Penile transplant could happen here, U.S. surgeons say

Penile transplant surgery, performed successfully for the first time in South Africa, is technically feasible and has potential clinical applications in the United States, according two leading U.S. urologists.

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The groundbreaking, 9-hour surgery was performed in December 2014 at Tygerberg Hospital in Bellville, Cape Town and led by urologist André van der Merwe, MB, ChB, of Stellenbosch University. The 21-year-old recipient's penis had to be amputated to save his life when he developed severe complications after a traditional circumcision.

While such “ritual” circumcisions are rare in the U.S., two of the country’s leaders in sexual medicine told Urology Times the transplant surgery could play a role in certain patients.

“To show that this is something that’s technically feasible, I think that’s great,” said Arthur L. Burnett, MD, MBA, of Johns Hopkins Medicine, Baltimore. “I think there are situations where men can sustain serious genital trauma in somewhat less sensational but more noble situations here, from war injuries to post-penile cancer penectomies. So I think there are some real indications.”

“We are fortunate in this country that this particular injury-loss of the phallus after a traditional, non-medical circumcision-is vanishingly rare, but there are situations in which this might be applicable such as after various types of trauma or cancer,” added William O. Brant, MD, of University of Utah Health Care in Salt Lake City. “Currently, the approach is a ‘free-flap phalloplasty’ to create a new phallus, but this is also done uncommonly and by a few experienced practitioners.

“In my view, the most important aspect of this surgery is that this 21-year-old man was cared for expertly and thoroughly,” Dr. Brant wrote in an email to Urology Times. “In both the lay press and even in the views of insurance payers, penile and sexual health is often treated as a purely cosmetic issue. Worse, it is often treated as something that is not important for patient health or quality of life.

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“However, we know that phallic loss or significant erectile dysfunction (which might be better termed as ‘end-stage penile disease’) is a truly significant issue with ramifications that include loss of self-esteem, loss of relationship intimacy and communication, a decline in the man's feelings of general health and masculinity, etc.”

NEXT: Not the first group to perform penile transplant

The South African group is not the first to perform a penile transplant. Surgeons in China completed the procedure in a 44-year-old man in 2006, and reported their findings in European Urology (2006; 50:851-3). However, the transplanted penis was removed after 2 weeks “because of a severe psychological problem of the recipient and his wife,” the Chinese authors wrote.

In the surgery by Dr. van der Merwe and colleagues in multiple specialties, the patient has “made a full recovery and has regained all function in the newly transplanted organ,” Stellenbosch University reported in a March 2015 news release.

"Our goal was that he would be fully functional at 2 years and we are very surprised by his rapid recovery," said Dr. van der Merwe. The result was the restoration of all the patient's urinary and reproductive functions, he said.

The planning and preparation for the study started in 2010. After extensive research, Dr. van der Merwe and his surgical team decided to employ some parts of the model and techniques developed for the first facial transplant.

"We used the same type of microscopic surgery to connect small blood vessels and nerves, and the psychological evaluation of patients was also similar. The procedure has to be sustainable and has to work in our environment at Tygerberg," he said.

Like Dr. Burnett and Dr. Brant, Dr. van der Merwe said the procedure could eventually also be extended to men who have lost their penises from penile cancer. But he went a step further in adding that it also could be a “a last-resort treatment for severe erectile dysfunction.”

“That would be a stretch,” Dr. Burnett said. “If somebody at least has the structure of the penis intact, we can conceivably do other things.”

 “I do not know whether the costs associated with immunosuppression and other care will prohibit penile transplant in general [in the U.S.], nor what the long-term effects will be as compared to flap phalloplasty,” Dr. Brant said. “But I am encouraged that dedicated practitioners are willing to improve care and caring, advance the field, and take these issues seriously.”

As part of the South African group’s study, nine more patients are scheduled to receive penile transplants.

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