BACKGROUND: Penile inversion vaginoplasty is the current gold standard procedure for male-to-female transgender patients seeking gender-confirming genital surgery. Although complication data have been reported extensively in the literature, studies on patient-reported outcomes are sparse. This study aimed to report both postoperative complications and patient-reported outcomes from the largest cohort in the United States to date to undergo penile inversion vaginoplasty. Ultimately, the authors hoped to identify the predictors of postoperative complications and patient satisfaction. METHODS: A retrospective chart review of a single surgeon's experience with penile inversion vaginoplasty was performed from July of 2014 to June of 2016. Patient demographic data, postoperative complications, and patient-reported outcome data were collected. Data were correlated by binary logistic regression to determine predictors of postoperative complications and patient satisfaction. RESULTS: A total of 117 patients underwent penile inversion vaginoplasty. The most common complications were granulation tissue (26 percent), intravaginal scarring (20 percent), and prolonged pain (20 percent). Overwhelmingly, patients reported "feeling positively about their genitals" (94 percent) and "would do this operation again" (94 percent). Seventy-one percent of patients reported resolution of their gender dysphoria. The top predictors of patient dissatisfaction were intravaginal scarring, prolonged pain, excessive external scarring, loss of sensation, and hematoma/excessive bleeding. CONCLUSIONS: This is the largest study of penile inversion vaginoplasty in the United States to report on both postoperative complications and patient-reported outcomes. Despite moderate complication risk, patient satisfaction remains very high after penile inversion vaginoplasty, with the majority of patients reporting improvement of their gender dysphoria. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.