The flap is then mobilized from the distal edge to the base: during this phase it is important to lift up the skin and the subcutaneous tissue down to the fascia of the rectus abdominis muscle in order to keep a satisfactory blood supply for the whole surface of the flap. In order to achieve a reasonable girth at the base of the phallus without tension in this area it is mandatory to fully mobilize this portion trying to preserve and include the superficial external pudendal vessels into the base of the phallus (Fig. 30.2).

Once the flap is lifted up, it is tubularized to fashion the neophallus. The success of this procedure is related to the blood supply coming from the base of the flap and to the pressure inside the phallus: for this reason the redundant fat should be removed to reduce the tension before suturing the edges.

The complete exposure of the fascia of the rectus abdominis muscle at this stage of the procedure allows performing a hysterectomy with salpingo-oophorectomy through a U-shaped incision of the fascia that allows having a good exposure of the uterus.

The abdominal incision can be closed mobilizing an advancement flap from the upper abdomen that is pulled till the base of the phallus, but in thin patients the available tissue could not be enough. For this reason, in order to close the incision with minimal tension, two lateral abdominal flaps can be rotated medially in addition to the above mentioned advancement flap. In the postoperative period the complete rest with both legs bent toward the abdomen for 48 h is mandatory to decrease the tension along the abdominal suture line, while the sutures are removed 2 weeks after surgery.

The Pryor technique is a reliable approach to create a phallus with satisfactory cosmetic results and reduce morbidity of the donor area. The positive aspect of this treatment is represented by a relative ease compared to a free flap: performing this technique the possible risks related to the complication of the microanastomosis are avoided. Furthermore the absence of scars on the arm or on the thigh (evident instead when a free flap is raised from these donor areas) represents another reason why patients choose this treatment. The negative aspect is represented by a less enthusiastic appearance of the neophallus compared to the RAP and ALT and by the need of an additional procedure to incorporate a neourethra into the phallus if the patient requires voiding while standing. To reach this purpose several techniques have been adopted and, according to the author’s experience, the radial artery urethroplasty can be a valid option [5]. With this technique the phallic urethra is reconstructed in its total length and is joined to the native urethra during the following procedure. During this procedure the skin of one side of the clitoris and an omolateral strip of skin of the major labia are mobilized and tubularized around a Foley catheter connecting the native urethra and the phallic urethra. The suture line is then covered with a Martius flap to reduce the risk of fistula formation. Garaffa et al. [5] performing this technique reported an overall satisfaction rate of 92 % with the ability to void from the tip of the phallus in all patients and minimal morbidity of the donor site. At the same time, for patients that do not want any female part left behind, the clitoris can be buried into the base of the phallus to maintain erogenous sensation and the vagina can be completely removed.

In order to improve the cosmesis and the functional outcomes of the phalloplasty, glans sculpting can be performed and, as the last step of the SRS, a penile implant can be inserted into the neophallus.