Most recent reviews [1, 2] in penile reconstruction for female-to-male patients confirm the difficulty of this peculiar surgery in terms of possible complications and limits of the final achievable outcomes, with surgery necessitating several steps and high number of revision.

Currently, there are several different operative techniques for penile reconstruction. Choices for a specific technique may be restricted by anatomical and surgical considerations [1, 3]. If the patient’s goal is a neophallus of good appearance, standing micturition, sexual sensation, and/or coital ability, patients should be clearly informed that surgery would require several separate stages, with technical difficulties and high likelihood of additional operations [1, 3].

Phalloplasty, using a pedicled or a free vascularized flap, is a lengthy, multistage procedure with significant morbidity that includes frequent urinary complications (urinary tract stenoses and fistulas (can be as high as to 20–40 %)), unavoidable donor site scarring, and occasionally necrosis (partial or total) of the neophallus (1–2 %) [1, 2, 4].

Even metoidioplasty (clitoris enlargement), which in theory is a one-stage procedure for construction of a microphallus, often requires more than one operation, and standing micturition cannot be guaranteed. Furthermore, metoidioplasty results in a micropenis, without the capacity for standing urination or sexual intercourse [1, 2]. Finally, erectile function is difficult to achieve. The radial forearm flap requires an inflatable penile prosthesis, with a considerable failure/revision rate. When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis, with no need of an inflatable implant. Flaps harvested with bone (e.g. fibula and osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection [1].

For these reasons, many female-to-male transsexuals never undergo genital surgery other than hysterectomy and salpingo-oophorectomy [5].

Theoretically, the ideal female-to-male sex reassignment surgery should be a one-stage procedure. The resulting neophallus should be cosmetically acceptable to both patient and partner, should have sufficient rigidity for vaginal penetration, and should maintain tactile sensitivity. Furthermore, scarring in the donor area should be minimized, and a neourethra constructed to allow voiding while standing [6]. Although many patients would like to be able to use the phallus sexually and/or to void while standing, others only express a desire for a good cosmetic appearance to be accepted as males in society. Unfortunately, sex reassignment surgery usually requires several operations, which are very invasive and time-consuming. Herein we present our recent experience with single-stage sex reassignment surgery in female-to-male transsexuals, where mastectomy and chest contouring are carried out with oophorectomy and hysterectomy at the same time as the pedicled pubic phalloplasty.

Since 2000 we offered one-stage sex reassignment surgery in our departments. Before surgery each underwent a complete psycho-sexological evaluation, and hormonal therapy was discontinued 1 month before the intervention for anaesthetic reason.

Two operative teams are necessary: while the first team performs subcutaneous adenomammectomy and mastopexy using the round-block technique, hystero-oophorectomy, phalloplasty and testicular prosthesis implantation are carried out by the second team (Fig. 33.1).

The mastoplasty technique used in the one-stage procedure in these patients consists of subcutaneous adenomammectomy and mastopexy using the round-block technique (Fig. 33.2). Cutaneous excision depends upon the size and volume of the breast skin. A second round-block excision for a better aesthetic result is optional, but it is always undertaken when the breast is particularly big and a large amount of skin removed. In some cases, a high degree of ptosis may require an inferior pedicle mastopexy technique, leaving only periareolar and inframammary fold scars [7].