Inflatable Penile Prothesis Implantation After Partial Penectomy and Radial Forearm Flap Reconstruction in a Young Male

T. A. Pereira, L. Oscar, C.A. Pettaway, T. G. Smith, A. F. Mericli, R. Wang

erectile dysfunction, penile implant, penile cancer

Introduction:

Epithelioid sarcoma (ES) is a rare, aggressive soft tissue malignancy that typically affects the distal extremities of young adults but can rarely involve the penis. Management usually requires wide excision or partial/total penectomy to achieve negative surgical margins due to high local recurrence and distant metastasis rates. Phallic reconstruction using a radial forearm free flap (RFFF) offers satisfactory cosmetic and functional outcomes. However, inflatable penile prosthesis (IPP) implantation in a neophallus presents unique technical challenges due to the absence of native corpora cavernosa, the need for neurovascular protection, and limited tissue support.

Objectives:

To describe the surgical technique and outcomes of IPP implantation in a young male who underwent partial penectomy and radial forearm flap phalloplasty after penile epithelioid sarcoma, emphasizing anatomical considerations, flap preservation, and prosthesis integration.

Methods:

A 20-year-old male with penile ES underwent multimodal therapy including systemic and radiation therapy followed by partial penectomy with negative margins. Eighteen months later, he underwent total phallic reconstruction with a left radial artery–based forearm free flap. The urology team performed urethral anastomosis between the native urethral stump and the flap’s neourethra. Sensory reinnervation was achieved through coaptation of the lateral and posterior antebrachial cutaneous nerves with the bilateral dorsal penile sensory nerves. Six weeks postoperatively, glansplasty was performed using a distally based advancement flap technique.

Subsequently, an IPP was implanted through a penoscrotal approach. The proximal corporal remnants were identified and dilated bilaterally. The distal neophallus was carefully dissected and dilated. Two Tutoplast grafts were shaped into windsocks to cover the distal cylinder tips, which were inserted through the neoglans using a Furlow introducer. The prosthesis components were connected and filled with normal saline. Intraoperative Doppler and indocyanine green angiography confirmed adequate flap perfusion.

Results:

The implantation was completed without intraoperative or immediate postoperative complications. The flap maintained excellent perfusion and integrity throughout the procedure. Prosthesis inflation testing demonstrated full cylinder expansion and satisfactory penile rigidity. No ischemia, infection, or device malfunction was observed during the early postoperative period. The patient reported satisfactory cosmetic appearance, scrotal symmetry, and preserved tactile sensation in the neoglans at his six-week post-op follow-up.

Conclusions:

IPP implantation following phallic reconstruction in patients with prior partial penectomy for malignant disease is technically feasible and safe when meticulous dissection and flap preservation are ensured. Key surgical considerations include individualized corporal anchoring, protective distal grafting, and use of intraoperative perfusion assessment to avoid vascular compromise. This case highlights the multidisciplinary collaboration between reconstructive plastic surgery and urology as essential for restoring urinary, sensory, and sexual function in young patients undergoing complex genital reconstruction after oncologic surgery.

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