Implantation of inflatable penile prosthesis (IPP) in a neophallus is a technically challenging procedure. The level of complexity increases in the revision setting. In this video, we will demonstrate IPP reimplantation in a transgender male status post phalloplasty with radial forearm free flap (RFFF).

Patient was a 34-year-old transgender man who had undergone RFFF phalloplasty in 2016. He underwent 3-piece, dual cylinder IPP implantation in 2018. The entire hardware had to be explanted after 3 weeks secondary to infection. Six months later, another prosthetic surgery was carried out, this time with a single cylinder and 2-piece mechanism.
Perioperative prophylaxis was based on urine culture result and consisted of vancomycin and imipenem. A 16 Fr. urethral catheter was advanced into the bladder over a cystoscopically placed guidewire. An infrapubic skin incision was made. A tunnel was created within the neophallus. This tunnel was serially dilated with Hegar dilators.Attention was given not to injure urethra or vascular pedicle of the neophallus. Measurements of the intra-phallic tunnel and neophallic dimensions were conducted. We elected to proceed with a 2-piece prosthesis (14 cm with 0.5 cm rear-tip extender) and place a single cylinder in order not to cause vascular compromise.
A cadaveric dermal allograft section was sutured in a tubular fashion over one of the cylinders, while the other cylinder was removed. A Keith needle was used to advance the cylinder into the allograft and then through the created space in the neophallus. Rear-tip extender was secured on the pubic bone. Fluoroscence angiography confirmed intact neophallic perfusion. Pump was placed into the most dependent portion of the scrotum.

Early postoperative course was unremarkable, he was discharged on postoperative day 2. After 1 month, a CT scan was conducted due to persistent neophallic pain which demonstrated a 3-cm seroma. He was taken to OR for incision and drainage. Wound cultures were negative. Implant remained intact and in place. Follow-up duration was 3 months at which time he reported penetrative intercourse. No other infection-related problem occurred during this time frame.

IPP revision in transgender males following RFFF phalloplasty is a complex procedure. Perioperative administration of culture-specific antibiotics, avoiding urethral and pedicle injury during tunnel dissection, adjusting cylinder number and size according to neophallic dimensions, wrapping the cylinder(s) with tissue substitutes, assessing the vascularity of the neophallus intraoperatively, and addressing postoperative fluid collections aggressively will help to minimize the risk of complications and enhance outcomes.