A Mixed-Methods Analysis of Patient Decision-Making Between Penile Inversion and Robotic Peritoneal Vaginoplasty

Purpose: While penile inversion vaginoplasty (PIV) has been the gold standard, robotic-assisted peritoneal flap vaginoplasty (RPV) is increasingly used. We assessed factors influencing transgender patients’ choice between PIV and RPV. Methods: A mixed-methods study was conducted among pre- and post-operative patients at a single institution offering both PIV and RPV in 2023. Likert scales evaluated patients’ priorities. Multinomial logistic regression assessed differences in prioritization by favored technique. Interviews were analyzed qualitatively. Results: Sixteen patients were interviewed, and 30 completed the survey. Of the survey respondents, most were White (87%) and had public insurance (57%). Seventeen chose PIV (57%), 6 (20%) chose RPV, and 7 (23%) were undecided. Compared with PIV patients, RPV patients endorsed greater importance of vaginal depth (relative risk ratio [RRR] = 4.28, p = 0.031) and secretions (RRR = 2.44, p = 0.033). Qualitative findings revealed that perceived complications, particularly with RPV, and surgeon influence played a key role in decision-making. The enhanced depth attained with RPV was considered a minor benefit, while vaginal secretions were perceived both positively and negatively. Conclusions: Patients choosing between PIV and RPV weigh a range of factors, including perceived complication risks, expected vaginal depth and secretions, and the experience and recommendations of their surgeon. In our sample, fewer patients favored RPV, largely due to concerns about intra-abdominal complications and greater trust in surgeon familiarity with PIV. These findings underscore the importance of patient-centered counseling and the need for further research on surgical outcomes that are important to patients.