Reconstructive urologists’ approach to penile inversion vulvovaginoplasty: Multicenter outcomes and volume–outcome relationship

Introduction Gender-affirming vulvovaginoplasty is a key procedure for transfeminine individuals, yet robust multicenter data on outcomes and complications remain limited. This study evaluated perioperative outcomes, postoperative morbidity, and factors associated with complications following penile inversion vaginoplasty with scrotal grafting.Methods We conducted a retrospective multicenter cohort study including patients undergoing primary vulvovaginoplasty or vulvoplasty between 2006 and 2024 across three tertiary centers. Associations between outcomes and clinical variables, including surgical volume, were assessed using multivariate analyses.Results A total of 553 patients were included. Mean operative time was 4.3 h and hospital stay was 8 days. Early complications occurred in 40% of patients, mostly low grade (17% grade ≥ III). Late complications were observed in 41% of cases, approximately half requiring surgical revision. Neovaginal stenosis was the most frequent late complication. Younger age and longer operative time were associated with early complications. Surgical volume was the main determinant of both early and late complications, with a significant reduction beyond 50 procedures. Limitations include retrospective design, heterogeneous follow-up, and lack of patient-reported outcomes.Conclusions This large multicenter series confirms that penile inversion vaginoplasty is associated with substantial but predominantly minor morbidity. The volume–outcome relationship highlights the importance of surgical experience and supports centralization of care in high-volume centers. Prospective studies incorporating patient-reported outcomes are warranted.