Penis transplant. Successful surgery after amputation due to complications from ritual circumcision.

By: Dr. Will Boggs

Sources: http://bit.ly/2w489cd e http://bit.ly/2wFur6P 
Lancet 2017

Complications arising from ritual circumcision are a major cause of penis loss in young men in South Africa. Approximately 250 young men per year require amputations (of varying degrees) of the penis, and associated infections and subsequent septicemia cause 100 deaths annually.

Dr. Andre van der Merwe, from Stellenbosch University and Tygerberg Academic Hospital in Cape Town, South Africa, and colleagues, report the first functionally successful penile allotransplantation procedure, with 24 months of follow-up, in a 21-year-old man who had been eunuched three years earlier due to gangrene following a ritual circumcision.

The cold ischemia time was 16 hours because the same team that performed this transplant had to prioritize the transplant of a kidney from the same donor, a 36-year-old man who was brain dead but still had a beating heart.

The recipient recovered from anesthesia without complications and subsequently received immunosuppression with intravenous antithymocyte globulin, followed by prednisone, tacrolimus, and mycophenolate.

The postoperative period was complicated by thrombosis of an arterial anastomosis – which resolved after emergency thrombectomy and successful re-anastomosis – by an infected hematoma, which required a minor procedure, and by the development of a urethrocutaneous fistula that required surgical repair.

Satisfactory sexual relations

The recipient reported a first erection three weeks after surgery and, contrary to the recommendation of abstinence for at least three months, reported satisfactory penetrative sexual intercourse five weeks after the operation.

Six months after the transplant, the patient reported his partner's three-month pregnancy, but she ended up giving birth to a stillborn baby at term, according to the August 17 report in Lancet Online.

Two years after the operation, the patient is doing well, with no episodes of rejection. He reports regular, satisfying sexual relations in a stable relationship with normal ejaculation and orgasm.

 "Our findings show that penile allotransplantation is feasible and can result in the restoration of sexual function, penile sensation, and normal urination," the researchers conclude. "We also emphasize the importance of careful patient selection in terms of physical health, emotional and psychological stability, and adherence to treatment."

Sex reassignment surgery

"This case may also generate hypotheses that female-to-male gender reassignment surgery could benefit, in selected cases, in addition to the possibility of revascularization in vasculogenic impotence being reviewed, and other causes of complete penile loss being addressed in this way in the future," the researchers add.

Dr. Arthur L. Burnett of Johns Hopkins University School of Medicine, Baltimore, who co-authored an editorial accompanying the article, told Reuters Health via email: "The relatively durable result is impressive. It's also reassuring to know that a non-essential body organ, unlike a heart or liver, can be preserved with the patient adhering to their immunosuppression regimen over time."

"Penis transplantation can be considered a valid transplant procedure, just like transplants of other organs," he stated. "I hope this perspective will allow for greater acceptance of this option for managing penile loss conditions in the future."

"Teams need to prepare well and include a variety of specialists who meet various clinical, psychological, and ethical requirements for this effort to be successful," added Dr. Burnett.

Dr. Ryan P. Terlecki, director of the Men's Health Clinic at Wake Forest Baptist Health in Winston-Salem, North Carolina, told Reuters Health via email: "Penile allotransplantation is feasible, but it should not be considered simple. This is an operation that requires a multidisciplinary approach involving a urologist, plastic surgeon, vascular surgeon, and transplant team. The psychological state of candidates must be thoroughly investigated before surgery, as well as their resources to cope with numerous medical visits, and a plan to cover the cost of immunosuppression therapy."

"As a center that is also approved for this operation, it is important to carefully select patients based on the prior event necessary to consider this procedure," he said. "Loss of the penis due to benign pathology is also a valid indication."

Consent from the donor's family

"When the news showed this case from South Africa, our phones started ringing with requests from men who simply wanted a larger penis or better erections," said Terlecki. "The occurrence of erections after this case would not be surprising, as the patient was likely having erections from his penile stump before the surgery, and nerve signaling occurs upstream of the anastomosis. Thus, it would not be expected that this operation would restore erectile function to a man who lost it due to pathologies related to nerve or vascular diseases."

Dr. Keymanthri Moodley, director of the Center for Medical Ethics and Law at Stellenbosch University, who was not involved in the work, pointed out to Reuters Health that "the interesting issue surrounding seeking consent from grieving donor families for penis donation, compared to other organs, is that it is a form of external mutilation of the corpse."

"This would be significant in cultures that value the preservation of the human body even after death," she said.

In this particular case, the donor's family agreed to the donation only after being assured by the surgical team that they would create a false phallus from abdominal tissue to resemble a penis for aesthetic reasons, a procedure that took about 30 minutes to complete.

Dr. van der Merwe did not respond to a request for comment from Reuters Health.