Analysis of surgical complications and risk factors in genital feminization surgery: a retrospective cohort study of 407 transgender women

Background Penile inversion vulvo-vaginoplasty with addition of a scrotal skin graft is a widely used technique in genital feminizing surgery for trans women. Aim To identify the types and frequencies of complications following genital feminizing surgery and assess associated risk factors. Methods A retrospective review was conducted on all trans women who underwent primary genital feminizing surgery at Lyon Sud University Hospital between 2008 and 2022. Inclusion criteria were age over 18 and a minimum follow-up of 1 year. Data were collected from electronic medical records and included demographic and clinical characteristics, surgical details, intraoperative events, postoperative complications, and revision procedures. Outcomes The study focused on the incidence of intraoperative, early, and late postoperative complications, as well as the frequency and types of surgical revisions. Results Among 407 patients (mean (SD) age of 38.6 (12.7) years, mean (SD) BMI of 24.7), intra-operative rectal injury occurred in 5 patients (1.2%). Early graft failure requiring revision was seen in 1%, and 23.1% underwent secondary revisions. Late complications included recto-neovaginal fistula (0.5%) and vaginal stenosis requiring revision (3.4%). Labiaplasty was the most frequent revision procedure (n = 68). Younger age was associated with increased early revisions, while BMI and smoking were not. Clinical Implications Clear, individualized preoperative counseling is essential to prepare patients for the potential need for revision surgery. Strengths & Limitations This study benefits from a large sample size and long follow-up but is limited by its retrospective design and reliance on electronic records. Conclusion Penile inversion vulvo-vaginoplasty with scrotal skin graft is a generally safe procedure; detailed knowledge of complications supports better patient counseling and informed decision-making.