliparous with minimal uterine descent and having not engaged in vaginal
intercourse. The majority (95%) of transmasculine patients decide to have concomitant bilateral
salpingectomy with unilateral or bilateral oophorectomy . Unilateral oophorectomy may be performed in
[31]
patients wishing to retain ovarian function for future fertility or hormone reserve where there is concern of
potential inability to access gender-affirming testosterone therapy in the future.

It is suggested that transmasculine patients are more likely to undergo the minimally invasive route for
hysterectomy ± BSO [31,32] , although there are only a few studies specifically assessing outcomes of using a
robotic approach in the transgender population. Our literature search revealed four original studies
[Table 3] and one systematic review regarding outcomes of robotic-assisted TLH ± BSO.

Giampaolino et al. reported retrospective outcomes in a single-surgeon, single-center study of 20
transmasculine patients undergoing robotic hysterectomy using the multi-port Da Vinci Xi system between
2016 and 2018 . All patients were nulliparous and established on testosterone for a minimum of 6 months.
[33]
Median operative time was 90 min, with low median blood loss (90 mL) and average length of stay of 2.5
days. Pain was well controlled using the visual analogue scale (VAS). Thus, they concluded that a robotic
transabdominal approach to gender-affirming hysterectomy is feasible, safe, and effective.

In the previously mentioned study by Groenman et al., 36 patients underwent multi-port robotic-assisted
TLH ± BSO alongside robotic-assisted laparoscopic total vaginectomy as a single-stage procedure . Median
[21]
operative time was longer than in the Giampaolino study at 230 min , which may be related to the addition
[33]
of vaginectomy to the procedure. Median length of stay was 3 days.

Bogliolo et al. reported preliminary outcomes with single-port robotic-assisted TLH ± BSO in 5 patients .
[34]
Median operative time was 166 min, with a low median blood loss of 33 mL. Postoperative pain was low,
with a median VAS score of 1. Length of stay was relatively long in this group at 5 days, although the
reasons for this are unclear. The authors reported benefits of a single-port robotic approach in reducing
scarring and postoperative pain, as well as enabling a quicker return to usual activity. However, potential
downsides included challenges with instrument crossover, although encountered fewer using a robotic
approach compared with traditional laparoscopy.