Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications

Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know

OBJECTIVE

To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS).

METHODS

A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis.

RESULTS

The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure.

CONCLUSION

Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

Surgical Outcomes at a Single Institution of Infrapubic Insertion of Malleable Penile Prosthesis in Transmen

OBJECTIVE

To describe our technique for the infrapubic approach for malleable penile prosthesis (MPP) insertion after phalloplasty in transgender men and review surgical outcomes.

METHODS

The infrapubic prosthesis insertion technique involves a horizontal incision anterior to the pubic symphysis, allowing dissection of the neophallus tract and anchor site on the pubic symphysis. Surgical outcomes by a single surgeon using a Spectra or Genesis MPP between October 2017 and May 2022 were retrospectively reviewed. Complications were categorized into erosions, infections, device detachment, device malposition, pain or activity limitation, urethral injury, and flap loss. Implant survival kinetics were assessed by evaluating time to surgical revision.

RESULTS

Forty patients underwent infrapubic MPP insertion; 35 patients had a prior radial forearm free flap (RFFF) and 5 had a prior anterolateral thigh flap (ALT) phalloplasty. Of 30 patients who maintained follow-up, mean follow-up was 34.9 months. Complications were not mutually exclusive, with 7 implant detachments from the anchor site, 3 malpositions, 2 with pain/activity limitation, and 1 infection. Surgical revision was required in 12/30 patients (40%). There were no neophallus erosions, flap loss, nor urethral injuries. More complications occurred with the Spectra (9/17 or 53%) than the Genesis MPP (3/13 or 23%), but this was not statistically significant (P = .10).

CONCLUSION

Infrapubic insertion in transmen after phalloplasty using commercially available MPPs is safe compared with other post-phalloplasty penile prosthesis insertion techniques, with similarly high surgical revision rates. Further study of techniques is needed to improve outcomes after penile prosthesis insertion in transmen.

Insertion of inflatable penile prosthesis in the neophallus of assigned female at birth individuals: a systematic review of surgical techniques, complications and outcomes

Devices such as inflatable penile prostheses (IPP) can be used to achieve erectile rigidity after phalloplasty in assigned female at birth (AFAB) individuals. The approach to inserting an IPP in a neophallus is different and more challenging compared to that of an anatomical penis due to the absence of anatomical structures such as the corpora cavernosa, and the more tenuous blood supply of the neophallus and reconstructed urethra. In addition, the ideal surgical techniques and devices for use in the neophallus have not been defined. This review systematically summarises the literature on the insertion of IPP in the neophallus of individuals AFAB. In particular, the described techniques, types of devices used and peri-operative and patient-reported outcomes are emphasised. An initial search of the PubMed database was performed on 16 September 2022 and an updated search was performed on 26 May 2023. Overall, 185 articles were screened for eligibility and 15 studies fulfilled the inclusion criteria and were included in the analysis. Two studies reported outcomes on the zephyr surgical implant 475 FTM device and the others reported outcomes on the Boston Scientific AMS 600/700TM CX 3-piece inflatable, AMS AmbicorTM 2-piece inflatable, Coloplast Titan® or Dynaflex devices. Overall, 1106 IPPs were analysed. The infection rate was 4.2%-50%, with most studies reporting an infection rate of <30%. Mechanical failure or dysfunction occurred in 1.4%-36.4%, explantation was required in 3.3%-41.6%, and implant revision or replacement was performed in 6%-70%. Overall, 51.4%-90.6% of patients were satisfied and 77%-100% were engaging in sexual intercourse. An IPP in a neophallus is an acceptable option to achieve rigidity for sexual intercourse. However, this challenging procedure has good reports of patient and partner satisfaction despite significant risks of complications.

Feasibility of an External Erectile Prosthesis for Transgender Men Who have Undergone Phalloplasty

Introduction

Transgender men interested in achieving penetration after phalloplasty are currently limited to internal devices and makeshift supports. More options are needed to support sexual penetration after phalloplasty.

Aim

This study was designed to assess the feasibility of an external erectile prosthesis (the Elator) for transgender men who have undergone phalloplasty and wish to use their neophallus for sexual penetration, assess how the device affected the sexual experiences of men and their partners, and identify any side effects and concerns.

Methods

Transgender men and their partners were provided with an erectile device to use for one month. They were surveyed at 4 time points: enrollment, measurement, receipt, and after using the device, using a combination of pre-existing and device-specific measures.

Main Outcome Measure

The primary outcome was whether men found it feasible to use an external penile prosthesis for sexual penetration after phalloplasty – defined as interest in, and willingness to, use the device more than once over the study period; intention to continue using the device on the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS); and no decrease in relationship satisfaction on the Gay and Lesbian Relationship Satisfaction Scale (GLRSS). The secondary outcome was an increase in sexual or relationship satisfaction with use of the device, defined as a statistically significant increase on either the Quality of Sexual Experience Scale (QSE) or the GLRSS.

Results

Fifteen couples enrolled in the pilot study. Of the 10 who completed the study, only 3 found device use feasible and endorsed strongly positive experiences, while the remaining 7 found it unusable. There were no changes in QSE or GLRSS scores. Most device issues were related to proper fit.

Conclusion

There is a great deal of interest in non-surgical options for achieving penetration after phalloplasty. The tested external erectile device can work well, but its utility is limited to individuals with very specific post-phalloplasty anatomy. Most individuals and couples found the device unsuitable for the neophallus and/or that it could not be used comfortably.

Boskey ER, Jolly D, Mehra G, et al. Feasibility of an External Erectile Prosthesis for Transgender Men Who have Undergone Phalloplasty. Sex Med 2022;10:100560.