Bottom surgery carries real risks, but it is not life-threatening for the vast majority of people who undergo it. Deaths within 30 days of vaginoplasty are essentially zero in published studies, and no blood clot events were recorded within 90 days of gender-affirming surgical procedures in one vascular surgery journal review. That said, complication rates vary dramatically depending on the specific procedure, and some types of bottom surgery have notably high rates of non-life-threatening complications that require follow-up procedures.
Vaginoplasty Risks
Vaginoplasty, the creation of a vaginal canal, is the lower-risk option among the major bottom surgeries. A retrospective study found no deaths, no strokes, no cardiac arrests, and no cases of septic shock or renal failure within 30 days of surgery. The most common complications tend to involve wound healing, urinary issues, and narrowing of the vaginal canal (called stenosis), which can usually be managed with dilation or minor revisions.
Rectovaginal fistula, an abnormal connection between the rectum and vagina, is one of the more serious possible complications. Some studies report zero cases, while others show low single-digit percentages. The risk depends heavily on the surgical technique and the surgeon’s experience. Most people who undergo vaginoplasty recover without a major complication, though minor issues requiring outpatient follow-up are common enough that patients should expect the possibility.
Phalloplasty Has the Highest Complication Rates
Phalloplasty, the construction of a penis using tissue grafted from another part of the body (usually the forearm or thigh), is one of the most complex reconstructive surgeries performed anywhere in medicine. It involves microsurgical tissue transfer, nerve hookups, and urethral construction, all in a single series of procedures. The complication rates reflect that complexity.
The most common problems involve the constructed urethra. A meta-analysis of forearm-based phalloplasty found urethral stricture and fistula rates ranging from 20% to 77%, with an average around 51%. Even among the most experienced contemporary surgeons, stricture rates still run between 21% and 35%. When you combine strictures, fistulas, and narrowing at the urethral opening, the all-cause urological complication rate sits around 36% in the best hands.
A urethral stricture means scar tissue narrows the urine channel, making it difficult to urinate. A fistula is an unintended opening where urine leaks out somewhere along the constructed urethra. Both are treatable, and roughly 17% to 35% of fistulas heal on their own without additional surgery. But many patients end up needing one or more revision procedures, which adds months to the overall recovery.
Surgical technique matters enormously here. One study found that patients who had a particular preparatory step (using tissue from near the vaginal area to reinforce the urethra) had a stricture rate of 37%, compared to 67% for those who did not. Newer techniques using additional tissue flaps have shown fistula rates dropping from 63% to 0% in small studies, though these sample sizes are too small to draw firm conclusions.
Metoidioplasty: A Middle Ground
Metoidioplasty is a less invasive option that works with existing tissue growth from hormone therapy rather than grafting tissue from another body site. It results in a smaller phallus but avoids the major tissue-transfer risks of phalloplasty. The trade-off is still significant: average urethral stricture rates run about 25%, and fistula rates average 21%. These are lower than phalloplasty’s numbers but still mean roughly one in four patients will need some kind of urethral follow-up.
Blood Clots and Anesthesia Risks
Any surgery lasting several hours under general anesthesia carries a risk of blood clots, and bottom surgeries are long procedures. Phalloplasty in particular can stretch across multiple staged operations. However, published data on gender-affirming surgeries specifically shows reassuringly low clot rates. One study in the Journal of Vascular Surgery found zero blood clot events within 90 days of gender-affirming procedures, even though clots did occur after other types of surgery in the same patient population. Standard prevention measures like compression devices and blood-thinning medication during recovery help keep this risk low.
Surgeon Experience Changes the Odds
The gap between complication rates at high-volume centers and less experienced programs is significant. High-volume surgeons consistently achieve lower complication rates, use less invasive approaches more often, and have lower rates of unplanned reoperations. This pattern holds across all surgical specialties, but it is especially pronounced in complex reconstructive procedures like phalloplasty, where the learning curve is steep. Choosing a surgeon who performs these procedures regularly, ideally at a center that tracks and publishes its outcomes, is one of the most meaningful things a patient can do to reduce risk.
Recovery Takes Longer Than Most Surgeries
Hospital stays for phalloplasty typically run at least five days, and full recovery extends over months. Patients generally need multiple weeks off work, and phalloplasty is often performed in stages spread across several months or longer, with each stage requiring its own recovery period. Vaginoplasty recovery is somewhat shorter but still involves weeks of limited activity and a long-term dilation routine to maintain the vaginal canal.
Revision surgeries are common enough that patients should plan for the possibility from the start. This does not mean something went “wrong” in the traditional sense. Given the complexity of these procedures, minor revisions are often part of the expected course rather than a sign of failure.
Regret Rates Are Extremely Low
One concern people have about any irreversible surgery is whether they will regret it. A systematic review in The American Journal of Surgery found that regret after gender-affirming surgery runs less than 1%. For context, regret rates after prostatectomy reach 30%, bariatric surgery up to 19.5%, breast reconstruction up to 47%, and even common life decisions like getting a tattoo have a 16% regret rate. Gender-affirming surgery has the lowest regret rate of virtually any elective procedure studied.
This does not mean the surgery is without difficulty. Complication rates, especially for phalloplasty, are high enough that patients should go in with realistic expectations about follow-up procedures and recovery timelines. But the risk profile is one of frequent manageable complications rather than frequent life-threatening ones. The surgeries are not without danger, but for most patients, the dangers are correctable and the outcomes are ones people are overwhelmingly glad they pursued.