Design: Case series observational study.

Setting: Single tertiary medical center.

Patients or Participants: All patients undergoing hysterectomy with bilateral salpingo-oophorectomy by vNOTES for gender affirmation between February 2022 to April 2023.

Interventions: vNOTES approach was used to perform hysterectomy with bilateral salpingo-oophorectomy. Primary outcome was defined as compound complication rate including intraoperative (organ damage, bleeding, conversion to alternative approach) and post-operative (urinary tract infections, surgical site infection and vascular complications).

Measurements and Main Results: Patients’ demographic, medical history, obstetrical and gynecological history, operative and post-operative follow up (24 hours post-surgery) were collected from the electronic medical files. Pain at post-operative follow up was evaluated using visual analog scores, which ranges from 0 (no pain) to 10 (worst pain possible). The study population included 8 transgender men, all of whom were nulliparous and had undergone testosterone treatment for more than a year. Median age at surgery was 24(IQR 22-32) years and median BMI was 30( IQR 25-35) kg/m². Mean operative time of the surgery was 111 (IQR 91-143) min and none required converting from vNOTES to an alternative approach. No extensive bleeding or organ damage was reported. For one patient, there was one small vaginal laceration requiring suture. All but one patient complicated by post-operative urinary retention, were discharged the same day. On post-operative follow up, median pain score was 3 (range 1-5).

Conclusion: vNOTES approach is a feasible option for gender affirming hysterectomy with low complication rate and low associated pain scores.