Penis Transplantation: First US Experience

Curtis L. Cetrulo Jr, MD; Kai Li, MD; Harry M. Salinas, MD; Matthew D. Treiser, MD, PhD; Ilse Schol, BS; Glen W. Barrisford, MD; Francis J. McGovern, MD; Adam S. Feldman, MD, MPH; Michael T. Grant, MD; Cigdem Tanrikut, MD; Jeffrey H. Lee, MD; Richard J. Ehrlichman, MD; Paul W. Holzer, BS; Garry M. Choy, MD, MBA; Raymond W. Liu, MD; Zhi Yang Ng, MD; Alexandre G. Lellouch, MD; Josef M. Kurtz, PhD; William G. Austen Jr, MD; Jonathan M. Winograd, MD; Branko Bojovic, MD; Kyle R. Eberlin, MD; Ivy A. Rosales, MD; Robert B. Colvin, MD; Dicken S. C. Ko, MD, FRCSC, FACS

Disclosures

Annals of Surgery. 2018;267(5):983-988. 

In This Article

Abstract and Introduction

Abstract

Objective: We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer.

Background: Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide.

Methods: After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone.

Results: Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future.

Conclusions: We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.

Introduction

Vascularized composite allotransplantation (VCA) has become an established means of restoring complex soft tissue defects of the hand, face, and abdominal wall after extensive injury,[1–4] offering patients more optimal functional and physical restoration than conventional reconstructive options. Although initially met with ethical consternation, VCA has become widely accepted, and has resulted in excellent aesthetic and functional outcomes. Morbidity and mortality from these procedures is infrequent and has been almost uniformly due to sequelae or complications from the immunosuppressive medications required to prevent allograft rejection. Abrogation of the need for these drugs through induction of immunologic tolerance remains a critical focus of current research in this field.

Considering promising functional and psychosocial outcomes with other types of VCAs,[2] penis transplantation represents the next step in VCA evolution. Genitourinary injuries and diseases that result in partial or complete penile loss have devastating functional and emotional consequences for patients, leading to significant mental health sequelae, including depression and suicide.[5–7] Current reconstructive options for men with devastating genitourinary tissue loss are suboptimal in their ability to create a natural-appearing sensate phallus with sufficient voiding and erectile function.[8–11]

In 2006, the first penis transplantation was performed in China; however, the allograft was explanted 14 days postoperatively, reportedly due to psychological distress in the recipient.[12,13] The second was completed in December 2014 in South Africa with return of urinary and sexual function.[14]

We describe the first case of penis transplantation in the United States in a patient with a history of subtotal penectomy for penile cancer (Supplementary Table 1, http://links.lww.com/SLA/B229).

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