 Penile inversion vaginoplasty is the most commonly performed gender affirming surgery globally. Despite the wide range of practices among surgeons, there is general agreement on certain aspects such as the use of extra genital tissues for vaginal canal slash apex creation, clitoral hood and inner labia minora elevation, neoclitoral neurovascular bundle elevation, and perioperative hormonal management. Additionally, there is considerable variability in pathway length of stay, which ranges from one day to nine days. Some surgeons are transitioning away from complete cessation of estrogen during the perioperative period and instead using partial or continued estrogen therapy. This article was authored by Devin Kuhn, M.D., M.S.E., Shane D. Morrison, M.D., M.S., Martin P. Morris, M.D., M.B.E., and others.