•Penile-inversion vaginoplasty (PIV) is a gender-affirming surgery associated with significant postoperative pain.

•Pain management challenges: Higher rates of depression, anxiety, and chronic pain among the transgender population.

•Regional anesthesia has shown efficacy in similar surgeries, but its use in PIV is underexplored.

•Study Design: Retrospective, single-center study at Women’s College Hospital in Toronto (Feb 2022 - Apr 2024).

•Participants: 72 transgender females undergoing PIV.

•Group 1: 30 patients received saddle block + IT morphine.

•Group 2: 42 patients received standard analgesia.

•Primary Outcome: Cumulative opioid consumption in the first 24 hours.

•Secondary Outcomes:

•Postoperative pain severity.

•Time to first opioid request.

•Duration of stay in PACU.

•Opioid- or block-related side effects.

•Saddle Block Protocol: 0.75% hyperbaric bupivacaine and 100 mcg IT morphine.

•No difference in cumulative opioid consumption at 24 hours between groups.

•Significant improvements in short-term postoperative pain outcomes:

•Lower pain severity scores (mean and maximum) in the recovery room.

•Delayed time to first opioid request.

•Shorter duration in the PACU.

•No significant differences in nausea/vomiting rates between the two groups.

•No complications related to saddle block technique.

•Our findings suggest that a saddle block with IT morphine resulted in clinically significant improvements in short-term postoperative pain control.

•While there were no significant changes in opioid consumption, the saddle block's short-term benefits in pain management and recovery suggest a promising analgesic approach for PIV.

•Further prospective randomized controlled trials are needed to validate these findings.

•Limitations of this study include its retrospective design, the small sample size, and variability in the saddle block protocol.