For the new vagina to be formed, the operative technique involves several procedures. After the usual bilateral orchidectomy, the penis is dissected into its anatomical entities: corpora cavernosa, the glans cap with the urethra and the neurovascular bundle and the vascularized penile skin. The corpora cavernosa are removed up to their attachments to the pubic bones. Remnants of the corpora cavernosa, i.e. erectile tissue, are destroyed in order to prevent their postoperative erection which can hinder sexual intercourse. The glans cap is divided into two parts: ventral and dorsal. Reduction of the dorsal part of the glans is performed by an excision of the central ventral tissue, leaving lateral sides of the glans intact. Lateral excisions on the glans are not recommended in order to avoid injury of the neurovascular bundle which enters into the glans cap lateroventrally. However, lateral sides are deepithelialized and sutured to obtain the conical shape of the neoclitoris. The ventral half of the glans, which remains attached to the urethra, is used to form the neocervix at the bottom of the new vagina. The urethra is spatulated, including the bulbous part, and used for creation of the mucosal part of the neovagina. The urethra of the female type is formed. The neoclitoris is fixed above the new urethral meatus. In reconstructing the new vagina, the skin of the penile body and prepuce (if present) are fashioned into a vascularized island tube flap. It is very important to obtain a very long vascularized pedicle of the tube. Therefore, the level of the incision is approximately 2 cm above the base of the mobilized penile skin. Only here, the existing loose subcutaneous tissue permits formation of a long vascularized pedicle. At the base of the pedicle, a hole is made for the transposition of the urethral flap. On the dorsal side of the skin tube flap, only the skin is incised, whereas the vascularized subcutaneous tissue remains intact. The urethral flap is embedded into the skin tube. The bottom of the tube is closed with the distal part of the urethra and the remaining ventral half of the glans cap after its inner side deepithelialization. The tube, consisting of skin and urethral flap, is inverted, thus forming the new vagina.

In cases of insufficient penile skin (a small and/or circumcised penis), there is a disproportion between the short skin tube and the long urethral flap. The vagina can then be formed in two ways. The proximal part at the bottom of the vagina is formed only from the urethral flap which initiates secondary epithelialization. If the length of the tube pedicle is insufficient for placing the tube into the perineal cavity, the new vagina is created using the vascularized urethral flap and free penile skin grafts. In this case, the vascularized urethral flap plays the key role in creating the new vagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder and rectum. The neovagina is fixed to the sacrospinous ligament, usually to the right one. The sacrospinous ligament is palpated between the ischial spine and coccyx. After exposure of the ligament, long-handled Deschamps ligature carrier preloaded with 2-0 absorbable suture is used to pierce the ligament medially to the ischial spine. Care must be taken not to place the suture close to the ischial spine in order to prevent injury of the pudendal nerve and internal pudendal vessels.

Also, the suture must not be placed behind the ligament to prevent injury of the pudendal artery whose course is variable and may be found at any distance from the ischial spine. Both ends of the suture are brought out. One of them is passed through the skin part, while another one is passed through the urethral part of the neovagina and tied. This way, vaginopexy to the sacrospinous ligament is achieved and the neovagina is placed deeply in the perineal cavity.

Vulvoplasty involves creation of the labia minora and majora. The remaining part of the base of the penile skin is employed to form the labia minora, which are sutured to the deepithelialized area of the neoclitoris. This way the neoclitoris is hooded with the labia minora. The excessive scrotal skin is removed and the remaining part is used to form the labia majora.

Perivaginal Jackson-Pratt drain is left for 3 days. Urethral catheter and vaginal packing (condom filled with soft material) are removed on the 7th postoperative day. Vaginal stenting is dependent on the type of the new vagina. If the vagina is formed from sufficient penile skin, the vaginal stent is applied during the night for 6 weeks. If the vagina is formed from insufficient penile skin or from free penile skin flaps, the stent is applied continuously day and night for 3 months (Figs. 12.1, 12.2, 12.3, 12.4, 12.5, 12.6, 12.7, 12.8, 12.9, 12.10, 12.11, 12.12, 12.13, 12.14, 12.15, and 12.16).