Determinants of Adverse Events after Gender-Affirming Vaginoplasty: a National NSQIP Analysis.

INTRODUCTION:Vaginoplasty is a high benefit but technically complex procedure that is associated with reduced gender dysphoria, improved quality of life, and high patient satisfaction. Despite increasing utilization of gender-affirming vaginoplasty, national data identifying predictors of perioperative morbidity remain limited. This study evaluates patient risk factors and morbidity following gender-affirming vaginoplasty to inform patient counseling and optimize perioperative care. METHODS:This retrospective cohort study utilizes the American College of Surgeons National Surgical Quality Improvement Program database (2011-2023) to characterize patient profiles, operative factors, and outcomes for vaginoplasty. Patients were identified using ICD-9/10 codes for gender dysphoria and relevant CPT codes. Multivariable analyses were performed to identify factors independently associated with surgical complications, readmissions, and reoperations. RESULTS:A total of 978 vaginoplasty procedures were identified. Procedure volumes increased rapidly from under 15 operations a year through 2015, to a peak of 156 procedures in 2017. Most procedures were performed by plastic surgeons (82.6%), followed by urologists (16.2%).Overall, 16.0% of patients experienced an adverse event within 30 days, including 13.0% with recorded complications, 3.6% with an unplanned readmission, and 4.9% with an unplanned reoperation.On multivariable analysis, Black race (relative risk [RR] 1.59, 95% confidence interval [CI] 1.12-2.27 relative to White patients), obese BMI (RR 1.56, 95% CI 1.04-2.34), and procedures attributed to urology (RR 1.52, 95% CI 1.09-2.11 relative to plastic surgery) were associated with higher recorded risk of adverse events, while hypertension was associated with increased risk of readmission or reoperation (RR 2.04, 95% CI 11.05-3.96). CONCLUSIONS:Vaginoplasty is a complex but rapidly growing surgical procedure with low rates of serious adverse outcomes in the 30-day postoperative period. This study characterizes short-term outcomes and risk factors in one of the largest national cohorts of gender-affirming vaginoplasty to date. Although procedures attributed to urology as the primary specialty were associated with higher recorded adverse event rates, this finding may reflect differences in case complexity or multidisciplinary practice patterns rather than surgeon specialty itself. Observed differences across patient characteristics and operative contexts highlight the importance of preoperative optimization, multidisciplinary collaboration, and standardized perioperative care.