PENILE TRANSPLANTATION SURGERY

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2 PENILE TRANSPLANTATION SURGERY First successful penile transplant was performed at Tygerberg Academic Hospital on 11 December 2014 by a team of plastic surgeons and urologists The patient was 21 years and lost his penis due to infection following ritual circumcision Publication accepted: The Lancet: A van der Merwe, F Graewe, A Zuhlke et al. Penile allotransplantation for penis amputation following ritual circumcision with 24 months follow-up.

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4 BACKGROUND The surgery was part of a study project: Penile allograft transplantation for men with penile loss after ritual circumcision The goal of the study is to perform 10 penile transplants and to investigate the feasibility of penile transplants in a pragmatic setting in South Africa Human Research Ethics Committee approval obtained (N11/243)

5 THE DIFFERENT PARTS OF THE STUDY PROJECT Ethical work up and research Cadaver study Patient accrual: donor/recipient Transplantation surgery Immunosuppression Analysis of study results

6 IMMUNOSUPPRESSION Protocol: Conventional protocol for high risk renal transplant patients at the Tygerberg Nephrology Unit: Anti-thymocyte globulin for 10 days Methylprednisolone Tacrolimus Mycophenolate mofetil

7 BACKGROUND ON RITUAL CIRCUMCISION Up to 250 young males suffer severe penile mutilation or amputation per year

8 WHY DO A PENILE TRANSPLANT? ADVANTAGES Better cosmetic result No prosthesis needed No other donor area: No functional loss No cosmetic defect Erectile function: Sexual wellbeing Psychological wellbeing Better chance to produce offspring DISADVANTAGES Immunosuppression Possible psychological problems High costs

9 PENILE RECONSTRUCTION: RADIAL FOREARM FLAP

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13 PENILE RECONSTRUCTION ADVANTAGES No immunosuppression needed Lower costs Relatively good cosmetic result DISADVANTAGES Donor site cosmetic defect Donor site functional loss Hair on reconstructed penis and urethra Prosthesis related complications Limited sensation? Not erectile!

14 PENIS TRANSPLANTATION First attempt in China 2005 Transplant was removed on day 14 Due to severe psychological problems of recipient and his wife Severe swelling Partial skin necrosis No signs of rejection Hu W, Lu J, Zhang L, Wu W, Nie H, Zhu Y et al. A preliminary report of penile transplantation. Eur Urol 2006 October;50(4):851-3

15 We had a look at the neurovascular anatomy CADAVER STUDY

16 PENIS TRANSPLANTATION It took 2 years to find a donor on condition that we reconstruct the removed organ

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24 PENIS TRANSPLANTATION Before the blood vessels were reconnected we had 13 hours cold ischemia time

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38 POST OPERATIVE Tadalafil for the post-operative period to help with penile rehabilitation Anticoagulation with iv Heparin Post op admission in renal high care unit

39 COMPLICATIONS 4 hours post-op: thrombosis of one arterial anastomosis Thrombectomy and re-anastomosis 4 days post-op: small hematoma Drainage and debridement of sloughy skin edge 3 months post-op: Repair urethral fistula

40 2 days post op

41 1 month post op

42 3 months post op

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44 PENIS TRANSPLANTATION

45 6 MONTHS POST OP OUR PATIENT IS: A happy and positive young man Has regular intercourse Has minimal side effects of the immune suppression

46 PENIS RECONSTRUCTION VS PENIS TRANSPLANTATION

47 SECOND CAPE TOWN PENILE TRANSPLANT APRIL 2017

48 LESSONS LEARNED Recipient vessels frequently damaged look immediately for alternative blood supply Central arteries not necessary for survival Anastomosis of dorsal artery and vein and anastomosis of corpora sufficient for survival and function of transplant

49 PENILE TRANSPLANT First and third penile transplant performed in Cape Town, SOUTH AFRICA Second penile transplant performed in USA, Massachusetts last year

50 THANK YOU