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Penile prosthesis implantation in a
transsexual neophallus
Hui-Meng Tan .
Subang Jaya Medical Centre,
Subang Jaya 47500, Malaysia .
Abstract
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1 Introduction
Total phallic reconstruction is commonly done
for patients with severe penile injury, total penectomy for cancer surgery,
multiple congenital genitalia abnormalities and after female to male
transsexual surgery[1]. The anterior abdominal cutaneous flap is the most
common pedicle used in neophallus reconstruction in transsexual patients in
Singapore and Malaysia. A malleable rod is the common prosthesis used for
achieving rigidity. This approach has a high failure rate dueto the frequent
occurrence of pressure necrosis of the subcutaneous flap pedicle, which has
poor blood supply. We have had the opportunity to successfully insert an
inflatable prosthesis using the AMS CX prosthesis in a 45-year old
transsexual with anterior abdominal subcutaneous fat pedicle.
2 Patient and Surgery
The patient is presently happily married
female-to-male transsexual with adopted children and is a very successful
businessman. He has male external features and a hoarse manly voice.
Abdominal examination revealed a puckered, midline lower abdominal scar. The
neophallus was reconstructed from the anterior abdominal cutaneous flap done
about 9 years ago. The pedicle is 19 cm in length with a circumference of 14
cm. It is ‘chordeed’ and curved concavely dorsally. Thick fibrotic
incisional scar is noted dorsally over the curved part of the neophallus.
The overlying skin throughout the whole pedicle including the tip is
sensitive to touch and pinprick. The labial folds, clitoris, external
urinary meatus and vaginal opening are normal.
The operation was performed 20 months ago.
Antibiotics (cetafzidime, netromycin and Flagyl) were given perioperatively.
The skin was prepared routinely using povidone solution. A midline
suprapubic incision extending about 5 cm into the proximal part of the
neophallus was done. An infrapubic space was created and dilated for 8 cm
along the left ischial ramus with 18 mm diameter. A transverse incision
across the distal dorsal scar of the neophallus was made to correct the
chordee. Dilatation of the shaft of the neophallus along its central axis
was done up to 14 mm diameter. Antibiotic (Cefuroxime) was constantly
irrigated during dilatation of the infrapubic space and the shaft of the
neophallus.
A Dacron tubular graft 16 mm diameter with
one end closed like a windsock was created and anchored to the symphysis
pubis and left ischial ramus[2]. A single 20 cm cylinder of AMS CX
prosthesis with 5 cm rear tip extender was inserted into the open end of the
dacron graft. The tubing of the cylinder was brought out by perforating the
dacron graft to ensure secured anchorage. The open end of the dacron
windsock was apposed around the cylinder and sutured to the symphysis pubis,
creating a neosuspensory ligament. The distal part of the cylinder was
inserted with a Furlow's inserter. The CXM pump was inserted into the most
dependent part of the right labium. The second cylinder tubing from the CXM
pump was spigotted with a metal stopcap. A 50 mL reservoir was inserted
below the rectus muscle in the retropubic space.
The transverse incision over the distal
shaft of the neophallus was closed longitudinally correcting the chordee.
The midline suprapubic and infrapubic incision was closed in 2 layers, using
an absorbable suture (Vicryl) for the subcutaneous layer and nylon suture
for the skin.
The prosthesis was recycled and kept
semi-inflated postoperatively. No pressure dressing was applied over the
shaft of the neophallus (Figure 1).
3 Results
Recycling of the prosthesis was started after
24 hours. The patient was discharged well on the sixth postoperative day
with wound healing well and no skin necrosis. The patient was taught to do
self-recycling after 1 week. He had no problem with the inflation pump.
However, to activate the deflating valve, he has to press it against the
pubic bone, which requires some practice.
The patient had liposuction of the pedicle
to decrease the circumference of the shaft 8 months postoperatively. The
prosthesis is still in good function to date i.e. twenty months
postoperatively. The patient and partner satisfaction was graded as good to
excellent.
4 Discussion
The goal in the reconstruction surgery for a
female-to-male transsexual is to create a manly image. This always includes
mastectomy, hysterectomy and creating an aesthetically appealing neophallus
that can be made erect for sexual intercourse. Reconstruction of the urethra
to allow urination while standing is currently not advisable as this usually
prolongs the postoperative recovery period and urinary fistula invariably
occurs at the neourethra.
Neophallus reconstruction can be done from
local tubed pedicle flaps and skin flaps, muscle and myocutaneous flaps,
local fasciocutaneous flaps or sensate fasciocutaneous microvascular free
flaps. Rigidity of the neophallus is currently achieved with either
semi-rigid or inflatable implants. Reestablishing good sensation over the
skin of neophallus using either the ilioinguinal, genitofemoral or dorsal
nerves to the clitoris will certainly allow erogenous sensation[3].
Most reconstructive surgery for
female-to-male transsexuals stopped at the stage of reconstruction of a
neophallus. It usually takes up to 2 years for completion. The majority of
these patients are indeed very satisfied to have male external features.
Activation of the neophallus to allow coitus is desired but is generally not
possible because it involves further surgery and further rehabilitation and
it incurs more hospital expenditure.
Failures of the implants in neophallus
include extrusion of the prosthesis due to pressure necrosis or shear force,
infection and migration of implant. Inflatable implant, whenever possible,
is obviously the preferred choice.
The ideal functional neophallus which will
provide erection and erogenous sensation results from implantation of an
inflatable prosthesis in a neophallus that has been microsurgically
reconstructed to reestablish good sensation over the skin of the
neophallus[3]. This can be done by microsurgically re-anastomosing the flap
nerves or the local nerves to the ilioinguinal regiion, the genitofemoral
nerve or the dorsal nerves of the clitoris. This will provide protection
against pressure necrosis and allow erogenous sensation.
5 Conclusion
Most reconstructive surgery for female to male
transsexuals stopped at the stage of reconstruction of a neophallus. This
usually takes up to 2 years for completion. The majority of these patients
are indeed very satisfied to have male external features. Activation of the
neophallus to allow coitus is desired but is generally not done because it
involves further surgery, further rehabilitation and it incurs hospital
expenditure.
Our experience showed that implantation of
an inflatable prosthesis is possible even in a neophallus constructed from
subcutaneous skin flap. The postoperative recovery for this relatively
simple procedure is rapid, and the complications are minor and easily
correctable. The functional result and long term potential complication of
an inflatable penile prosthesis is certainly superior to the result of a
rigid rod, which is usually used for neophallus of a transsexual in this
part of the world.
6 References
- Jordan GH, Alter GJ, Gilbert DA, Horton
CE, Devine CJ. Penile prosthesis
implantation in total phalloplasty. J Urol 1994; 152: 410-14.
- Levine LA, Zachary LS, Gottlieb LJ.
Prosthesis placement after total phallic reconstruction. J Urol 1993;
149: 593-9.
- Gilbert DA, Horton CE, Terzis JK,
Devine CJ, Winslow BH, Devine PC.
New concepts in phallic reconstruction. Annals Mastic Surg 1987;
18: 128-36.
Citation:
Asian J Androl 2000 Dec; 2: 304-306.
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