Intraoperative complications include inadvertent injury to the vascular pedicle of the phallus and urethral perforation. Although the role of the vascular pedicle is uncertain, as 1 year after the phallic construction it is likely that the phallus has grown a new, independent blood supply arising from the pubic area, preservation of the pedicle is always advisable.

In order to minimize the chance of inadvertent injury to the vascular pedicle and the neourethra, it is paramount to create the space for the insertion of the cylinders with blunt dissection with Metzenbaum scissors and Hegar dilators. Performing the dissection laterally should reduce the chance of hitting the vascular pedicle, which runs on the dorsal aspect at the base of the phallus before moving towards its ventral aspect in an anticlockwise fashion towards the tip, if the radial artery flap has been harvested from the left forearm. In patients who had their phallus harvested from the right forearm, the pedicle instead runs in a clockwise fashion.

In order to minimize the risk of urethral injury, the catheter should be squeezed between the thumb and index finger of the nondominant hand in order to keep the neourethra away from the tip of the scissors and of the dilators. The presence of a urethral injury should be ruled out before proceeding with the insertion of the cylinder(s), and to do so the phallus should be irrigated with antibiotic solution. In case of fluid at the neomeatus, the presence of a neourethral injury should be suspected, and the procedure should be therefore abandoned. The catheter should be left in situ for 2 weeks to allow the urethra to heal, and a new attempt of penile prosthesis implantation should be deferred for 6 months to allow for the healing process to be complete and to rule out the presence of urethral strictures and fistulas.

Immediate postoperative complications include ischaemic necrosis of the phallus and penile prosthesis infection.

Ischaemic necrosis of the phallus is extremely rare and is either secondary to injury to the vascular pedicle or to excessive compression by the cylinders on the surrounding tissues. If phallic ischaemia is suspected, the only advisable procedure is to deflate the prosthesis, to reduce the pressure exerted by the cylinders on the phallus.

Penile prosthesis infection rate can be as high as 15 % [12–16], significantly higher than in virgin implants in the male. This is mainly due to the presence of foreign bodies in contact with the implant (polyethylene terephthalate sock and tip), which are required to house the cylinders and anchor them to the pubic bone.

Penile prosthesis infection can be subdivided into acute and chronic. The former is characterized by sepsis, purulent collection around the implant, swelling and erythema, while in the latter the symptoms are generally mild and usually patients complain of dull ache at the level of the phallus and pain while cycling the device.

In case of penile prosthesis infection, all the components of the device have to be removed, including the polyethylene terephthalate tip and sock, and the cavity irrigated with antiseptic and antibiotic solutions. Salvage procedures have not been described in these patients, and a new attempt of penile prosthesis implantation should be deferred for at least 4–6 months to allow for a complete healing process to occur.

Rates of mechanical failure of the device can be as high as 50 % at 4 years, which is significantly higher than in virgin male patients [13]. This is because of the lack of the tunica albuginea, which naturally protects the cylinders, and of a lax, loose scrotum, which guarantees an adequate shelter for the tubing and the pump. This is why the most common locations of device failure are the cylinders, due to the continuous friction with the polyethylene terephthalate tip and sock, and at the level where the tubings exit from the pump, as they are forcibly bent to be accommodated in a stiff, small neo-scrotum.

In case of mechanical failure, the faulty component of the device needs to be identified and replaced. If the prosthesis has been implanted more than 3 years before, all the components of the device should be replaced, as they have almost reached their full life expectancy [13].

Malposition of the device has been described in up to 15 % of cases and can cause pain when cycling the implant or having sexual intercourse. Revision surgery, which involves repositioning the device in the correct location, should not be postponed as malposition of the device can lead to premature wearing of the device or erosion.

As penile prosthesis implantation in a phallus is a very uncommon procedure, no standardized validated questionnaires are available in the literature to evaluate surgical outcome and patient’s satisfaction. Surgical outcome is assessed subjectively by the surgeon, and patients are directly questioned to investigate satisfaction rates. In particular, a straight phallus with enough rigidity to allow successful penetrative intercourse and a pump that is easy to access and cycle are considered a satisfactory surgical outcome.