Robot-Assisted Peritoneal Flap Vaginoplasty Versus Penile Inversion Vaginoplasty for Gender Affirming Surgery.

BACKGROUND: Direct comparison of robot-assisted peritoneal flap (PF) to penile inversion (PI) vaginoplasty for gender affirming surgery is absent. OBJECTIVES: We sought to compare these two techniques to aid patient decision-making. MATERIALS AND METHODS: A retrospective case-control study of patients who underwent primary PI (N = 40) or PF (N = 40) vaginoplasty by one of two surgeons at a single center from 2020 to 2023 was conducted. RESULTS: PF yielded greater vaginal depth at 1 month (18 cm [13-20] vs. 15 cm [4.0-23], p < 0.01) and 6 months (18 cm [11-20] vs. 15 cm [2.5-19], p < 0.01) compared to PI, despite shorter preoperative phallic skin length. No rectal injuries occurred with PF versus three with PI. PF had less estimated blood loss than PI (p < 0.01). Length of stay, operative time, vaginal stenosis, vault granulation tissue, and transfusion rates were similar among groups. DISCUSSION: This early institutional experience demonstrated that primary PF yielded longer perioperative vaginal depth compared to PI with short-term stability at 6 months, despite shorter preoperative phallic skin length. Complication rates were similar among techniques. CONCLUSION: Both PF and PI are safe options for gender affirming vaginoplasty with low risk of complications that warrant ongoing use and future study.