Penile transplant guidelines missing in action

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There are no national or international guidelines regarding penile transplants, raising a question without a concrete answer: What are the rules and the limits?

When Johns Hopkins University in Baltimore first announced that it planned to offer penile transplant surgery, several men called and asked if they could help. They wanted to assist in the most personal way possible-by donating their own organs while they’re still alive.

Dr. Burnett“I’m not using my penis any more. I’ll give it to you,” they would say, recalled urologist Arthur L. Burnett II, MD, MBA, professor of urology and director of the Basic Science Laboratory in Neurourology at Johns Hopkins Medical Institutions, in an interview with Urology Times.

While the men had the best intentions, the university declined their generous offer. At Johns Hopkins, penis donors must be deceased.

But there are no national or international guidelines regarding penile transplants as a whole, raising a question without a concrete answer: What are the rules and the limits?

Could a living man donate his penis to another man, as those callers to Johns Hopkins suggested? What about penis transplants in sex-change operations, in patients with erectile dysfunction, or even in those who simply want a larger or different-looking phallus?

“Unless guidelines are established and disseminated, penile transplants should not be undertaken,” bioethicists wrote in a 2017 report in the journal Transplantation (2017; 101:1200-5). But no such guidelines exist outside of individual institutions, and surgeons in the field of penile transplantation say they’re not aware of any that are in development.

Next: Areas of concern

Areas of concern

The Transplantation report points to several areas of concern, including issues of identity and physical intimacy, the pre-surgery role of intimate partners, and the expense of the transplant procedures.

On the cost front, a 2017 report notes that the first successful penile transplantation occurred in South Africa. Given limited resources and competing needs there, the report suggests, “prevention is a more appropriate response to botched traditional circumcisions than penile transplants” (J Med Ethics 2018; 44:86-90).

Bioethicists also worry about the role of potential donors.

“One of the concerns we raise is about ensuring that requests for penile donation do not end up compromising public support for organ donation in general,” said Laura Kimberly, MSW, MBE, an assistant research scientist in the department of plastic surgery at NYU Langone Health in New York and a co-author of the Transplantation report.

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A 2016 survey of 1,485 U.S. residents about vascularized composite allotransplantation (VCA) donation found that only 54.5% of men said they were willing to donate their penises (Am J Transplant 2017; 17:2687-95).

In contrast, a much higher 74.4% of women said they’d donate their uteruses, and two-thirds of respondents were willing to donate hands/forearms and legs.

“Many who opposed VCA donation expressed concerns about psychological discomfort, mutilation, identity loss, and the reaction of others to seeing familiar body parts on a stranger,” the authors wrote.

Dr. RodrigueThe study’s lead author, psychologist James R. Rodrigue, PhD, professor and vice chair of surgery at Beth Israel Deaconess Medical Center in Boston, told Urology Times that he’s gotten federal funding to examine VCA donation attitudes and perceptions in the veteran population.

“This seems to be an important area of inquiry since many of the individuals who could potentially benefit from penile transplantation are veterans with severe genitourinary battlefield injuries,” he explained. “That study is in the early stages, so nothing to report specifically.”