Penile prosthesis implantation technique for patients with a neophallus

Erectile function is an important goal for many patients post-phalloplasty. Our objective is to demonstrate a technique for placement of a single-cylinder inflatable penile prosthesis (IPP) in patients with a neophallus. IPP placement is performed 1-2 years post-phalloplasty for optimal return of sensation and vascularization. The patient voids preoperatively. Since the bladder is emptied immediately before surgery, we opt not to place a catheter in the potentially tortuous urethra and place the reservoir as early as possible to avoid significant bladder filling, which decreases the risk of bladder injury. Cefazolin and Gentamicin are administered preoperatively and a low concentration Chlorhexidine Gluconate solution is used for irrigation. An infrapubic incision is made and dissection is carried down to the pubic symphysis. The reservoir is placed in the midline prevesical space. Sharp dissection is used to develop a space in the dorsal midline of the neophallus opposite the neourethra, which is palpable without a catheter, prior to sequential distal dilation. After measuring proximally and distally, the appropriately sized device is selected and modified with a shortened, blunted tip and proximal synthetic graft. Previously placed 3-0 FiberWire anchoring sutures on the pubic bone are secured to the proximal aspect of the device. The device is then inflated to facilitate placement into the dilated space distally before tying down the sutures. Pump placement proceeds contralateral to the vascular pedicle in the most dependent aspect of the neoscrotum. Once the tubing is connected, device cycling is performed to ensure proper placement and functioning. Patients are discharged the same day with the device 60% inflated. Sexual activity may occur as early as 8 weeks postoperatively. Complications are seen in up to 40% of patients. Continued improvements in devices and techniques are necessary to decrease complications and improve surgical outcomes as more patients pursue IPP placement post-phalloplasty.