1. Depth of Neovagina:

• Peritoneal Pull-Through: This technique can provide greater depth for the neovagina because it uses a portion of the peritoneum, the lining of the abdominal cavity. This can be particularly advantageous for individuals with insufficient penile and scrotal tissue, ensuring a satisfactory vaginal depth without the need for additional grafts.
• Penile Inversion: The depth of the neovagina is largely determined by the amount of penile and scrotal tissue available. Patients with less tissue may require additional grafts (e.g., skin grafts) to achieve sufficient depth.

2. Lubrication:

• Peritoneal Pull-Through: The peritoneal lining is naturally lubricated, which can result in a neovagina that self-lubricates. This reduces the need for external lubricants during intercourse and can enhance the overall quality of life.
• Penile Inversion: The neovagina created from penile skin does not naturally lubricate, so external lubrication is often necessary during sexual activity.

3. Aesthetic and Sensory Outcome:

• Peritoneal Pull-Through: Because the peritoneal lining is a different tissue from penile skin, it may provide a different aesthetic and sensory experience. Some patients report more natural-feeling results with the peritoneal technique.
• Penile Inversion: This technique often results in a neovagina that closely resembles natural female genitalia in appearance, especially when adequate penile and scrotal tissue is available. Sensation is typically good, but the experience can vary based on the individual and surgical technique.

4. Scarring:

• Peritoneal Pull-Through: There is typically less external scarring with this method, as much of the work is done internally. However, this depends on whether laparoscopic or open techniques are used.
• Penile Inversion: Scarring is usually minimal and primarily occurs at the base of the neovagina and where tissue is harvested. However, this can vary based on the patient’s healing process and the surgeon’s technique.

5. Surgical Complexity and Recovery:

• Peritoneal Pull-Through: This technique is more complex and may involve a longer surgery and recovery time. The use of abdominal tissue can increase the risk of complications such as adhesions or hernias.
• Penile Inversion: This is generally a more straightforward procedure and is the most common method used worldwide. Recovery tends to be quicker, with fewer immediate post-operative risks.

6. Applicability:

• Peritoneal Pull-Through: This technique is particularly beneficial for patients who have insufficient penile and scrotal tissue, such as those who have undergone hormone therapy for a long time or had prior surgeries that reduced available tissue.
• Penile Inversion: Suitable for most patients, especially those with sufficient penile and scrotal tissue, this method has been extensively studied and refined, making it a reliable choice for many.

7. Risk of Neovaginal Stenosis:

• Peritoneal Pull-Through: There may be a lower risk of stenosis (narrowing of the neovagina) with this technique, as the peritoneal tissue is more elastic and less prone to contraction.
• Penile Inversion: Stenosis can occur, particularly if adequate dilation is not maintained post-operatively. However, this is typically manageable with proper care.

The peritoneal pull-through vaginoplasty offers significant advantages in terms of potential vaginal depth, natural lubrication, and reduced scarring, making it a good option for patients with limited penile and scrotal tissue. However, it is a more complex procedure with a longer recovery period.

The penile inversion vaginoplasty, being more straightforward, remains the most common approach, offering a reliable and familiar technique with generally good outcomes and shorter recovery times. The choice between these techniques should be made in consultation with a skilled surgeon, considering the individual’s specific anatomy, goals, and preferences.