Total phalloplasty can be a solution for transgender patients or patients suffering from congenital defects. However, frequent complications and less-than-perfect cosmetic results do not make it the best option.
In the past, penile transplantation was a theme for jokes, more than a medical reality. But now the Vascularised Composite Allotransplantation (VCA) has become a viable alternative for some complex defects (face, hands…), penile transplantation is considered a possibility. Total phalloplasty can be a solution for transgender patients or patients suffering from congenital defects. However, frequent complications and less-than-perfect cosmetic results do not make it the best option for male patients who lost their penis due to trauma or penile cancer.
Two recent publications attracted the attention of the urological reconstructive surgeons’ community. One was a letter published in NEJM announcing a ‘total penis, scrotum, and lower abdominal wall transplantation’. The second was a publication in Transplant International about ‘The Baltimore criteria for an ethical approach to penile transplantation: a clinical guideline’ in September 2019. Both articles came from Johns Hopkins institute, where a penile transplant programme was established recently.
There are a few important considerations that need to be made regarding penile transplantation; from ethical considerations to social acceptance, from patient selection to technical aspects, including surgical issues and prevention, but also management of rejection. All these concepts were discussed in an article published in Nature Reviews, highlighting the lack of guidelines to address the ethical concerns of this form of VCA. This paper establishes a hierarchy of steps which need to be taken for the success of a penile transplantation programme. The base of the pyramid should be formed by the ethical aspects.
Normal part of human existence
No question that male genital tissue loss can have devastating effects on self-image, on sexual and reproductive function as well as on the psychosocial wellbeing of the patient. This kind of transplantation is widely criticised, because it is supposed to be all about appearance and vanity, not life-saving. But it is not about getting an ‘enhancement’ of the penis for whim, it is the only way to allow individuals to recover a normal part of human existence.
The letter in NEJM describes the fifth report of a penile transplantation to date. There have been four previous reports: the first in Guangzhou, China in 2006, the next two in South Africa in 2014 and 2016, and the fourth at the Massachusetts General Hospital in 2017. This was done by a team led by Curtis Cetrulo, a plastic surgeon whom we had the opportunity to meet in Italy on two different occasions. One was in Rome in 2018, during a meeting organised by Salvatore Sansalone with the support of ESGURS. The other, which was very recent, was in Florence (see Picture 1).
It was very encouraging to listen to Prof. Cetrulo and hear from him directly which difficulties he encountered and the excitement of accomplishing such a huge task. It was amazing to hear about the training and rehearsals sessions before ‘D-day’. There was an immense group of people involved; not only surgeons but a multidisciplinary team which included plastic surgeons, urologists, radiologists, pathologists, psychiatrists, transplant coordinators, nurses, social workers, dieticians and financial coordinators.
Injured war veteran
In the Johns Hopkins case, not only the penis was transplanted but also the scrotum and the lower abdominal wall. The donor was a young, age-matched donor. The recipient was an injured war veteran who suffered a traumatic penile loss caused by a bomb blast. He also lost both legs above the knee, part of the lower abdominal wall, the scrotum and both testicles.
The surgery started with urethral anastomosis followed by corporal anastomosis, going from the ventral side of the penis to the dorsal aspect. The donor dorsal arteries and veins were anastomosed to the recipient’s deep inferior epigastric arteries and veins. Both recipient dorsal nerves were approximated and anastomosed to those of the graft. The technique was very similar to that of the Massachusetts General Hospital case.
Both had a very similar and successful evolution recovering near-normal erections and the ability to achieve orgasm and normal sensation in the glans. Both patients urinate while standing, with excellent stream, and low post-void residuals.
It is well known that the penis is a complex organ composed of many different tissue types, including skin, connective tissue, vascular sinuses, extensive innervation and urothelium. It is unclear how these tissues reject, how rejection affects function, how to best monitor the penis for rejection and which immunosuppression regimen is optimal. It has been reported that the onset and severity of rejection can be significantly reduced through tacrolimus treatment. The Johns Hopkins patient received alemtuzumab and glucocorticoid induction therapy, and tacrolimus maintenance monotherapy.
Viable and feasible alternative
One paper published in the Journal of Sexual Medicine about the attitudes toward penile transplantation among urologists and health professionals states that penile transplantation is accepted by most health professionals surveyed, albeit less than visceral organ transplantation. Anticipated limitations include the risk of immunosuppression, lack of available donors, and the effect on healthcare utilisation.
The current opinion is that penile transplantation is a viable and feasible alternative for male patients who have lost their penis due to trauma or cancer.
Urological surgeons should be part of the multidisciplinary teams involved in penile transplantation programmes. These programmes that should be implemented in Europe, assuming our role as leaders in reconstructive genital surgery.