Since our initial experiences when we perform male-to-female surgery, we do so with two surgical teams who work in the same time and sometimes all together: two surgeons are placed on either side of the patient, and another two surgeons are positioned between the legs (Table 11.1; Fig. 11.2) [9, 10].

Before the beginning of the surgery, we start by marking on the pubic-umbilical line, which is done for correctly locating all the structures. Another drawing is done at the scrotal level, heart shaped with the apex pointing towards the anus, which represents the scrotal flap (Fig. 11.2). The correct distance between the anal verge and the apex of the “heart” is 1–2 cm. The length of the scrotal flap varies between 12 and 15 cm. It is crucial that when measuring the length of the scrotal flap, we take into consideration that there must not be tension at the apex of the skin flap after suturing. For the circumcision, another line is drawn in order to leave 1 cm of skin at the periglandular level.

The drawing is then continued for the length of the penis on the ventral side (Fig. 11.3).

The sterile drop that we put on the patient is provided with a hole to give the possibility of inserting a finger in the anus. This manoeuvre is determinant in avoiding rectal injuries during dissection. It consists of a water-repellent drape which can cover the legs and has also a fluid collection pouch.

Power star bipolar scissors (Johnson & Johnson Medical GmbH) are very useful especially to dissect the urethra.

The surgical illuminator provides cool, shadowless, deep cavity lighting. Flexible or malleable, it may be attached to most retractors or instruments, using two-side adhesives. Once attached to the instrument, its thin, low-profile takes minimal space.

When connected to an ACMI cable and standard, 300 Watt xenon light source, it lights the cavity as if a fluorescent light were switched on inside the patient. The LightMat® brings bright, cool light where it is needed – into the surgical cavity, improving visualisation, helping surgeons save time and avoid complications.

The V-Loc™ wound closure device (COVIDIEN) is a new technology that eliminates the need to tie knots, so you can close incisions up to 50 % faster without compromising strength and security. The V-Loc™ device offers secure, fast and effective incision closure for our patients: in particular, the absence of knots into the neovagina avoids painful dilatation manoeuvres in the postoperative period.

A medium (4 × 12 cm) or small (3 × 9.5 cm) adjustable vaginal stent (Porges) is important to maintain the neovaginal canal after our surgical procedures. It is a compression stylet for vaginal surgery, consisting of a sealed silicone shell filled with polyurethane foam, fully adjustable by inflation (Fig. 11.4; Table 11.2).

The surgeon positioned between the legs incises the skin along the line drawned on the perineal area. The first step is the bilateral orchiectomy with dissection and suturing of both the spermatic cords at the level of the external inguinal rings. The peritesticular fat is preserved for later use as support for the labia majora. The dissection is extended through the subcutaneous tissue until reaching the corpus spongiosum, which is then isolated from the corpora cavernosa. The urethra is severed at the pubic simphysis, and the terminal portion is spatulated and longitudinally split on the ventral midline so as to obtain a Y-shape.

Only now do we insert the catheter (Fig. 11.5) [9].

The position of the neo-urethral meatus is ensured by applying a knot at the apex of the fork (Liguori’s stitch). This becomes the reference point for positioning the neoclitoris, which will be surrounded by urethral mucosa. The urethral bulb is carefully removed in order to prevent its bulging during sexual arousal and pain during penetration. Running absorbable suture of the two margins of the urethra decreases the risk of postoperative bleedings.

Surgery continues with the removal of the corpora cavernosa’s roots, facilitated by the placement of a traction point at the apex of the roots, paying attention to the vascular bundle. These manoeuvres allow the exposure of the perineal tendinous centre, which is then opened while monitoring the integrity of the rectal wall through the anal access provided by the sterile drop. At this point the surgeon creates in the rectoprostatic space a neo-cavity which will accommodate the neovagina: we usually use a LigaSure device to sever the subcutaneous tissue, while sight is aided by an aspirator provided with a light source.

The knowledge of the rectoprostatic space has been acquired, thanks to a large number of pelvic postoperative MRIs administered in order to have a precise anatomical visualisation of all the structures involved in the surgery. These allow for measurements of inclination, length and distance of the neovagina and its neighbouring organs (Fig. 11.6) [11, 12].

When the catheter’s balloon is palpated by the operator, it means that the neovagina is deep enough (Fig. 11.7). The fixation of the cul-de-sac in the rectoprostatic space is crucial to prevent the neovagina from prolapsing. Two Prolene double needle stitches are passed through the wall of the neo-cavity (anterior and posterior walls or the lateral walls), and both the ends of the sutures are passed through the penile-scrotal flap at the level of the cul-de-sac. In order to prevent prolapse, we also put another stitch through the scrotal flap and the subcutaneous tissue in proximity of the Denonvilliers’ fascia incision (Table 11.3).

The two surgeons positioned on either side of the patient begin by performing incisions following the line previously drawn, and the penile flap is obtained by isolation from the corpora cavernosa, taking care to preserve vitality of the skin. By means of positioning a tourniquet around the corpora cavernosa and the urethra, it is possible to obtain a hydraulic erection using a butterfly needle and infusing saline solution into the corpora cavernosa. This is done to facilitate the blunt dissection of Buck’s fascia from the tunica albuginea. Buck’s fascia is identified and incised at paraurethral level to avoid damage of the dorsal nerves of the penis. This procedure is done in order to permit the creation of a sensitive neoclitoris.