Comparing sexual outcomes and complications in Male-to-Female Gender-Affirming Surgery: penile inversion vs. robotic peritoneal vaginoplasty.

Gender dysphoria is a condition characterized by distress due to a mismatch between a person's gender identity and their assigned gender at birth. This study aimed to compare sexual satisfaction and complication rates in patients undergoing feminizing gender affirming surgery (fem-GAS) using two techniques: standard penile inversion vaginoplasty (PIV) and robotic peritoneal vaginoplasty (RPGAV). We conducted a retrospective analysis data from a prospective registry (2017-2022). All patients had at least two years of hormone therapy. Sexual satisfaction was evaluated one year postoperatively using a custom Likert scale-based questionnaire developed in collaboration with our psychosexologist. We also performed a non-systematic review of the literature on sexual outcomes following LPGAV and RPGAV. We included 19 patients (PIV = 11; RPGAV = 8). Median age at surgery was 32 years. No significant differences were observed between groups regarding preoperative characteristics or complication rates. One Clavien-Dindo grade >3b complication occurred in RPGAV group. Compared to the PIV group, patients in the RPGAV group reported significantly (p = 0.04) higher improvement in "quality of sexual intercourse" (87.5 vs. 27.3%) and "overall sexual satisfaction" (87.5 vs. 27.3%). No significant differences were found in orgasm quality, speed, or erogenous sensitivity. Although literature data on sexual outcomes remain limited, RPGAV may provide better satisfaction, particularly regarding vaginal width, depth, and lubrication, with similar complication rates. Although our study is limited by its small sample size and retrospective design, it represents the first direct comparison between these techniques. Larger prospective studies are needed to confirm these findings.