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

Abstract

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 600/700^TM CX 3-piece inflatable, AMS Ambicor^TM 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.

Keywords: gender affirmation surgery; inflatable penile prosthesis; neophallus; phalloplasty.

Figure 1.

PRISMA 2020 flow chart for the current systematic review.

Figure 2.

ZSI 475 FTM penile prosthesis. Source: Images obtained from Zephyr Surgical Implants (ZSIs) website: https://www.zsimplants.ch/en/products-en/phalloplasty/zsi-475-ftm-inflatable-penile-implant/zsi-475-ftm-information

Figure 3.

Intra-operative images of an inflatable penile prosthesis insertion into a neophallus. (a) A groin incision in the skin crease on the side of the eventual pump placement is made and deepened to the pubic bone. (b) A polyethylene terephthalate cap is used to cover the proximal and distal cylinder ends. (c) A contralateral incision in the groin is made for the testis insertion. A separate lower right abdominal is used for the reservoir placement. The urinary catheter is removed on post-operative day 1 and the implant is left semi-inflated for 1–2 weeks.