1 Introduction

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).

Figure 1. The penile prosthesis implantation after operation.

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.

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.

References

[1] Jordan GH, Alter GJ, Gilbert DA, Horton CE, Devine CJ. Penile prosthesis implantation in total phalloplasty. J Urol 1994; 152: 410-14.
[2] Levine LA, Zachary LS, Gottlieb LJ. Prosthesis placement after total phallic reconstruction.  J Urol 1993; 149: 593-9.
[3] Gilbert DA, Horton CE, Terzis JK, Devine CJ, Winslow BH, Devine PC. New concepts in phallic reconstruction.  Annals Mastic Surg 1987; 18: 128-36.