When the necessary criteria for carrying out the surgery are met (see above), the person concerned must:

• identify a specialized clinical center (Infotrans.it offers a list of structures, present on the national territory, able to provide this type of services in the "Service Map" section)
• schedule a medical consultation with the surgeon for:
  • examination of the build and genitals
  • prostatic rectal exploration
  • ultrasound of the urinary and prostatic system
  • urodynamic study (diagnostic test that evaluates the functionality of the bladder and urethra)
  • permanent epilation (hair removal) of the base of the penis, the region between the testes and the anus (perineum) and other areas indicated by the surgeon.

Suspension of hormone therapy with oestrogens from one month before surgery to fifteen days after. In general, if you are taking any prescription medication, you should discuss it with your health provider. It may be necessary to stop taking it even several days before the surgery. Drug therapy may be resumed at the doctor's discretion.

The surgical procedure involves two phases, a demolition phase and a reconstructive phase.
The demolition phase involves the removal of the original genital organs: testes, epididymis and funicles (sacs and canals that contain spermatozoa), penis and part of the urethra (the urethra is a channel that connects the bladder with the outside and that constitutes the last tract of the urinary tract). It should be noted that the prostate is not removed. The demolition phase of the intervention irreversibly precludes the ability to reproduce. In the reconstructive phase, a new vagina (neovagina) is created between the rectum and the bladder using the skin of the penis and scrotum (the sac that encloses the testes). For this reason, it is essential to perform a definitive removal of the hairs of the skin of the scrotum before surgery in order to avoid its presence inside the neovagina. Surgeons proceed with vulvoplasty or the creation of the external genitalia (clitoris, large and small labia) and opening the urethra to the outside to allow the person to urinate. In particular, a portion of the glans (apex of the penis) is preserved during the demolition phase to build a clitoris that allows, in most cases, to have a good erotic sensitivity during sexual intercourse. At the end of the surgery, gauze soaked in disinfectant are introduced into the neovagina, a bladder catheter (cannula that allows urine to be eliminated) and a compression bandage are applied.
The person must remain in bed for a few days. Then the person is raised, the gauze, the catheter and the bandage are removed.  Vaginal dilatations are then started, by means of dilators, which will be taught by the healthcare staff and which must be performed every day, twice a day for the first months after the surgery and in the remaining part of life following the indications of the surgeon. Sexual intercourse can be resumed about two months after the surgery. It should be noted that, while in cisgender people assigned female at birth is a moist surface over the entire cavity, which increases with the lubrication of arousal, in transgender women the lubrication (always partial) will depend very much on the surgical technique used.
Penile and scrotal inversion vaginoplasty remains the first choice technique due to the reduced risk of complications.
The surgical procedure lasts about four/five hours and takes place under general anesthesia.

Penile and scrotal inversion vaginoplasty involves hospitalization that varies from 5 to 8 days, depending on the characteristics of the person and post-operative recovery.

The complications of penile and scrotal inversion vaginoplasty are divided into immediate and secondary.
Immediate complications:

• Rectum and bladder perforation. This type of injury is repaired during the surgery itself. Sometimes due to this complication it will be necessary to keep the catheter (a cannula inserted into the urethra) for a few more days or it may be necessary to divert the stool into what doctors call "colonstomy". In this case, for a few months, the intestine will be connected to the belly and the feces will end up in a special bag.
• Nerve compression. The position on the operating table can involve compression of the nerves of the leg with possible momentary loss of functionality of the same.
• Bleeding complications. These are hemorrhages (blood loss), even abundant with the need, sometimes, for transfusion.
• Infections that can be controlled with the use of antibiotics.
• Partial or complete skin necrosis of the vagina. Sometimes the skin with which the neovagina is coated can be of little vitality and eventually go into necrosis. It is essential to keep the neovaginal cavity open thanks to braces. In fact, in their absence, the cavity closes very quickly and disappears almost completely. In some cases, subsequent enlargement and remodeling of the neovagina may be necessary.
• Scarring disorders, i.e. the appearance of abundant and raised scars which, at times, require further surgery.
• Difficult urinary weaning. After removal of the urinary catheter, there may be difficulty urinating spontaneously. A new urinary catheter will then need to be repositioned for an additional period of time.
• Vesico- or urethro-vaginal fistula, i.e. the appearance of a connection between the bladder or urethra and the vagina that may require surgery to close it.

Secondary complications (delayed):

• Stenosis of the meatus. Stenosis of the meatus is a narrowing or obstruction of the urethra, the channel from which urine comes out. This stenosis must be systematically prevented with plastic surgery techniques that aim to enlarge the opening.
• Stenosis and/or reduced size of the neovagina. There may be a reduction in the circumference or depth of the neovagina. When the size is very small, there is a need for further surgery to widen the vaginal cavity.
• Rectovaginal fistula. Sometimes communications can be created between the rectum and the vagina, requiring surgery to close them.
• Functional dissatisfaction. Difficulty urinating, incontinence, pain in defecation may occur rarely.

National Health Service (NHS): no cost.
Private care: at the discretion of the professional.

Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2012; 13(4): 165-232.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. Erratum in: J Clin Endocrinol Metab. 2018; 103(2): 699. J Clin Endocrinol Metab. 2018; 103(7): 2758-2759.