The procedure starts with removal of the internal genitalia, usually via a vaginal approach. Conversion was performed only in one patient who had a large myoma of the uterus that had not been diagnosed preoperatively. The vaginal fornix is opened circumferentially, the sacrouterine ligaments detached, and after ligation of the uterine vessels, the uterus with the tubes and ovaries are removed. In some patients a laparoscopic approach was used, but we found no advantage and longer operative times. The vaginal epithelium is completely removed starting with a circumferential superficial incision with cautery at the level of the introitus and carefully continued toward vaginal end (Fig. 29.2). The peritoneum is closed a using continuous suture, and the vaginal vault completely obliterated using a spiral suture up to the perineum (Fig. 29.3). Two longitudinal parallel incisions about 2.5 cm apart are made along the “urethral plate,” starting from the native urethral meatus up to the subcoronal level of the clitoris (Fig. 29.4). The urethral plate in females is short, pulling the clitoris down o the pubis; thus, it is transacted at a subcoronal level and carefully dissected off the ventral side of the clitoral bodies up to the urethral meatus, together with its thick spongiosum. This maneuver significantly lengthens the clitoris, forming a gap between the divided edges of the urethral plate, usually 4–7 cm long (Fig. 29.5). Mobilization of the clitoral skin off the corporal bodies follows without a subcoronal incision, to provide wide exposure of the suspensory ligament; it differs from that in males because it is much bigger, starting from mid-pubis proximally and spreading from the clitoral base up to the subcoronal level distally, in this way strongly pulling the whole clitoris toward the symphysis. The skin is fully released from the clitoral body and excised, leaving only its most proximal part intact to avoid the clitoris ​falling downward (Fig. 29.6). This procedure enables additional clitoral lengthening. Clitoral skin is tacked to the remaining proximal part of the suspensory ligament at its base using a mattress suture, which helps its distribution over the maximal clitoral length dorsally. The urethra is reconstructed after placement of a Ch12 siliconized Foley catheter – the proximal part is mobilized by tubularizing and transecting the urethral plate, which is carefully fixed to the base of the cavernosal bodies (Fig. 29.5). The distal part of the neourethra at the level of the gap between the transected urethral edges is created in two different ways, depending on the size of the labia minor; if it is not well developed, a combination of a dorsal inlay buccal mucosa graft and a ventral flap created from the labia minora or clitoral skin is used (63 patients – 68 %). The buccal mucosa graft is fixed to the corporal body by quilting (Fig. 29.7). Graft length ranged from 4 to 7 cm and width from 1 to 1.5 cm. The ventral part of the distal neourethra was created using a labia minora flap (Fig. 29.8). The lower parts of the labia minora are detached from their base and mobilized upward; flap vascularity is based solely on deep and superficial external pudendal vessels. The lateral side, together with the edge of one of the labia minora is de-epithelialized and its medial epithelial surface sutured over the quilted buccal/vaginal mucosa graft as an onlay (Fig. 29.9); its proximal part is anastomosed with the vaginal mucosa graft. The edges of the subglandular parts of the prepuce are de-epithelialized and sutured in two layers, creating a wide neourethral meatus at the coronal level (Fig. 29.10). In this way the neourethra is formed. In the remaining 30 patients (32 %) the urethra was created from combined labia minor flaps bilaterally, which are detached proximally, preserving their ventral vascularity from the pudenda externa superficialis and profunda (Fig. 29.11). The flaps are pulled-up distally and one of them fixed to the ventral part of the albuginea, creating the dorsal part of the urethra (Fig. 29.12). On the other side the flap is tubularized ventrally over the contralateral one and a tube is created that is fixed to the urethra proximally and to the glans distally (Fig. 29.13).