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 specialist to:
  • examination of the body size and genitals
  • prostatic rectal exploration
  • ultrasound of the urinary tract and prostate ultrasound
  • urodynamic study (diagnostic test that evaluates the functionality of the bladder and urethra)
  • colonoscopy and barium enema (barium enema is a medical procedure used to examine the colon by using X-rays and a contrast agent)
  • permanent epilation (hair removal) of the base of the penis, the region between the testicles 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 taking any prescription medication, one should discuss it with the specialist of reference. 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 intervention 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 using a part of the intestine in addition to the skin of the penis and scrotum. We then proceed with the creation of the external genitalia (clitoris, large and small labia) and the creation of the female urethra to be able to urinate. In particular, a part of the glans penis (apex of the penis) is preserved to build a clitoris which allows, in most cases, to have a good erotic sensitivity during sexual intercourse. At the end of the surgery, a bladder catheter (cannula that allows urine to be eliminated) and a compression bandage are applied, which will be kept for a few days. About four days after the operation, the vaginal dilation maneuvers will begin and will be taught by the healthcare staff and must be performed every day following the instructions of the surgeon. Sexual activity can be resumed approximately 2-3 months after surgery.
Colon vaginoplasty is only recommended for people who do not have the ability to perform penile and scrotal inversion vaginoplasty (for example because it is reasonable to think that one will not get a sufficiently deep vagina) or who need a second surgery to stretch the vaginal canal due to of a shortening of the neovagina. Colon vaginoplasty presents more health risks than penile and scrotal inversion vaginoplasty (mortality reported in the literature up to 3-4%) as a part of the intestine must be pre-washed and it is for this reason that it is avoided unless the conditions described occur.
The surgical procedure lasts about seven hours and takes place under general anesthesia.

Colon vaginoplasty surgery involves hospitalization ranging from 7 to 14 days, depending on the characteristics of the person and post-operative recovery.

The complications of colon 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 temporary 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 dilators. 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.
• Peritonitis: when the two parts of the intestine used for the surgery do not connect (stick) properly and the feces come out.
• Intestinal canalization problems (stools do not pass well in the intestine).
• Fatal events such as death (3-4% of cases).

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 practice: at the discretion of the health provider.

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.