Elsevier

European Urology

Volume 57, Issue 2, February 2010, Pages 334-341
European Urology

Andrology
Erectile Implants in Female-to-Male Transsexuals: Our Experience in 129 Patients

https://doi.org/10.1016/j.eururo.2009.03.013Get rights and content

Abstract

Background

The combination of a neourethra and erection prosthesis in a single neophallus in the female-to-male transsexual remains a challenge. No good data are available on this subject.

Objective

To report the outcome in 129 female-to-male transsexuals with a neophallus after the implantation of an erectile prosthesis.

Design, setting, and participants

From March 1996 until October 2007, 129 female-to-male transsexuals with a neophallus underwent the implantation of an erectile prosthesis. The mean follow-up was 30.2 mo (range: 0–132 mo).

Intervention

A Dynaflex prosthesis was implanted initially in 9 patients, a three-piece hydraulic device (AMS CX or AMS CXM) in 50 patients, and a CX Inhibizone, Ambicor, and Coloplast/Mentor prosthesis in 17, 47, and 6 patients, respectively.

Measurements

Data on outcome in these patients were retrospectively evaluated.

Results and limitations

Of 129 patients, 76 patients (58.9%) still have their original implant in place. Fifty-three patients (41.1%) needed to undergo either removal or revision of the prosthesis due to infection, erosion, dysfunction, or leak. Forty-one patients underwent a replacement of the prosthesis, nine needed a second revision, five needed a third revision, and one patient needed a fourth revision of prosthesis. Malposition of prosthesis was corrected by surgical repositioning so that removal or revision could be avoided. Of 185 prostheses used in 129 patients, 108 (58.4%) still remain in place, with a total infection rate of 11.9%, a total protrusion rate of 8.1%, a total prosthesis leak rate of 9.2%, a total dysfunction rate of 13%, and a total malposition rate of 14.6%.

The period of follow-up in the more recent types of prostheses (Ambicor, Coloplast/Mentor) is much shorter; therefore, comparison with earlier types is difficult to make.

Conclusions

Despite high complication rates, implantation of a hydraulic erectile prosthesis remains the best option for achieving the possibility of sexual intercourse in female-to-male transsexuals.

Introduction

The final step in the multidisciplinary approach of gender reassignment therapy in female-to-male transsexuals consists of the construction of a neophallus [1]. This procedure allows the patient to void while standing. Although voiding while standing is a priority for most female-to-male transsexuals [2], most patients want to use the neophallus for sexual experience after they are accustomed to their new voiding abilities. The main limiting factor is that there is no good substitute for the unique erectile tissue of the penis. Different techniques have been used to obtain rigidity in the neophallus, but often, they resulted in complications and failure [3].

In 1973, Scott et al introduced the first inflatable erectile prosthesis [4]. Puckett and Montie were the first to use this technique in a female-to-male transsexual in 1977 [5]. We started to perform this procedure in March 1996 with the one-piece Dynaflex hydraulic prosthesis (American Medical Systems, Minnetonka, MN, USA). After 2 yr, the Dynaflex prosthesis was no longer available, and so we implanted a three-piece CX, CXM, or CX Inhibizone hydraulic system (American Medical Systems) [6]. In 2003, the two-piece Ambicor (American Medical Systems) and Coloplast/Mentor (Mentor Corporation, Santa Barbara, CA, USA) systems were also introduced.

Section snippets

Patients and methods

From March 1996 until October 2007, 129 out of a group of 182 female-to-male transsexuals with a neophallus underwent the implantation of a hydraulic erectile prosthesis. The mean age at the time of operation was 34.1 yr (range: 17–53 yr). All patients had already undergone a phalloplasty, using a free sensate radial forearm flap, at an average age of 31.9 yr (range: 15–52 yr). Our technique of phalloplasty has been previously described [1]. Implantation of the hydraulic prosthesis was done as

Results

The following protheses were initially implanted: a Dynaflex one-cylinder (standard) prosthesis in 9 patients; an AMS three-piece hydraulic device (AMS CX or AMS CXM) in 50 patients (37 with one cylinder, 13 with two cylinders); an AMS CX Inhibizone prosthesis in 17 patients (13 with one cylinder, 4 with two cylinders); an AMS Ambicor prosthesis in 47 patients (22 with one cylinder, 25 with two cylinders); and a Coloplast/Mentor prosthesis in 6 patients (all with two cylinders) (Table 1). The

Discussion

In our study, we retrospectively evaluated the outcome in 129 female-to-male transsexuals after implantation of a hydraulic erectile prosthesis. Because the groups in this study were too small, statistical significance could not be attained; however, this is the largest series of female-to-male transsexual patients with a hydraulic erectile device ever reported. Average follow-up in these patients was 44.3 mo (range: 0–139 mo) (Fig. 4).

Reports in the literature are poor, with only a few studies

Conclusions

Despite these high complication rates, implantation of a hydraulic erectile prosthesis remains the best option for achieving the possibility of voiding while standing as well as sexual intercourse in female-to-male transsexuals after phalloplasty. The choice of device cannot be decided based on the data presented in this paper; however, trends seem to reflect that two-piece devices are better than three-piece devices.

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