- The penile transplantation procedure proved to be feasible and had excellent results
- The procedure was performed using conventional immunosuppression, and acute rejection episodes were managed successfully
- This report provides proof of concept that genitourinary vascularized composite allotransplantation can restore functional defects and improve the patient's self-image
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A multidisciplinary team at Massachusetts General Hospital performed the first penis transplantation in the United States in May 2016, and in Annals of Surgery, they describe excellent initial results.
In 2014, vascularized composite allografts, such as the tissue needed for face or hand transplantation, were categorized as organs by the Organ Procurement and Transplantation Network. Mass General subsequently established a pilot program for genitourinary vascularized composite allotransplantation (VCA).
For the initial penis transplantation, Dicken S. C. Ko, MD, now vice president of medical affairs at St. Elizabeth's Medical Center, and colleagues including Mass General Director of Urology Research Adam S. Feldman, MD, MPH, and Urologist Francis McGovern, MD, selected a patient who had undergone a partial penectomy for penile cancer and had remained disease-free for four years.
The patient's eligibility for the transplant was reviewed by a multidisciplinary team of plastic surgeons, urologists, radiologists, pathologists, psychiatrists, transplant coordinators, nurses, social workers, dietitians and financial coordinators. Preoperatively he had detailed education and extensive medical, surgical and radiological evaluations.
The published report gives full details of the preoperative imaging, transplantation procedure and perioperative immunologic management. One surgical team procured the donor allograft, while another prepared the recipient. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein and dorsal nerves were performed, with the inclusion of a donor skin pedicle as the composite allograft. A 2-cm gap between the dorsal penile nerves of the recipient and allograft was bridged with a commercially available acellular nerve allograft. The surgeons were able to determine allograft perfusion intraoperatively.
Postoperatively, the allograft had excellent capillary refill and strong Doppler signals. The patient had to be returned to the operating room on postoperative day (POD) two for hematoma evacuation, and on POD 13 for a small eschar on the skin flap that required operative debridement. The patient's catheter was removed three weeks postoperatively based on normal findings on a retrograde urethrogram. He was able to void immediately with excellent urinary stream and was discharged on POD 25.
Steroid resistant-rejection developed on POD 28 (Banff grade I) and required two pulse doses of methylprednisolone. It progressed to grade III by POD 32, and the patient received a repeat two-dose course of methylprednisolone along with antithymocyte globulin for four days. That regimen resulted in complete resolution of rejection.
Six months after surgery, the patient had recovered sensation in the penile shaft and was voiding with excellent stream. Postvoid residual volumes were low. The patient described spontaneous partial erectile function with increasing quality and frequency. He also reported increased overall health satisfaction, dramatic improvement of self-image and significant optimism for the future.
Dr. Ko's group comments that when VCA was introduced, it was challenged on ethical grounds because patients have to use powerful drugs for a lifetime to prevent graft rejection. Why subject people to the potential for systemic complications, and even death, when a procedure is not life-saving?
The authors' answer is that the holistic approach allows individuals to retain some normalcy in their lives that would have been otherwise unachievable. They note that VCA has become widely accepted and has resulted in excellent aesthetic and functional outcomes.
A critical focus of research at Mass General and elsewhere is to eliminate the requirement for immunosuppressive drugs by finding other ways to induce immunologic tolerance.
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