Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male

Abstract

For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.

Imaging in Gender Affirmation Surgery

“…Finally, if penile or testicular prostheses are employed, common complications include infection, implant failure, erosion through soft tissue, and implant migration [ 19 ]. For unclear reasons, the rate of prosthesis failure is higher in postoperative transgender patients compared to cis-gender individuals requiring prosthesis [ 20 , 21 ].…”

“…The interpreting radiologist should also remain alert of the possibility of obstruction and fistula. Evidence of testicular or penile prosthetic infection or migration should also be evaluated [ 3 , 14 , 20 ].…”

Phalloplasty: understanding the chaos

“…Most commonly, bilateral, anteriorly based labia majora flaps are used for the skin of the scrotum [ Figure 4] [19] . The placement of testicular implants is straightforward and has been well described elsewhere [76] .…”

“…Although a few centers use osteocutaneous flaps or place cartilage grafts primarily at the time of phallic construction [21,74] , for most patients, the ability to achieve penile rigidity sufficient for penetrative intercourse will rely on the placement of an erectile prosthesis. Despite enthusiastic demand from some patients and short-term data indicating efficacy, considerable variation in philosophy and the technical specifics regarding erectile prostheses are driven by high rates of eventual prosthetic infection and/or extrusion and of prosthesis malfunction [76] . Analysis of existing data by some centers leads them to conclude that the risks outweigh the benefits, and they advise patients in advance that they do not recommend erectile prosthesis placement.…”

“…For trans-males, some centers place a single inflatable cylinder or semi-rigid element, especially for RFFF phalloplasties. Other centers may place dual-cylindered devices, especially for ALT phalloplasties, where the weight and bulk of the flap makes rigidity difficult with a single chamber [76] . In addition, attempts to reduce the extrusion rate have focused on anchoring the prosthesis to the pubis with Mitek anchors [77] and/or encasing the prosthesis within a sleeve of acellularized dermal matrix, or other biocompatible material [76] .…”