Propensity-Adjusted Analysis Evaluating Early Discharge Within 2 Days After Gender-Affirming Vaginoplasty

Introduction: Although gender-affirming vaginoplasty (GAV) has become more common, optimal postoperative length of stay (LOS) remains unclear, with recommendations ranging from 3 to 9 days. As the transgender population grows, establishing standardized care is critical. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, this study examines predictors of prolonged LOS in GAV and evaluates the safety of discharging patients within 2 days. Methods: The ACS-NSQIP identified patients who underwent GAV from 2012 to 2022 and were grouped based on LOS: early (≤2 d) and prolonged (>2 d). Categorical variables were analyzed using the χ 2 or Fisher exact tests, and continuous variables with Student t test or Wilcoxon rank-sum. Logistic regression with propensity adjustment was used for multivariate analysis. Significance threshold was set at P <0.05. Results: A total of 663 patients were included. Significant differences between groups were observed for age, race, surgical specialty, and American Society of Anesthesiologists (ASA) classification ( P =0.03, 0.03, 0.001, and 0.02, respectively). Patients with prolonged LOS had higher preoperative hematocrit values ( P =0.01) and longer operative times ( P <0.0001). Early discharge had fewer complications ( P =0.03), readmissions (2 vs. 25), and reoperations (4 vs. 25), although the latter were not statistically significant. Although univariate logistic regression identified preoperative hematocrit, operative time, and surgical specialty as predictors of prolonged LOS, only operative time remained significant after multivariate adjustment. Conclusions: Among patients undergoing GAV, operative time was the strongest predictor of prolonged LOS. Significant associations with age, race, surgical specialty, ASA classification, and hematocrit levels highlight areas for targeted intervention. Discharge by 2 days was associated with significantly fewer complications, with trends toward lower readmission and reoperation rates, supporting early discharge as a safe option in selected patients.