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Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus
Accepted Manuscript Title: Novel Technique for Proximal Bone Anchoring of Penile Prosthesis after Radial Forearm Free Flap Neophallus Author: Andrew J Cohen, Raj R Bhanvadia, Joseph J Pariser, David M Hatcher, Lawrence J. Gottlieb, Gregory T Bales PII: DOI: Reference:
S0090-4295(17)30043-2 http://dx.doi.org/doi: 10.1016/j.urology.2017.01.016 URL 20252
To appear in:
Urology
Received date: Accepted date:
30-10-2016 11-1-2017
Please cite this article as: Andrew J Cohen, Raj R Bhanvadia, Joseph J Pariser, David M Hatcher, Lawrence J. Gottlieb, Gregory T Bales, Novel Technique for Proximal Bone Anchoring of Penile Prosthesis after Radial Forearm Free Flap Neophallus, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.01.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus Authors: Andrew J Cohena, Raj R Bhanvadiaa, Joseph J Parisera, David M Hatchera, Lawrence J. Gottliebb, Gregory T Balesa, a Section of Urology, Department of Surgery University of Chicago, Chicago, Illinois 60637 b Section of Plastic and Reconstructive Surgery, Department of Surgery University of Chicago, Chicago, Illinois, 60637 Corresponding Author: Andrew Cohen Tel: 813-245-0378 Fax: 773-702-1001 Email: [email protected]
Acknowledgments: We would like to acknowledge that portions of this video were presented at the American Urological Association 2016 conference in San Diego, CA as part of the Reconstruction Video Session.
Abstract: Background: Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to pubic bone is one strategy to achieve proximal stabilization of the prosthesis. Purpose: To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures.
Page 1 of 10
Methods: A single institution retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue. Results and limitations: The overall peri-operative complication rate was 20% with a mean follow up of 49 months. 70% of patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of patients have fully functioning prosthesis as of last follow up. Limitations include retrospective study design and the small patient cohort. Conclusions: Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear-tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary. Key Words: prosthesis
complications;
neophallus;
technique;
trans-gender;
penile
Video Legend: IPP= Inflatable Penile Prosthesis; AMS = American Medical Systems Inflatable Penile Prosthesis Insertion After radial forearm free flap neophallus Background (00:08): Proximal fixation of an inflatable penile prosthesis is challenging in female-to-male transgender patients due to the absence of corporal bodies, putting them at risk for proximal migration. Our technique incorporates proximal anchoring to the pubic symphysis, which allows for adequate support during intercourse. Alternative methods
Page 2 of 10
include using a permanent windsock. However, these are relatively unstable and can lead to mechanical failure and poor proximal support. Methods (00:36): At our institution, the preferred method for phalloplasty is a radial forearm free flap. We routinely wait at least 6 months after neophallus creation before prosthesis placement. This ensures there is sensation and allows for complete urethral healing. An infrapubic approach is used for all patients, with care taken to avoid the arterial supply, especially during skin incision. In this series, we waited a median of 206 days between forearm free flap placement and IPP placement, such that these flaps were proven to be viable. Dilation in this patient population is typically difficult given the lack of true corporal bodies and the number of cylinders is personalized to the patient, whereas we initially favor two cylinders. Case (01:15): The patient in this video is a 38-year-old genetic female who has been living as a man for the last ten years. As the final step in his transition, he will undergo placement of the AMS-700 penile prosthesis. He previously underwent neophallus creation two years ago and subsequently developed a stricture of his neourethra, which was repaired with the buccal mucosa urethroplasty about one year ago. Incision (01:42) A longitudinal incision is made along the previous phalloplasty incision, again with care taken to avoid the blood supply, which can be indentified by palpation or handheld Doppler. Dissection to the Pubic Symphysis (01:54) Dissection is carried down to the pubic symphysis with electro-cautery and the location of the future corticotomy defect is determined, ensuring it is in alignment with the neophallus and planned cylinder position. Corticotomy (02:11) On the anterior aspect of the bone, the corticotomy is created in the shape of an inverted cone; geometrically complementary to the proximal rear tip extender. The depth and width of the corticotomy site is checked periodically to ensure a precise fit. Seating the Rear Tip (02:26) You see the rear tip seats nicely in the defect. Note that as long as a rear tip can accommodate an anchoring suture any prosthesis could be used for this technique. Distal Dilation (02:37) Distal dilation is performed, which again may be difficult given that there are no true corporal bodies. Measurement for Cylinder Length (02:47) The phallic length is measured and the appropriately sized IPP is selected. Suture Placement (02:53) Sutures are passed through the corticotomy defect, the rear tips, and the proximal cylinder to allow the rear tip and the proximal cylinder to be seated and secured in the
Page 3 of 10
bony defect. In our patients, permanent anchoring sutures of either prolene or Ticron were used. Cylinders (03:31) In this case, only one cylinder will be used based on the girth of the neophallus, so the other is cut and the tubing is tied off. While capable of placing two cylinders, we have seen aesthetically pleasing results with only a single cylinder in our patients, with adequate sexual functioning of the device. Completed Bony Fixation (03:30) The anchoring sutures are next tied down. Here we see the secured cylinder and rear tip within the corticotomy defect. Passage of Keith Needle/ Distal Placement of Cylinder (03:40) The remainder of the procedure proceeds routinely. The furlow instrument is used to pass a Keith needle, facilitating distal placement of the cylinder. Two Cylinders (03:52) An alternate approach, depicted here in a different patient, is placing two cylinders. There maybe additional difficulty using two cylinders due to lack of girth, fibrotic tissue, and the lack of native corpora. Additional Support (04:12) An additional technique, which we have just recently begun to incorporate, is depicted here, again in an alternate patient. A hole for each cylinder is cut in a gortex strip; this material is secured at the base of pubic symphysis. The angle of force applied to the prosthesis may be important for durability. With an angle of force applied perpendicular to the corticotomy defect, the device is stable. Any motion that pulls the prosthesis away from the bone puts the patient at risk for device detachment. Female to male transgender patients are typically younger than the typical male patients receiving an implant for erectile dysfunction and may be at greater risk for device damage and malfunction. We hypothesize this additional gortex may buttress the bone anchor of the prosthesis;. however, this technique adaptation has not been attempted in enough patients to draw adequate conclusions on the effects on device longevity Reservoir Placement (05:04) A counter incision is made in the right lower quadrant and carried down into a subrectus pouch for placement of a reservoir. Pump Placement (05:14) The pump is placed to the right scrotal pouch previously occupied by a tissue expander. Rarely, a counter incision in the scrotum can be helpful for proper pump placement, in particular in cases of revision, as depicted here in a separate patient. Final Steps (05:43) All tubing is connected and the incisions are closed This is the appearance of the neophallus with IPP at the conclusion of the procedure. Results (06:00):
Page 4 of 10
Results are summarized in this table. As you can see, our complication and revision rates, while high, are in line with our peers. When comparing complication rates, shared definitions are pivotal. In one reported experience, malposition of the prosthesis corrected by surgery was not considered revision surgery despite 14.6% of patients experiencing this complication. In our series, repositioning was considered revision surgery. Due to our concern regarding infections, we are hesitant to provide repositioning without device replacement. Given our median follow-up is longer than most other series, we may also capture more device malfunctions. Importantly, no cases of infection were a result of osteomyelitis secondary to the corticotomy defect. Of the two cases of mechanical malfunctions, one patient had a leak in the IPP reservoir, the second patient damaged one of the prosthesis cylinders during intercourse. The cases of poor fixation we suspect were a result of vigorous sexual activity based on clinical history Conclusions (07:06): In conclusion, inflatable penile prosthesis placement with proximal bony fixation is safe and feasible after radial forearm free flap neophallus. Future work may directly compare different prosthesis anchoring techniques. Additionally, given the lack of experience that gender reassignment patients have with carrying a mass in the groin, efforts to develop a validated quality of life score similar to the Sexual Health Inventory in Men (SHIM) score are both critical and necessary.
Page 5 of 10
References 1. Hoebeke, P. B., Decaestecker K., Beysens M., et al. Erectile implants in femaleto-male transsexuals: our experience in 129 patients. Eur. Urol. 57, 334–340 (2010). 2. Leriche, A., Timsit M.O., Morel-Journel N., et al. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 101, 1297–1300 (2008). 3. Callens, N., De Cuypere G., T’Sjoen G., et al. Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study. World J. Urol. 33, 137–143 (2015). 4. Zuckerman, J. M., Smentkowski K., Gilbert D., et al. Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction. J. Sex. Med. 12, 2485–2491 (2015). 5. Hage, J. J. Dynaflex prosthesis in total phalloplasty. Plast. Reconstr. Surg. 99, 479–485 (1997).
Page 6 of 10
Table 1.Patient characteristics Age, yr (IQR) Weight, kg (IQR)* Body mass index, kg/m2 (IQR) Other chronic health problems, n (%) Hypertension Hyperlipidemia Depression Asthma Hyperthyroidism Current smoker, n (%) Follow up time, months (IQR)
41.7 (39.145.5) 69.2 (61.274.8) 25.9 (22.828.7) 1 (10) 1 (10) 3 (30) 1 (10) 1 (10) 4 (40) 49.0 (21.089.0) 887 (59- 956) 10 (100)
Distance from hospital, km (IQR) Radial forearm free flap, n (%) Indication for Neophallus, n (%) Transgender, sexual reassignment 8 (80) Penile necrosis 1 (10) Penile cancer 1 (10) Interval between last neo-phallus procedure and inflatable penile 206 (149prosthesis, d (IQR) 212) IQR = interquartile range, * Weight available in 9 of 10 patients
Page 7 of 10
Table 2. Peri-operative characteristics Concomitant procedures, n (%) Testicular prosthesis placement 5 (50) Z-plasty scrotal tissue enlargement 1 (10) Urethral dilation 1 (10) Estimated blood loss, ml (IQR)* 33 (20- 50) Drill used, n (%) 8 (80) IPP model, n (%) LGX 5 (50) CX 5 (50) Rear tip size, cm (IQR) 1.8 (1- 1.5) Number of cylinders used, n (%) One 9 (90) Two 1 (10) Cylinder length, cm (IQR) 16.8 (15- 17.3) Length of stay, d (IQR) 1.3 (1- 4) * Estimated blood loss available in 5 of 10 patients
Page 8 of 10
Table 3. Prosthesis revision and causes Characteristic Patients undergoing IPP revision, n (%) Mean number of revisions per patient, (IQR) Primary cause of each revision, n (%) Infection Inadequate fixation Mechanical failure
N (%) 7 (70) 1.4 (1.0- 1.5) 5 (50) 3 (30) 2 (20)
Page 9 of 10
Table 4. Summary of published series Author Number of Type of Indication patients neophallus
IPP placed, n (%)
Anchor Type
Median Follow up, months (IQR) 30.2 (0 – 132)
Perioperative Complication Rate %
Revision Rate, %
58.3
41.1 (Complete Replacement) & 14.6 (Revision)
Hoebeke PB4
129
Radial forearm free flap
Transgender
129 (100)
Suture Fixation to Bone Or Dacron Windsock
Leriche A10
56
Transgender
38 (67)
Unknown
110 (11 – 204)
37
29
Callens N11
18
Radial forearm free flap Multiple
Penile Deficiency
16 (89)
Unknown
36.9 (14 – 92)
67
25
Zuckerm an JM5
31
Multiple
Multiple
10 (32)
GORETEX Neotunica
59.7
23
23
Hage JJ
5
Transgender
5 (100)
Dacron Windsock
14 (5 – 21)
80
80
Our Cohort
10
Radial forearm free flap Radial forearm free flap
Multiple
10 (100)
Bone Anchored
49.0 (21.089.0)
20
70
12
Page 10 of 10
S0090-4295(17)30043-2 http://dx.doi.org/doi: 10.1016/j.urology.2017.01.016 URL 20252
To appear in:
Urology
Received date: Accepted date:
30-10-2016 11-1-2017
Please cite this article as: Andrew J Cohen, Raj R Bhanvadia, Joseph J Pariser, David M Hatcher, Lawrence J. Gottlieb, Gregory T Bales, Novel Technique for Proximal Bone Anchoring of Penile Prosthesis after Radial Forearm Free Flap Neophallus, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.01.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus Authors: Andrew J Cohena, Raj R Bhanvadiaa, Joseph J Parisera, David M Hatchera, Lawrence J. Gottliebb, Gregory T Balesa, a Section of Urology, Department of Surgery University of Chicago, Chicago, Illinois 60637 b Section of Plastic and Reconstructive Surgery, Department of Surgery University of Chicago, Chicago, Illinois, 60637 Corresponding Author: Andrew Cohen Tel: 813-245-0378 Fax: 773-702-1001 Email: [email protected]
Acknowledgments: We would like to acknowledge that portions of this video were presented at the American Urological Association 2016 conference in San Diego, CA as part of the Reconstruction Video Session.
Abstract: Background: Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to pubic bone is one strategy to achieve proximal stabilization of the prosthesis. Purpose: To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures.
Page 1 of 10
Methods: A single institution retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue. Results and limitations: The overall peri-operative complication rate was 20% with a mean follow up of 49 months. 70% of patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of patients have fully functioning prosthesis as of last follow up. Limitations include retrospective study design and the small patient cohort. Conclusions: Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear-tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary. Key Words: prosthesis
complications;
neophallus;
technique;
trans-gender;
penile
Video Legend: IPP= Inflatable Penile Prosthesis; AMS = American Medical Systems Inflatable Penile Prosthesis Insertion After radial forearm free flap neophallus Background (00:08): Proximal fixation of an inflatable penile prosthesis is challenging in female-to-male transgender patients due to the absence of corporal bodies, putting them at risk for proximal migration. Our technique incorporates proximal anchoring to the pubic symphysis, which allows for adequate support during intercourse. Alternative methods
Page 2 of 10
include using a permanent windsock. However, these are relatively unstable and can lead to mechanical failure and poor proximal support. Methods (00:36): At our institution, the preferred method for phalloplasty is a radial forearm free flap. We routinely wait at least 6 months after neophallus creation before prosthesis placement. This ensures there is sensation and allows for complete urethral healing. An infrapubic approach is used for all patients, with care taken to avoid the arterial supply, especially during skin incision. In this series, we waited a median of 206 days between forearm free flap placement and IPP placement, such that these flaps were proven to be viable. Dilation in this patient population is typically difficult given the lack of true corporal bodies and the number of cylinders is personalized to the patient, whereas we initially favor two cylinders. Case (01:15): The patient in this video is a 38-year-old genetic female who has been living as a man for the last ten years. As the final step in his transition, he will undergo placement of the AMS-700 penile prosthesis. He previously underwent neophallus creation two years ago and subsequently developed a stricture of his neourethra, which was repaired with the buccal mucosa urethroplasty about one year ago. Incision (01:42) A longitudinal incision is made along the previous phalloplasty incision, again with care taken to avoid the blood supply, which can be indentified by palpation or handheld Doppler. Dissection to the Pubic Symphysis (01:54) Dissection is carried down to the pubic symphysis with electro-cautery and the location of the future corticotomy defect is determined, ensuring it is in alignment with the neophallus and planned cylinder position. Corticotomy (02:11) On the anterior aspect of the bone, the corticotomy is created in the shape of an inverted cone; geometrically complementary to the proximal rear tip extender. The depth and width of the corticotomy site is checked periodically to ensure a precise fit. Seating the Rear Tip (02:26) You see the rear tip seats nicely in the defect. Note that as long as a rear tip can accommodate an anchoring suture any prosthesis could be used for this technique. Distal Dilation (02:37) Distal dilation is performed, which again may be difficult given that there are no true corporal bodies. Measurement for Cylinder Length (02:47) The phallic length is measured and the appropriately sized IPP is selected. Suture Placement (02:53) Sutures are passed through the corticotomy defect, the rear tips, and the proximal cylinder to allow the rear tip and the proximal cylinder to be seated and secured in the
Page 3 of 10
bony defect. In our patients, permanent anchoring sutures of either prolene or Ticron were used. Cylinders (03:31) In this case, only one cylinder will be used based on the girth of the neophallus, so the other is cut and the tubing is tied off. While capable of placing two cylinders, we have seen aesthetically pleasing results with only a single cylinder in our patients, with adequate sexual functioning of the device. Completed Bony Fixation (03:30) The anchoring sutures are next tied down. Here we see the secured cylinder and rear tip within the corticotomy defect. Passage of Keith Needle/ Distal Placement of Cylinder (03:40) The remainder of the procedure proceeds routinely. The furlow instrument is used to pass a Keith needle, facilitating distal placement of the cylinder. Two Cylinders (03:52) An alternate approach, depicted here in a different patient, is placing two cylinders. There maybe additional difficulty using two cylinders due to lack of girth, fibrotic tissue, and the lack of native corpora. Additional Support (04:12) An additional technique, which we have just recently begun to incorporate, is depicted here, again in an alternate patient. A hole for each cylinder is cut in a gortex strip; this material is secured at the base of pubic symphysis. The angle of force applied to the prosthesis may be important for durability. With an angle of force applied perpendicular to the corticotomy defect, the device is stable. Any motion that pulls the prosthesis away from the bone puts the patient at risk for device detachment. Female to male transgender patients are typically younger than the typical male patients receiving an implant for erectile dysfunction and may be at greater risk for device damage and malfunction. We hypothesize this additional gortex may buttress the bone anchor of the prosthesis;. however, this technique adaptation has not been attempted in enough patients to draw adequate conclusions on the effects on device longevity Reservoir Placement (05:04) A counter incision is made in the right lower quadrant and carried down into a subrectus pouch for placement of a reservoir. Pump Placement (05:14) The pump is placed to the right scrotal pouch previously occupied by a tissue expander. Rarely, a counter incision in the scrotum can be helpful for proper pump placement, in particular in cases of revision, as depicted here in a separate patient. Final Steps (05:43) All tubing is connected and the incisions are closed This is the appearance of the neophallus with IPP at the conclusion of the procedure. Results (06:00):
Page 4 of 10
Results are summarized in this table. As you can see, our complication and revision rates, while high, are in line with our peers. When comparing complication rates, shared definitions are pivotal. In one reported experience, malposition of the prosthesis corrected by surgery was not considered revision surgery despite 14.6% of patients experiencing this complication. In our series, repositioning was considered revision surgery. Due to our concern regarding infections, we are hesitant to provide repositioning without device replacement. Given our median follow-up is longer than most other series, we may also capture more device malfunctions. Importantly, no cases of infection were a result of osteomyelitis secondary to the corticotomy defect. Of the two cases of mechanical malfunctions, one patient had a leak in the IPP reservoir, the second patient damaged one of the prosthesis cylinders during intercourse. The cases of poor fixation we suspect were a result of vigorous sexual activity based on clinical history Conclusions (07:06): In conclusion, inflatable penile prosthesis placement with proximal bony fixation is safe and feasible after radial forearm free flap neophallus. Future work may directly compare different prosthesis anchoring techniques. Additionally, given the lack of experience that gender reassignment patients have with carrying a mass in the groin, efforts to develop a validated quality of life score similar to the Sexual Health Inventory in Men (SHIM) score are both critical and necessary.
Page 5 of 10
References 1. Hoebeke, P. B., Decaestecker K., Beysens M., et al. Erectile implants in femaleto-male transsexuals: our experience in 129 patients. Eur. Urol. 57, 334–340 (2010). 2. Leriche, A., Timsit M.O., Morel-Journel N., et al. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 101, 1297–1300 (2008). 3. Callens, N., De Cuypere G., T’Sjoen G., et al. Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study. World J. Urol. 33, 137–143 (2015). 4. Zuckerman, J. M., Smentkowski K., Gilbert D., et al. Penile Prosthesis Implantation in Patients with a History of Total Phallic Construction. J. Sex. Med. 12, 2485–2491 (2015). 5. Hage, J. J. Dynaflex prosthesis in total phalloplasty. Plast. Reconstr. Surg. 99, 479–485 (1997).
Page 6 of 10
Table 1.Patient characteristics Age, yr (IQR) Weight, kg (IQR)* Body mass index, kg/m2 (IQR) Other chronic health problems, n (%) Hypertension Hyperlipidemia Depression Asthma Hyperthyroidism Current smoker, n (%) Follow up time, months (IQR)
41.7 (39.145.5) 69.2 (61.274.8) 25.9 (22.828.7) 1 (10) 1 (10) 3 (30) 1 (10) 1 (10) 4 (40) 49.0 (21.089.0) 887 (59- 956) 10 (100)
Distance from hospital, km (IQR) Radial forearm free flap, n (%) Indication for Neophallus, n (%) Transgender, sexual reassignment 8 (80) Penile necrosis 1 (10) Penile cancer 1 (10) Interval between last neo-phallus procedure and inflatable penile 206 (149prosthesis, d (IQR) 212) IQR = interquartile range, * Weight available in 9 of 10 patients
Page 7 of 10
Table 2. Peri-operative characteristics Concomitant procedures, n (%) Testicular prosthesis placement 5 (50) Z-plasty scrotal tissue enlargement 1 (10) Urethral dilation 1 (10) Estimated blood loss, ml (IQR)* 33 (20- 50) Drill used, n (%) 8 (80) IPP model, n (%) LGX 5 (50) CX 5 (50) Rear tip size, cm (IQR) 1.8 (1- 1.5) Number of cylinders used, n (%) One 9 (90) Two 1 (10) Cylinder length, cm (IQR) 16.8 (15- 17.3) Length of stay, d (IQR) 1.3 (1- 4) * Estimated blood loss available in 5 of 10 patients
Page 8 of 10
Table 3. Prosthesis revision and causes Characteristic Patients undergoing IPP revision, n (%) Mean number of revisions per patient, (IQR) Primary cause of each revision, n (%) Infection Inadequate fixation Mechanical failure
N (%) 7 (70) 1.4 (1.0- 1.5) 5 (50) 3 (30) 2 (20)
Page 9 of 10
Table 4. Summary of published series Author Number of Type of Indication patients neophallus
IPP placed, n (%)
Anchor Type
Median Follow up, months (IQR) 30.2 (0 – 132)
Perioperative Complication Rate %
Revision Rate, %
58.3
41.1 (Complete Replacement) & 14.6 (Revision)
Hoebeke PB4
129
Radial forearm free flap
Transgender
129 (100)
Suture Fixation to Bone Or Dacron Windsock
Leriche A10
56
Transgender
38 (67)
Unknown
110 (11 – 204)
37
29
Callens N11
18
Radial forearm free flap Multiple
Penile Deficiency
16 (89)
Unknown
36.9 (14 – 92)
67
25
Zuckerm an JM5
31
Multiple
Multiple
10 (32)
GORETEX Neotunica
59.7
23
23
Hage JJ
5
Transgender
5 (100)
Dacron Windsock
14 (5 – 21)
80
80
Our Cohort
10
Radial forearm free flap Radial forearm free flap
Multiple
10 (100)
Bone Anchored
49.0 (21.089.0)
20
70
12
Page 10 of 10