ESSM Newsletter # 38

12 ESSM Today Penile transplantation in men: Past, present and future by Nikolai Sopko Penile transplantation is a novel treatment strat- egy for severe penile disfigurement. In recon- structive surgery, replacing like tissues with like tissues is the goal. Given the penis’ complex ar- chitecture required for its functions of fluid trans- portation and penetrative intercourse, no other tissues in the body are similar. Phalloplasty using soft tissues from the arm, leg, or other areas achieve satisfactory cosmetic results. However, neophalluses have no erectile capability without implanting a penile prosthesis, which is delayed from the time of transplantation by approximately one year to allow the development of protective sensation and is fraught with complication rates approaching 40% [1]. The South African experi- ence suggests that even when a neophallus is successfully implanted, it cannot withstand the physical demands of frequent sexual intercourse. Neophallus fluid transport capabilities are also less than ideal with complications including fis- tulas and strictures at rates of 42% to 65% [2]. With the increasing experience and success in vascularized composite allotransplantation (VCA) such as face and arm transplantation, penile transplantation has become a reality. To date, there have been 4 attempts at human penile transplantation, 3 of which were success- ful. The first documented case was performed in 2006 in China on a 44-year-old man who lost his entire pendulous penis in a traumatic accident 8 months prior. Although there were no signs of rejection and the patient was able to spontaneously void on post-operative day 10, the transplanted penis was removed on post- operative day 14 due to “a severe psychologi- cal problem of the recipient and his wife”[3]. The second attempt and first successful human penile transplantation was performed in Decem- ber 2014 at the Tygerberg Academic Hospital in South Africa.[4] The 21-year-old man lost his pendulous penis due to infectious complications of a ritual circumcision performed 3 years earlier. This case has the longest documented follow-up of 24 months with encouraging results. By 24 months, the patient did not experience an epi- sode of rejection, was having unaided erections with normal orgasm and ejaculation that was sufficient enough to impregnate his girlfriend. Most importantly, the patient has fully accepted his transplanted penis and his quality of life is significantly improved. His immunosuppresion regimen consists of prednisone, tacrolimus, and azathioprine and complications thereof include acne and hypertension, which resolved with dose adjustment, and a successfully treated episode of a supra-patellar bursa fungal infection. The same group has recently performed their second penile transplantation (4th penile transplant overall) April 2017, of which the results and follow-up have not been published [4]. The second successful penile transplant was performed at the Massachusetts General Hos- pital in May 2016 after the 64 year-old recipient had a penectomy for penile cancer 4 years prior. [5] After 7 months of follow-up the patient has had 2 acute rejection episodes, has partial penile sensation and erectile function, and is voiding spontaneously. In both reported successful penile transplantations, recipients required several ad- ditional procedures for complications including hematoma evacuation, eschar debridement, and urethralcutaneous fistula closures. Given that penile transplantation is life-enhanc- ing and not life-saving, thorough discussions with the patient regarding the risks and benefits of the procedure are paramount. In both documented cases, patients underwent extensive psychologi- cal evaluation with assessment of motivation and treatment adherence. Treatment teams empha- sized discussions regarding possible psychologi- cal rejection of the graft, unmet expectations of treatment outcomes, graft failure, and social stigmatization. Patients were also counseled on the need of life-long immunosuppression and the associated risks including infection and malig- nancy. Psychological counseling and support is continued following the procedure. Informing society and organ donors of the benefit of this procedure to facilitate the donation of this very intimate organ is also important. To this end, the South African team created a neophallus for the donor, which was critical for the consent of the donor’s family [4]. To date, penile transplantation has been per- formed for complete loss of penile tissues either due to trauma or iatrogenesis. Likely, this will be the largest population of patients who will benefit from penile transplantation. Complications of ritual circumcision result in varying degrees of penile tissue loss in 250 young-men per year [4]. The protracted military conflicts in the Middle East with the extensive use of buried improvised explosive devices and improved survival in bat- tlefield trauma has resulted in large amounts of young soldiers with disfiguring genital trauma. Other indications include congenital penile dis- figurement in the setting of bladder exstrophy and disorders of sexual development. There is no rigorous data as of yet to determine whether penile transplantation will be desired for gen- der reassignment in the transgender population. Thus, one of the most important factors for the indication of penile transplantation will be the patient’s wishes and desires for their genital re- construction. If only cosmesis is desired, then a reconstructive neophallus may be sufficient. If the patient desires include frequent sexual intercourse and/or robust urinary transport then replacing like tissue with like tissue using penile transplantation may be the best option. One of the greatest impedances to widely adopt- ing this treatment modality is the significant risk associated with life-long immunosuppression. These include hypertension, renal failure, neu- ropathy, infection, and increased risk for develop- ing a malignancy. Exciting immunosuppression research seeking to achieve immune tolerance Nikolai Sopko, M.D., Ph.D. Chief Resident, Urologic Surgery The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine Baltimore, Maryland, USA nas@jhmi.edu