Navigating the neophallus: Surgical: Strategies for ZSI 475 FTM hydraulic prosthesis placement

Objective The Zephyr Surgical Implants (ZSI) FTM 475 is an inflatable erectile prosthesis tailored to the neophallus. Incorporating such a device into this delicate site is challenging, as the neophallus lacks the corpora cavernosa that normally house and protect the implant. This article and accompanying video describe our surgical technique for ZSI FTM 475 implantation following phalloplasty, alongside the relevant anatomical and ethical considerations, and report a rare vascular complication. Patients and Surgical Procedure We present a 57-year-old trans male who had undergone free radial forearm flap phalloplasty with urethral lengthening. Through a para-scrotal incision, the implant cavity is dilated while protecting the neourethra. The titanium fixation plate is secured onto the anterior pubic bone with non-absorbable sutures, compensating for the absent corpora cavernosa and providing proximal stability. A second groin incision allows placement of the reservoir into the preperitoneal space under direct vision, and the pump is positioned in the scrotum. Results Postoperatively, the patient developed ischemia of the distal neophallus, presenting with discoloration and bullae. This necessitated immediate explantation of the prosthesis and resulted in full-thickness skin loss over approximately 20% of the distal shaft. Conclusion The ZSI FTM 475 offers a potential advantage through its unique fixation method, addressing proximal device stability in the absence of corpora cavernosa. Nonetheless, the procedure demands meticulous execution—particularly urethral protection and avoidance of the vascular pedicle—and thorough patient counselling regarding its substantial complication risk.