Progress on penile transplant moves forward

Since 2014, three men have entered hospitals in the U.S. and South Africa without fully functioning genitalia. At least two departed with transplanted penises that allowed urination, erectile function, and-in at least one case-the capacity for intercourse.

A variety of hurdles remain before penile transplants become anything near routine. But the trio of cases has provided urologists and their teams with something valuable: experience and a track record of sorts.

Dr. Burnett“Things are moving slowly by all accounts. But it’s more than just a phenomenon that happened once and is fading,” said Arthur L. Burnett II, MD, MBA, professor of urology and director of the Basic Science Laboratory in Neurourology at Johns Hopkins Medical Institutions, Baltimore, in an interview with Urology Times.

“There have been challenges on different levels,” said Dr. Burnett, whose institution plans to offer penile transplants. “But I think it’s going to gain momentum.”

8-year gap from failure to success

The initial penis transplant, which took place in China in 2006, was unsuccessful. The 44-year-old recipient had suffered a recent traumatic penile injury and was matched with a brain-dead 22-year-old donor.

The donor penis was not rejected, surgeons said in a case report, and the man was able to urinate standing up after just 10 days. However, in their published report, the surgeons wrote: “At day 14 postoperatively because of a severe psychological problem of the recipient and his wife, the transplanted penis regretfully had to be cut off” (Eur Urol 2006; 50:851-3).

The first successful case came 8 years later, in late 2014, in South Africa. This time, the patient was an unidentified 21-year-old man who’d suffered penile loss as a result of complications of a ritual circumcision. In 2017, researchers published a 24-months follow-up case report about the 9-hour procedure (Lancet 2017; 390:1038-47).

Immediate complications included an arterial thrombus, an infected hematoma, and an area of proximal skin necrosis. Other complications included acute kidney injury at 7 months, which was reversed via lowering the dose of an immunosuppressant.

At discharge at 1 month post-operation, the patient was advised to wait to have sexual intercourse. The patient, however, did not wait. According to the new report, the patient began having sex 1 week after discharge, and began regular sexual intercourse at 3 months postoperatively.

Six months after the procedure, surgeon and lead author Andre van der Merwe, MD, professor and head of urology at Cape Town’s Stellenbosch University, told the BBC that the patient’s wife had become pregnant. It’s not clear if the wife went on to have a child or if paternity was confirmed.

The 2017 case report says questionnaires showed that the patient’s quality of life improved dramatically after the operation, and both maximum urine flow rate and International Index of Erectile Function scores reached normal levels.

Next - First U.S. case: A patient speaks out

First U.S. case: A patient speaks out

The first man to undergo a successful penis transplantation outside of South Africa did not hide his identity. In fact, Thomas Manning, a 64-year-old Massachusetts bank courier, who’d had most of his penis removed due to cancer, agreed to speak openly to the media about his operation and his motivations.

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“I want to go back to being who I was,” he told The New York Times from his bed after the 15-hour surgery in May 2016.

In May 2017, plastic surgeon Curtis L. Cetrulo, Jr., MD, of Massachusetts General Hospital in Boston, and colleagues provided a 7-month update about the case in Annals of Surgery (May 15, 2017 [Epub ahead of print]). According to the team, complications at 2 and 13 days postoperatively required treatment for hematoma and skin eschar debridement, and rejection detected on day 28 required an extra course of two immunosuppressants.

Patient’s improvement partial but significant

“At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence,” the team reported. “Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future.”

Dr. CetruloIn an interview with Urology Times, Dr. Cetrulo said that about a year after the surgery, Manning underwent an unrelated heart operation due to issues uncovered during his penile transplantation workup. Manning suffered dehydration, a kidney stone, and an infection. Doctors adjusted the patient’s medications.

“But now that he’s fully recovered, he’s back on testosterone and has had some really great nerve recovery. Sensitivity has progressed down the dorsum and the shaft to the glans. He’s gotten much more partial erectile function, and we’re happy that’s improving,” said Dr. Cetrulo, assistant professor of surgery at Harvard Medical School.

At 2 years, he said, doctors will consider the patient’s erectile function and consider if other measures, like a penile prosthesis, are appropriate.

In terms of urination, “his course has been amazing,” Dr. Cetrulo said, and the patient has met his goal of being able to urinate while standing up.

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“He [previously] had to sit down and urinate and splashed all over the place, always had his clothes smelling like urine,” he said. “One of his prime goals was to get urologic function.”

Next: In South Africa, a third transplant

In South Africa, a third transplant

Dr. van der MerweDr. van der Merwe of South Africa’s Stellenbosch University and his team performed a second successful penis transplant, the third in the world, in April 2017.

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According to a press statement provided by the university shortly after the procedure, the unidentified 40-year-old patient had lost his penis 17 years earlier after complications from a circumcision. “He is certainly one of the happiest patients we have seen in our ward. He is doing remarkably well. There are no signs of rejection, and all the reconnected structures seem to be healing well,” said Dr. Van der Merwe in the statement.

“A color discrepancy between the recipient and the donor organ will be corrected with medical tattooing between six to eight months after the operation,” the press statement noted. A news report quoted Dr. Van der Merwe as saying the deceased donor was white and the recipient is black.

A call for acceptance, urologist support

What now? “We’re pleased to see that it has been effective, that the penis can be functional,” said Dr. Burnett of Johns Hopkins. “It’s not that we’re transplanting a dead organ that sits there like a sock between the legs.

“We’ve learned that any of these surgeries are not easy. Yes, there can be strictures, fistulas, and things that need revisions. We know those are some of the realities, but it can also be successful for the long term. We’ve achieved what we imagined would be good outcomes.”

At Massachusetts General Hospital, one patient is ready to receive a donor penis when one becomes available, and another is nearing that status, Dr. Cetrulo said.

At Johns Hopkins, where the focus will be on men with injuries related to military service, a patient was matched with an appropriate donor, Dr. Burnett said. However, another patient had a higher priority to undergo a hand transplant from the donor, he said. Immunologic complications prevented both the donor’s hand and penis from being transplanted.

Moving forward, Dr. Burnett urged fellow urologists to take penile transplantation seriously. “This is not sensational,” he said. “This is a real advance for patients who have a penile deficiency or penile loss-military veterans, patients with congenital problems, traumatic accidents, cancers in the genital area. Urology may be one of the main specialists to help bring this forward, and we should champion this.”

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