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Preoperative care
Patients are advised to stop smoking at least 1 month prior to surgery. A negative urine culture is required.
All patients are instructed to shave the pubic and genital area and to use antimicrobial soap the day before
surgery.

Vancomycin is administered intravenously 30 min prior to anesthesia induction.

Surgical technique
Patients are positioned supine. The genital region is scrubbed with chlorhexidine and povidone-iodine for
5 min, followed by placement of sterile drapes. A semicircular 4 cm incision is made on the dorsal aspect of
the neophallus [Figure 2A]. Blunt dissection is performed through the subcutaneous tissue until the pubic
symphysis is identified, creating a space for the prosthesis fixation plate. The space within the neophallus is
then created using metal dilators up to 10 mm, making sure to avoid getting too close to the distal tip,
maintaining the midline and taking care not to injure the urethra [Figure 2B]. The appropriate length of the
cylinder is determined using a Furlow measurement. The prosthesis is immersed in a gentamicin and
rifampicin solution prior to insertion.

In cases with excessive girth or length of the neophallus, several strategies are considered, including
shortening the neophallus, or reshaping the base of the neophallus simultaneously with its width. The
specific approach is tailored to the individual patient’s anatomy and desired outcome.

Malleable prosthesis
The prosthesis base is anchored to the pubic symphysis with four interrupted non-resorbable monofilament
sutures through the periosteum. The cylinder is then inserted into the neophallus. No drain is placed. The
incision is closed in layers using absorbable sutures. A compressive dressing is applied, and the neophallus
is fixed to the inferior abdominal wall.

Inflatable prosthesis
A hemiscrotal space is created through the same infrapubic incision on the contralateral side of the vascular
pedicle using blunt dissection. In cases with a previously placed testicular implant, the implant is removed,
and a new space is created next to the capsule.

A second horizontal incision is made in the left iliac fossa, followed by blunt dissection of the Retzius space.
The reservoir is then inserted and filled with saline. The prosthesis plate is anchored to the pubic symphysis
with four interrupted sutures through the periosteum [Figure 3A and B]. The pump is positioned in the
previously created hemiscrotal pocket [Figure 3C]. The cylinder is then inserted into the neophallus
[Figure 3B]. The reservoir tubing is connected to the pump and cylinder tubing. Inflation is tested to
confirm the proper functioning of the prosthesis. The prosthesis is inflated to 60% to maintain the dissected
space. The incisions are closed, and a compressive dressing is applied.

Postoperative care
The urethral catheter is removed the day after surgery, and the patient is discharged. Oral antibiotics
(amoxicillin and metronidazole) are prescribed for five days. The first postoperative visit is scheduled one
week following the surgery. For patients with an inflatable ZSI 475 FTM, the cylinder is maintained at 60%
inflation for four weeks to preserve the dissected space. Patients with a malleable penile implant are
instructed to hold the neophallus upward to the abdominal wall for four weeks. During the first two
months, patients should avoid strenuous activities, heavy lifting, and vigorous exercise to facilitate initial
healing. Sexual activity is prohibited for two months.