COMPARING STAGED COMPREHENSIVE RECONSTRUCTION AND SELECTIVE STEP-WISE SURGERY IN FTM TRANSITION: SURGICAL, SEXUAL, AND PSYCHOLOGICAL OUTCOMES
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Abstract
Background: Female-to-male (FTM) gender-affirming surgery involves coordinated endocrine, psychological, and surgical interventions to align physical characteristics with affirmed gender identity. In India, increasing acceptance of gender diversity has led to greater demand for such care; however, comparative outcome data for different surgical pathways remain limited. Objectives: This study compares surgical, functional, psychosocial, sexual, and endocrine outcomes between two surgical pathways among FTM individuals: a combined staged approach versus a selective or step-wise approach. Methods: This multi-centre retrospective cohort study included 61 female-tomale (FTM) individuals who underwent gender-affirming surgical procedures at tertiary-level gender surgery units between 2021 and 2025. Group A underwent a combined staged pathway, including hysterectomy with or without bilateral salpingo-oophorectomy, top surgery, and phalloplasty in a single or planned two-stage sequence. Group B underwent selective or step-wise procedures, such as isolated top surgery, selective reproductive organ removal, delayed or omitted phalloplasty. Outcomes assessed included hysterectomy technique (laparoscopic vs vaginal), extent of top and bottom surgery, organ-preservation decisions, postoperative complications, sexual and marital function, psychological outcomes (PHQ-9, GAD-7, Gender Congruence and Life Satisfaction Scale), and long-term testosterone-related effects. Results: Group A demonstrated shorter overall transition timelines, higher gender congruence scores, and greater completion of masculinizing reconstruction, but had higher early postoperative complication rates, particularly following phalloplasty. Laparoscopic hysterectomy was associated with reduced blood loss, shorter hospital stay, and faster recovery compared to vaginal hysterectomy. Retention of ovaries (salpingectomy alone) reduced hypoandrogenic symptoms during interruptions in testosterone therapy but was associated with higher dysphoria related to organ retention. Phalloplasty significantly improved sexual satisfaction and penetrative function Background: Female-to-male (FTM) gender-affirming surgery involves coordinated endocrine, psychological, and surgical interventions to align physical characteristics with affirmed gender identity. In India, increasing acceptance of gender diversity has led to greater demand for such care; however, comparative outcome data for different surgical pathways remain limited. Objectives: This study compares surgical, functional, psychosocial, sexual, and endocrine outcomes between two surgical pathways among FTM individuals: a combined staged approach versus a selective or step-wise approach. Methods: This multi-centre retrospective cohort study included 61 female-tomale (FTM) individuals who underwent gender-affirming surgical procedures at tertiary-level gender surgery units between 2021 and 2025. Group A underwent a combined staged pathway, including hysterectomy with or without bilateral salpingo-oophorectomy, top surgery, and phalloplasty in a single or planned two-stage sequence. Group B underwent selective or step-wise procedures, such as isolated top surgery, selective reproductive organ removal, delayed or omitted phalloplasty. Outcomes assessed included hysterectomy technique (laparoscopic vs vaginal), extent of top and bottom surgery, organ-preservation decisions, postoperative complications, sexual and marital function, psychological outcomes (PHQ-9, GAD-7, Gender Congruence and Life Satisfaction Scale), and long-term testosterone-related effects. Results: Group A demonstrated shorter overall transition timelines, higher gender congruence scores, and greater completion of masculinizing reconstruction, but had higher early postoperative complication rates, particularly following phalloplasty. Laparoscopic hysterectomy was associated with reduced blood loss, shorter hospital stay, and faster recovery compared to vaginal hysterectomy. Retention of ovaries (salpingectomy alone) reduced hypoandrogenic symptoms during interruptions in testosterone therapy but was associated with higher dysphoria related to organ retention. Phalloplasty significantly improved sexual satisfaction and penetrative function
References
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Dr. Nivedita Reshme
Assistant Professor of OBG, Department of OBG, Ramaiah Medical College, Bengaluru, Karnataka
Dr. Varsha
Associate Professor of OBG, Department of OBG, Viswabharathi Medical College and General Hospital, Kurnool, Andhra Pradesh.
Dr. Arjun Nagaraj
Associate Professor of Urology, Department of Urology, Sapthagiri Medical College, Bangalore
