This one-stage procedure is done under general anesthesia in the lithotomy position (legs elevated and separated in stirrups).  All incision sites are infiltrated with zylocaine containing epinephrine, which constricts blood vessels and reduces bleeding. 

The skin of the scrotum is excised and placed aside, where electrolysis is used to eliminate the hair follicles, the skin is trimmed and sutured around a stent, then wrapped in moist gauze for later use.   A triangular incision is made on the glans (head) of the penis and another incision made completely around the distal shaft of the penis just proximal (in front of) to the coronal ridge.  This skin is elevated from the shaft and the entire penis is removed from the skin, which is left attached at the pubes.  The shaft of the penis is incised at the 3 o’clock and 9 o’clock positions all the way up to join the incisions at the glans at the top of the shaft.  The glans incision is deepened to about 5 mm and is maintained connected to the deep fascia of the upper surface of the penis which is elevated as a flap all the way down to the base of the penis. This “glans flap” will eventually become the neo-clitoris flap and is wrapped in moist gauze. 

The urethra (tube of urination) is separated from the corpora cavernosa (erectile tissues) and the corpora are dissected down to their attachment at the ischial tuberosities (the bones which we sit on), transected near their attachment and their bases over-sewn with sutures. 

The neo-clitoral flap is folded on itself and the portion of glans, now the neo clitoris, is sutured to the deep fascia at the exact location of a normal female clitoris.  The urethra is transected approximately 4.5 cm from the site of the urethral meatus (opening of the urethra) and discarded.  The remaining portion of urethra is split vertically, opened, and sutured to the deep tissues.  The end of the urethral flap is sutured to the end of the neo-clitoral flap providing a strip of pink, moist tissue in the midline of the vulva which closely simulates normal female anatomy and lubrication. 

The neo-vagina is made by creating an opening midway between the urethral opening and the anus and is extended deeply into the pelvis below the urethra and prostate and above the anterior wall of the rectum.  The cavity created extends up to the peritoneal reflection of the abdomen and can vary from 4” to 8” depending upon the height of the individual. 

The scrotal skin, which has already been sutured together into a tube, is now sutured to the end of the penile skin and this entire tube of skin is placed, inverted, into the neo-vaginal canal and packed with antibiotic impregnated vaginal packing. 

The penile skin flap is now incised in the midline of the flap, exposing the neo-clitoris, urethral flap and urethral meatus.  The apex of this incision is sutured to the upper border of the neo-clitoris and the lower end of the incision is sutured to the lower border of the urethral meatus.  The sides of the incision are sutured to the outer borders of the urethral flap, becoming the inner borders of the labia minora.  The outer edges of the penile flap are sutured to the remaining edges of the former scrotum and this becomes the labia majora. 

The entire vulva is covered with multiple layers of sterile gauze dressings which are held under mild compression with surgical underpants.  The Foley catheter which was placed in the bladder at the beginning of the surgery is connected to an over-side drainage bag and will remain for approximately 1 week.  The patient is awakened from anesthesia, placed on a stretcher and transferred to the recovery room.