Outcomes Of Inﬂatable Penile Prosthesis Insertion in 247 Patients Completing Female to Male Gender Reassignment Surgery
Marco Falcone, Giulio Garaffa, Arianna Gillo, Dino Dente, Andrew N. Christopher, and David J. Ralph
FIRST PUBLISHED: October 20, 2017 – BJU International
For individuals undergoing a female-to-male gender transitional surgery, one important goal is the creation of a realistic, fully-functioning penis that allows the patient to stand while urinating and penetrate a partner during sexual intercourse.
Erection rigidity in female-to-male patients can be challenging, as there is no substitute for the corpora cavernosa.
Penile prosthesis (PP) implantation is an option, although there are concerns about surgically anchoring the PP, maintaining its stability, and preventing erosion.
This study discussed the outcomes of PP implantation after total phallic reconstruction in patients with gender dysphoria.
Patients and Methods
The study population comprised 247 female-to-male transsexuals who had inflatable penile prostheses implanted between January 2001 and October 2015 at one medical center.
- 157 patients underwent a free-flap radial artery phalloplasty (RAP)
- 90 patients underwent umbilical pubic flap phalloplasty (PFP)
Including revision surgeries, 328 PPs were implanted in 247 patients. PPs were either three-piece or two-piece inflatable devices.
Data were collected using clinical records, operative notes, and a non-validated ad hoc questionnaire administered 12 months after surgery.
PP implantation took place at least a year after initial phallic construction, after the probable development of cutaneous sensation and the correction of any urethral complications.
Three-piece PPs were implanted in two stages. First, the reservoir and a single large testicular prosthesis were inserted. Three months later, in the second stage, the prosthesis was anchored to the pubic bone. The testicular prosthesis was removed, and the penile prosthesis pump was placed in its capsule. The device was then connected to the previously placed reservoir. The original testicular prosthesis was inserted into the contralateral labia.
The patients ranged in age from 21 to 69 years at the time of their surgery, with an average age of 38 years. No significant comorbidities were reported.
After a median follow up of 20 months, 140 of the patients (56.6%) still had their original devices.
The remaining 107 patients (43.3%) required revision surgery due to infection of the device (21 patients or 8.5%), mechanical failure (38 patients or 15.4%), or patient dissatisfaction (48 patients or 19.4%).
Twelve patients needed more than one revision surgery.
The overall 5-year survival rate of the implants was 78%. There was no statistical significance in survival between the different types of prostheses.
One hundred four patients completed the patient and partner satisfaction questionnaire. Of these, 83% had satisfactory phallic sensation. All patients could cycle their device, 77% were having penetrative intercourse, 61% had achieved orgasm, and 88% were fully satisfied with the cosmetic and functional outcomes. Sixty percent of partners were satisfied.
The authors noted that while 88% of patients were satisfied, only 77% were having penetrative intercourse. The latter result could be explained by lack of partners.
When comparing the technique and results in this study to previous studies, the authors noted the following:
1. Only two- and three-piece hydraulic PPs should be implanted, as the risk of erosion is lower than with semirigid devices.
2. A polyethylene terephthalate sock and cap, or alternative, should be used to house the cylinders.
3. PFP represents a significant risk factor for PP dysfunction and revision.
4. The life expectancy of an implant in a neophallus is shorter than that in a patient without gender dysphoria, due to a “lack of protective constituents” of the penis and the fact that these patients tend to be younger and more sexually active. Patients should know that multiple revisions may be needed.
5. While satisfaction rates were high, the most common complaints were an inability to have penetrative intercourse and difficulty reaching orgasm. Partner satisfaction rates should be researched further.
PP implantation is the “only solution to guarantee the rigidity necessary to engage in penetrative sexual intercourse in gender dysphoric patients,” the authors wrote. However, the procedure is “highly complex” and has high complication rates, so it should be performed by experienced surgeons in large-volume, dedicated centers.