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Girard AO, Lake IV, Lopez CD, Kalsi R, Brandacher G, Cooney DS, Redett RJ. Vascularized composite allotransplantation of the penis: current status and future perspectives. Int J Impot Res 2021; 34:383-391. [PMID: 34711953 DOI: 10.1038/s41443-021-00481-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/30/2021] [Accepted: 10/11/2021] [Indexed: 12/13/2022]
Abstract
Given the multifunctional role of the penis in daily life, penile loss can be a physically and emotionally devastating injury. Options to restore penile loss have traditionally relied on autogenous free flap, local flaps, and skin grafts. These techniques provide satisfactory outcomes but carry high rates of urologic and prosthesis-related complications. Vascularized composite allotransplantation may offer a novel solution for these patients through reconstruction with true penile tissue. Still, penile transplants pose ethical, logistical, and psychosocial challenges. These obstacles are made more complex by the limited cases detailed in published literature. A review of the literature was conducted to assay current practices for penile reconstruction. Most modern complex penile reconstructions utilize autogenous pedicled or free tissue flaps, which may be harvested from a variety of donor sites. A total of five penile transplants have been described in the literature. Of these, four report satisfactory outcomes. The advent of genital allotransplantation has recently broadened the landscape of treatment for penile loss. Reconstruction using true penile tissue through vascularized penile allotransplantation has the possibility to engender increased penile function, sensation, and overall quality of life.
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Affiliation(s)
- Alisa O Girard
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Plastic Surgery, Rutgers - Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Isabel V Lake
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richa Kalsi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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The Ethics of Facial Allotransplantation: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2425. [PMID: 31772878 PMCID: PMC6846319 DOI: 10.1097/gox.0000000000002425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/02/2019] [Indexed: 01/12/2023]
Abstract
Supplemental Digital Content is available in the text. Currently, there are more than 40 cases of facial allotransplantation performed by 13 different groups in 10 countries. Although it has become a potential option to reconstruct and restore the function and appearance of severely facially disfigured individuals, the ethical concerns of facial allotransplantation remain unsolved. We conducted a systematic review to better understand the ethical concerns on facial allotransplantation and the changing trends of the ethical debate over time.
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Abstract
OBJECTIVE We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer. BACKGROUND Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide. METHODS After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone. RESULTS Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future. CONCLUSIONS We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.
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Logistics in Coordinating the First Adult Transatlantic Bilateral Hand Transplant. Plast Reconstr Surg 2018; 142:730-735. [DOI: 10.1097/prs.0000000000004672] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Enhanced Drug Delivery to the Skin Using Liposomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1739. [PMID: 30175003 PMCID: PMC6110675 DOI: 10.1097/gox.0000000000001739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 02/07/2018] [Indexed: 12/02/2022]
Abstract
Background: Enhancing drug delivery to the skin has importance in many therapeutic strategies. In particular, the outcome in vascularized composite allotransplantation mainly depends on systemic immunosuppression to prevent and treat episodes of transplant rejection. However, the side effects of systemic immunosuppression may introduce substantial risk to the patient and are weighed against the expected benefits. Successful enhancement of delivery of immunosuppressive agents to the most immunogenic tissues would allow for a reduction in systemic doses, thereby minimizing side effects. Nanoparticle-assisted transport by low temperature–sensitive liposomes (LTSLs) has shown some benefit in anticancer therapy. Our goal was to test whether delivery of a marker agent to the skin could be selectively enhanced. Methods: In an in vivo model, LTSLs containing doxorubicin (dox) as a marker were administered intravenously to rats that were exposed locally to mild hyperthermia. Skin samples of the hyperthermia treated hind limb were compared with skin of the contralateral normothermia hind limb. Tissue content of dox was quantified both via high-performance liquid chromatography and via histology in skin and liver. Results: The concentration of dox in hyperthermia-treated skin was significantly elevated over both normothermic skin and liver. (P < 0.02). Conclusions: We show here that delivery of therapeutics to the skin can be targeted and enhanced using LTSLs. Targeting drug delivery with this method may reduce the systemic toxicity seen in a systemic free-drug administration. Development of more hydrophilic immunosuppressants in the future would increase the applicability of this system in the treatment of rejection reactions in vascularized composite allotransplantation. The treatment of other skin condition might be another potential application.
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Cooney CM, Siotos C, Aston JW, Bello RJ, Seal SM, Cooney DS, Shores JT, Brandacher G, Lee WPA. The Ethics of Hand Transplantation: A Systematic Review. J Hand Surg Am 2018; 43:84.e1-84.e15. [PMID: 28985978 DOI: 10.1016/j.jhsa.2017.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE We conducted a systematic review to document ethical concerns regarding human upper extremity (UE) allotransplantation and how these concerns have changed over time. METHODS We performed a systematic review of 5 databases to find manuscripts addressing ethical concerns related to UE allotransplantation. Inclusion criteria were papers that were on the topic of UE allotransplantation, and related ethical concerns, written in English. We extracted and categorized ethical themes under the 4 principles of bioethics: Autonomy, Beneficence, Nonmaleficence, and Justice. We assessed theme frequency by publication year using Joinpoint regression, analyzing temporal trends, and estimating annual percent change. RESULTS We identified 474 citations; 49 articles were included in the final analysis. Publication years were 1998 to 2015 (mean, 3 publications/y; range, 0-7 publications/y). Nonmaleficence was most often addressed (46 of 49 papers; 94%) followed by autonomy (36 of 49; 74%), beneficence (35 of 49; 71%), and justice (31 of 49; 63%). Of the 14 most common themes, only "Need for More Research/Data" (nonmaleficence) demonstrated a significant increase from 1998 to 2002. CONCLUSIONS Upper extremity transplantation is an appealing reconstructive option for patients and physicians. Its life-enhancing (vs life-saving) nature and requirement for long-term immunosuppression have generated much ethical debate. Availability of human data has influenced ethical concerns over time. Our results indicate that discussion of ethical issues in the literature increased following publication of UE transplants and outcomes as well as after meetings of national societies and policy decisions by regulatory agencies. CLINICAL RELEVANCE Because UE transplantation is not a life-saving procedure, much ethical debate has accompanied its evolution. It is important for UE surgeons considering referring patients for evaluation to be aware of this discussion to fully educate patients and help them make informed treatment decisions.
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Affiliation(s)
- Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Charalampos Siotos
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey W Aston
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ricardo J Bello
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stella M Seal
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Arav A, Friedman O, Natan Y, Gur E, Shani N. Rat Hindlimb Cryopreservation and Transplantation: A Step Toward "Organ Banking". Am J Transplant 2017; 17:2820-2828. [PMID: 28422434 DOI: 10.1111/ajt.14320] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/07/2017] [Accepted: 04/12/2017] [Indexed: 01/25/2023]
Abstract
In 2016, over 5 million reconstructive procedures were performed in the United States. The recent successes of clinical vascularized composite allotransplantations, hand and face transplantations included, established the tremendous potential of these life-enhancing reconstructions. Nevertheless, due to limited availability and lifelong immunosuppression, application is limited. Long-term banking of composite transplants may increase the availability of esthetically compatible parts with partial or complete HLA matching, reducing the risk of rejection and the immunosuppressive burden. The study purpose was to develop efficient protocols for the cryopreservation and transplantation of a complete rodent limb. Directional freezing is a method in which a sample is cooled at a constant-velocity linear temperature gradient, enabling precise control of the process and ice crystal formation. Vitrification is an alternative cryopreservation method in which the sample solidifies without the formation of ice crystals. Testing both methods on a rat hindlimb composite tissue transplantation model, we found reliable, reproducible, and stable ways to preserve composite tissue. We believe that with further research and development, cryopreservation may lead to composite tissue "banks." This may lead to a paradigm shift from few and far apart emergent surgeries to wide-scale, well-planned, and better-controlled elective surgeries.
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Affiliation(s)
- A Arav
- FertileSafe Ltd, Nes-Ziona, Israel
| | - O Friedman
- The Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Natan
- FertileSafe Ltd, Nes-Ziona, Israel
| | - E Gur
- The Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - N Shani
- The Department of Plastic and Reconstructive Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
PURPOSE Hand transplantations have been initiated and have been encouraged by promising results for more than 1 decade. The aim of this study was to present the first case of hand transplantation performed in Taiwan. MATERIALS AND METHODS On September 3, 2014, we transplanted the left distal forearm and hand of a brain-dead managed 37 years to a man aged 45 years who had traumatic amputation of the distal third of his right forearm 30 years ago. The total ischemic time during the transplantation was 6 hours and 45 minutes. Immunosuppression included anti-thymocyte globulins, and methylprednisolone (Solumedrol) was used for the induction. Maintenance therapy included systemic tacrolimus, mycophenolic acid [mycophenolate mofetil (MMF)], and prednisone. A combination of systemic (tacrolimus/MMF/prednisolone) and topical immunosuppressant cream (clobetasol and tacrolimus) was applied if acute rejection occurred. Follow-up included routine posttransplant laboratory tests, skin biopsies, intensive physiotherapy, and psychological support. RESULTS The initial postoperative course was uneventful. No surgical complications were observed. Immunosuppression was well tolerated using tacrolimus, MMF, and prednisone, except for some immune-related complications. One episode of mild clinical and histological signs of cutaneous rejection was seen at 105 days after surgery. These signs disappeared after pulse therapy with Solumedrol and the topical application of immunosuppressive creams (tacrolimus and clobetasol). One infection episode occurred due to local cellulitis and axillary lymphadenopathy on day 140 and was successfully treated with antibiotics. The patient developed cytomegalovirus infection at 7 months that responded to medication. Intensive physiotherapy led to satisfactory progress in motor functioning. Sensory progress (Tinel sign) was good and reached the wrist by 3 months for the median and ulnar nerves, and could be felt in the finger tip by 9 months in response to deep pressure and light touch sensations. The patient has a lateral pinch that allows him to pick up and grip objects during daily living, although his muscle power is still insufficient. CONCLUSIONS Hand allotransplantation is technically feasible. Currently available immunosuppression methods seem to control vascularized composite tissue allotransplantation rejection. A combination of topical and systemic immunosuppressants is a useful method to prevent acute hand allotransplant rejection.
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Kiwanuka H, Aycart MA, Bueno EM, Pomahac B, Talbot SG. Experience With Patient Referrals for Upper Extremity Transplantation at a U.S. Academic Medical Center. J Hand Surg Am 2017. [PMID: 28648330 DOI: 10.1016/j.jhsa.2017.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To date, there have been over 100 upper extremity transplantations (UET) performed worldwide. However, little data are available regarding institutional screening practices or description of the population of patients that seek transplantation as a treatment modality for their upper extremity disabilities. We performed a review of our institutional experience in an attempt to better understand our referral patterns and identify factors that may be associated with successful screening. METHODS Contact demographic data, injury characteristics, and mode of referral were retrospectively reviewed from 2010 through 2015. Differences in demographic data, injury-related characteristics, and clinical trial outcomes were assessed with the Chi-square test or Fisher exact test. RESULTS There were a total of 89 UET contacts. The average age was 35.2 years, with most contacts being white (n = 24). The majority were male (n = 66; 75.0%) and the most common indication for referral was trauma (n = 43; 55.8%). Of the 89 contacts, 20 (22.5%) were physician referrals and 69 (77.5%) were self-referrals. Physician referrals led to the most screened and accepted contacts, whereas self-referrals more often led to immediate exclusion. CONCLUSIONS This study gives an overview of the demographic composition of our UET contacts, with a specific emphasis on mode of referral. We have identified that physician referrals have led to more screened and accepted patients versus self-referred individuals. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Harriet Kiwanuka
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mario A Aycart
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ericka M Bueno
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Simon G Talbot
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Tuffaha SH, Cooney DS, Sopko NA, Bivalacqua TJ, Lough DM, Cooney CM, Brandacher G, Lee WPA, Burnett AL, Redett RJ. Penile transplantation: an emerging option for genitourinary reconstruction. Transpl Int 2017; 30:441-450. [PMID: 28130926 DOI: 10.1111/tri.12928] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/05/2016] [Accepted: 01/24/2017] [Indexed: 01/10/2023]
Abstract
Penile transplantation is an emerging option for patients with severe genital defects not amenable to traditional reconstructive options. In this article, we discuss the burgeoning problem of severe male genitourinary trauma in the military, the limitations of traditional reconstructive options in addressing these problems, and the potential for penile transplantation to provide improved outcomes. We also review the preclinical research and limited worldwide experience with penile transplantation to date, including lessons learned, and discuss the many important technical, logistical, and ethical considerations pertaining to penile transplantation that must be addressed to maximize the likelihood of successful implementation.
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Affiliation(s)
- Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nikolai A Sopko
- Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Denver M Lough
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Wei-Ping Andrew Lee
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arthur L Burnett
- Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
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Momeni A, Chang B, Levin LS. Technology and vascularized composite allotransplantation (VCA)-lessons learned from the first bilateral pediatric hand transplant. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2016; 27:161. [PMID: 27638100 DOI: 10.1007/s10856-016-5771-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/24/2016] [Indexed: 06/06/2023]
Abstract
The reconstructive principle of replacing "like with like" is best met with vascularized composite allotransplantation in which the components of an existing defect are "matched" to the greatest extent possible in a single stage restoration. Hand transplantation is a labor-intensive and time-intensive process and can be conceptualized into distinct phases that include (1) patient selection and preoperative preparation, (2) technical execution of the procedure, and (3) postoperative rehabilitation and follow-up. The advent of technological innovations, such as 3D printing technology, novel implant technology, as well as innovative imaging technology, such as functional magnetic resonance imaging have the potential of favorably affecting all phases of this process, thus contributing to improved outcomes. The use of these technologies in the world's first case of bilateral hand transplantation in a pediatric patient is discussed.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University, 770 Welch Road, Suite 400, Palo Alto, CA, USA.
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Benjamin Chang
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Kumnig M, Jowsey-Gregoire SG. Key psychosocial challenges in vascularized composite allotransplantation. World J Transplant 2016; 6:91-102. [PMID: 27011907 PMCID: PMC4801807 DOI: 10.5500/wjt.v6.i1.91] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 12/16/2015] [Accepted: 01/08/2016] [Indexed: 02/05/2023] Open
Abstract
Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation (VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation (SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.
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Seyam RM, Kattan SA, Assad LW, El-Sayed RM, Almohanna FH. Penile autotransplantation in rats: An animal model. Urol Ann 2013; 5:255-8. [PMID: 24311905 PMCID: PMC3835983 DOI: 10.4103/0974-7796.120300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Accepted: 08/02/2012] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Penile allotransplantation might be a viable option for patients who need penile reconstruction. AIMS A successful autotransplantation rat model is the first step toward proceeding for allotransplantation. We herein evaluate autotransplantation following transaction of the rat penis just distal to the urethral bulb. SETTINGS AND DESIGN Experimental animal study. MATERIALS AND METHODS Five Sprague-Dawely rats weighing 520 g (SD 19) were used. Utilizing a magnification of 6-40, transection and immediate anastomosis of the tunica albuginea, urethra, dorsal vein and nerves were carried out. Vesicostomy was made to divert urine. The glandular skin was sutured to the perineum and the abdominal wall was closed in layers. STATISTICAL ANALYSIS USED Descriptive statistics. RESULTS Average surgery time was 8 h. The first two rats had no vesicostomy and died in the first postoperative day from retention. Three rats tolerated well the procedure and survived to the end point. One rat was sacrificed at day 10 and histopathology showed 30-50% necrosis of the implanted penis. Another rat was sacrificed at day 20 and showed normal cavernous tissue. The fifth rat was sacrificed 3 months postoperatively and showed evidence of moderate corporal fibrosis. Urethral fistula and necrosis of corpus spongiosum, dorsal nerve necrosis and dorsal vein occurred in all animals. CONCLUSIONS Penile autotransplantation in rats is feasible and provides the basis for evaluation of the corpora cavernosa in an allotransplantation model. Long-term urethral continuity and dorsal neurovascular bundle survival in this model is difficult to establish.
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Affiliation(s)
- Raouf M Seyam
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Ravindra K, Haeberle M, Levin LS, Ildstad ST. Immunology of vascularized composite allotransplantation: a primer for hand surgeons. J Hand Surg Am 2012; 37:842-50. [PMID: 22464235 DOI: 10.1016/j.jhsa.2012.01.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 01/31/2012] [Indexed: 02/02/2023]
Abstract
Vascularized composite allotransplantation is a recent innovation in the fields of transplantation surgery, plastic and reconstructive surgery, and orthopedic surgery. The success of hand and face transplantation has been based on extensive experience in solid organ transplantation. Advances in understanding the immunology of transplantation have had a major role in achieving excellent results in this new field. The purpose of this article is to introduce the basics of human immunology (innate and adaptive systems) and the immunological basis of human transplantation (the importance of human leukocyte antigen, direct and indirect pathways of antigen recognition, the 3 signals for T-cell activation, and mechanisms and types of allograft rejection) and focus on the mode of action of immunosuppressive drugs that have evolved as the mechanisms and pathways for rejection have been defined through research. This includes recent studies involving the use of costimulatory blockade, regulatory T cells, and tolerance induction that have resulted from research in understanding the mechanisms of immune recognition and function.
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Affiliation(s)
- K Ravindra
- Duke University Medical Center, Durham, NC, USA
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Sensitized recipients exhibit accelerated but not hyperacute rejection of vascularized composite tissue allografts. Transplantation 2011; 92:627-33. [PMID: 21822173 DOI: 10.1097/tp.0b013e31822b9264] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Currently, the donor-recipient matching process for vascularized composite tissue allotransplantation (VCTA) closely follows the standard practices for solid organ transplantation. Sensitization is considered a contraindication to VCTA. However, the role of sensitization in VCTA rejection is largely unstudied. METHODS Major histocompatibility-mismatched ACI (RT1) donors and Wistar Furth (WF) (RT1) recipients were used to determine whether sensitization would lead to hyperacute rejection in VCTA as in other organs, such as kidneys. WF rats were presensitized to ACI antigens by skin transplantation and received heterotopic osteomyocutaneous VCTA flaps. Kidney transplants served as controls. RESULTS Production of anti-donor antibody was detected in WF recipients after rejection of the ACI skin grafts. Sensitized WF rats rejected VCTA grafts from ACI rats significantly faster (P<0.05) than unsensitized recipients, but not hyperacutely. Rejection in the sensitized recipients was not prevented by immunosuppression with FK506 and mycophenolate mofetil. In contrast, kidney allografts from ACI rats were hyperacutely rejected within 30 min by sensitized recipients. To confirm the role of antibody-mediated rejection in the sensitized recipients, serum from presensitized rats was adoptively transferred into naïve WF rats. Hyperacute rejection occurred only in transplanted kidneys but not VCTA. Histologic examination of tissues from acceleratedly rejected VCTA showed dense lymphocytic infiltrates, and no antibody deposition. CONCLUSIONS VCTA are rejected in an accelerated fashion but not hyperacutely in the presence of allosensitization and preformed anti-donor antibody. The rejection of VCTA in sensitized recipients is mainly cell mediated and differs mechanistically from that for renal transplants.
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Gorantla VS, Demetris AJ. Acute and chronic rejection in upper extremity transplantation: what have we learned? Hand Clin 2011; 27:481-93, ix. [PMID: 22051389 DOI: 10.1016/j.hcl.2011.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To date, 78 upper extremity transplants have been performed in 55 recipients around the world. The purpose of this article is to provide an overview of acute and chronic rejection (CR) and to summarize collective insights in upper extremity transplantation. To date, almost all patients experienced AR that is pathophysiologically similar to that in solid organs. The spectre of chronic rejection is just emerging. Upper extremity transplantation has significant potential as a reconstructive option only if efforts are invested in strategies to reduce risks of prolonged immunosuppression and in approaches to better diagnose, monitor and treat AR and CR.
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Affiliation(s)
- Vijay S Gorantla
- Pittsburgh Reconstructive Transplantation Program, Division of Plastic Surgery, Department of Surgery, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Abstract
Hand transplantation is an elective non-life saving but quality of life-giving surgery for good candidates that is not without risk. Patient screening and selection is the most critical element to successful transplantation outcomes and cannot be overemphasized in terms of importance in the overall scheme of an active composite tissue allotransplantation (CTA) program. This article discusses the various criteria that are important in the selection of patients for CTA.
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Affiliation(s)
- Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Suite 8140C, Baltimore, MD 21287, USA.
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Ravindra K, Wu S, McKinney M, Xu H, Ildstad S. Composite Tissue Allotransplantation: Current Challenges. Transplant Proc 2009; 41:3519-28. [DOI: 10.1016/j.transproceed.2009.08.052] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 08/05/2009] [Indexed: 12/16/2022]
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Rahhal DN, Xu H, Huang WC, Wu S, Wen Y, Huang Y, Ildstad ST. Dissociation between peripheral blood chimerism and tolerance to hindlimb composite tissue transplants: preferential localization of chimerism in donor bone. Transplantation 2009; 88:773-81. [PMID: 19920776 PMCID: PMC2780434 DOI: 10.1097/tp.0b013e3181b47cfa] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mixed chimerism induces donor-specific tolerance to composite tissue allotransplants (CTAs). In the present studies, we used a nonmyeloablative conditioning approach to establish chimerism and promote CTA acceptance. METHODS Wistar Furth (RT1A(u)) rats were conditioned with 600 to 300 cGy total body irradiation (TBI, day-1), and 100 x 10(6) T-cell-depleted ACI (RT1A(abl)) bone marrow cells were transplanted on day 0, followed by a 11-day course of tacrolimus and one dose of antilymphocyte serum (day 10). Heterotopic osteomyocutaneous flap transplantation was performed 4 to 6 weeks after bone marrow transplantation. RESULTS Mixed chimerism was initially achieved in almost all recipients, but long-term acceptance of CTA was only achieved in rats treated with 600 cGy TBI. When anti-alphabeta-T-cell receptor (TCR) monoclonal antibody (mAb) (day-3) was added into the regimens, donor chimerism was similar to recipients preconditioned without anti-alphabeta-TCR mAb. However, the long-term CTA survival was significantly improved in chimeras receiving more than or equal to 300 cGy TBI plus anti-alphabeta-TCR mAb. Higher levels of donor chimerism were associated with CTA acceptance. The majority of flap acceptors lost peripheral blood chimerism within 6 months. However, donor chimerism persisted in the transplanted bone at significantly higher levels compared with other hematopoietic compartments. The compartment donor chimerism may be responsible for the maintenance of tolerance to CTA. Long-term acceptors were tolerant to a donor skin graft challenge even in the absence of peripheral blood chimerism. CONCLUSIONS Mixed chimerism established by nonmyeloablative conditioning induces long-term acceptance of CTA, which is associated with persistent chimerism preferentially in the transplanted donor bone.
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Affiliation(s)
- Dina N Rahhal
- Institute for Cellular Therapeutics, University of Louisville, Louisville, KY 40202-1760, USA.
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de With MCJ, van der Heijden EPAB, van Oosterhout MF, Kon M, Kroese ABA. Contractile and morphological properties of hamster retractor muscle following 16 h of cold preservation. Cryobiology 2009; 59:308-16. [PMID: 19733556 DOI: 10.1016/j.cryobiol.2009.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 07/14/2009] [Accepted: 08/31/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cold hypoxia is a common factor in cold tissue preservation and mammalian hibernation. The purpose of this study was to determine the effects of cold preservation on the function of the retractor (RET) muscle of the hamster in the non-hibernating state and compare these with previously published data (van der Heijden et al., 2000) on the rat cutaneus trunci (CT) muscle. MATERIALS AND METHODS After cold storage (16 h at 4 degrees C), muscles were stimulated electrically to measure maximum tetanus tension (P(0)) and histologically analyzed. The protective effects of addition of the antioxidants trolox and deferiprone and the calcium release inhibitor BDM to the storage fluid were determined. RESULTS After storage, the twitch threshold current was increased (from 60 to 500 microA) and P(0) was decreased to 27% of control. RET morphology remained unaffected. RET muscle function was protected by trolox and deferiprone (P(0), resp., 43% and 59% of control). Addition of BDM had no effect on the RET. CONCLUSIONS The observed effects of cold preservation and of trolox and deferiprone on the RET were comparable to those on CT muscle function, as reported in a previously published study (van der Heijden et al., 2000). Both hamster RET and rat CT muscles show considerable functional damage due to actions of reactive oxygen species. In contrast to the CT, in the RET cold preservation-induced functional injury could not be prevented by BDM and was not accompanied by morphological damage such as necrosis and edema. This suggests that the RET myocytes possess a specific adaptation to withstand the Ca(2+) overload induced by cold ischemia.
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Affiliation(s)
- Miriam C J de With
- Department of Plastic Reconstructive and Hand Surgery, University Medical Center, G04.122, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Abstract
On November 2006, a bilateral hand allotransplantation was performed for a 47-year-old female who had suffered radiocarpal amputations 28 years before. Technical aspects of the operation are detailed. Alemtuzumab induction, and triple therapy of tacrolimus, mycophenolate mofetil and prednisone were used to control rejection. The evolution of the result and functioning at 20 months are presented in detail. Two acute rejection episodes occurred and were successfully treated with steroids. In addition the patient developed a factitious visual disorder and a facial basal cell carcinoma. Functionally, at 20 months, the patient had a Hand Registry Functional Score of 69 (good), and a DASH score of 19.
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Kuo YR, Shih HS, Lin CC, Huang CC, Yang JCS, Wu WS, Goto S, Chen CL, Lee WA. Swine Hemi-Facial Composite Tissue Allotransplantation: A Model to Study Immune Rejection. J Surg Res 2009; 153:268-73. [DOI: 10.1016/j.jss.2008.03.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 03/26/2008] [Accepted: 03/31/2008] [Indexed: 10/22/2022]
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Increased Signs of Acute Rejection With Ischemic Time in a Rat Musculocutaneous Allotransplant Model. Transplant Proc 2009; 41:531-6. [DOI: 10.1016/j.transproceed.2009.01.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hand transplantation in the United States: experience with 3 patients. Surgery 2008; 144:638-43; discussion 643-4. [PMID: 18847649 DOI: 10.1016/j.surg.2008.06.025] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 06/17/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND Composite tissue allotransplantation (CTA) is a newly emerging field of transplantation that involves the simultaneous transfer of multiple tissues with differing antigenicity. Hand transplantation, the most widely recognized form of CTA, aims to improve function and the quality of life of upper limb amputees. METHODS In 1999, an institutional review board-approved hand transplantation protocol was implemented at the Jewish Hospital, University of Louisville. Suitable patients were evaluated and underwent hand transplantation. The surgical technique was akin to that used in limb reimplantation, and the immunosuppression protocol used was similar to renal transplantation. RESULTS Between 1999 and 2006, 3 patients underwent hand transplantation at our center. Although episodes of acute rejection were seen in all patients during the early postoperative period, only 1 immunologic event occurred after the first year. Graft function improved with time period. Carroll test scores were superior to those recorded with a prosthesis at the end of 1 year. Additionally, recovery of protective sensation was seen in all 3 patients and limited discriminatory sensation in 2. Complications related to immunosuppression have included cytomegalovirus infection in 2 patients, diabetes in 1, hyperlipidemia in 2, and osteonecrosis in 1. At a follow-up of 8, 6, and 1 year(s), all the recipients are healthy and have returned to a productive life. CONCLUSIONS The long-term success reported here should encourage wider application of the CTA in general and hand transplantation in particular. Methods of minimizing long-term immunosuppression need to be pursued.
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Swearingen B, Ravindra K, Xu H, Wu S, Breidenbach WC, Ildstad ST. Science of composite tissue allotransplantation. Transplantation 2008; 86:627-35. [PMID: 18791440 PMCID: PMC2629383 DOI: 10.1097/tp.0b013e318184ca6a] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The science of composite tissue allotransplantation (CTA) is rooted in progressive thinking by surgeons, fueled by innovative solutions, and aided by understanding the immunology of tolerance and rejection. These three factors have allowed CTA to progress from science fiction to science fact. Research using preclinical animal models has allowed an understanding of the antigenicity of complex tissue transplants and mechanisms to promote graft acceptance. As a result, translation to the clinic has shown that CTA is a viable treatment option well on the way of becoming a standard of care for those who have lost extremities and suffered large tissue defects. The field of CTA has been progressing exponentially over the past decade. Transplantation of hands, larynx, vascularized knee, trachea, face, and abdominal wall has been performed. Several important observations have emerged from translation to the clinic. Although it was predicted that rejection would pose a major limitation, this has not proven true. In fact, steroid-sparing protocols for immunosuppression that have been successfully used in renal transplantation are sufficient to prevent rejection of limbs. Although skin is highly antigenic when transplanted alone in animal models, when part of a CTA, it has not proven to be. Chronic rejection has not been conclusively demonstrated in hand transplant recipients and is difficult to induce in rodent models of CTA. This review focuses on the science of CTA, provides a snapshot of where we are in the clinic, and discusses prospects for the future to make the procedures even more widely available.
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Affiliation(s)
| | | | - Hong Xu
- Institute for Cellular Therapeutics, Louisville, KY
| | - Shengli Wu
- Institute for Cellular Therapeutics, Louisville, KY
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Kanitakis J. The challenge of dermatopathological diagnosis of composite tissue allograft rejection: a review. J Cutan Pathol 2008; 35:738-44. [DOI: 10.1111/j.1600-0560.2007.00889.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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The feasibility of diaphragmatic transplantation as potential therapy for treatment of respiratory failure associated with Duchenne muscular dystrophy: acute canine model. J Thorac Cardiovasc Surg 2008; 135:1398-9. [PMID: 18544399 DOI: 10.1016/j.jtcvs.2007.12.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Accepted: 12/04/2007] [Indexed: 11/22/2022]
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Ravindra KV, Wu S, Bozulic L, Xu H, Breidenbach WC, Ildstad ST. Composite tissue transplantation: a rapidly advancing field. Transplant Proc 2008; 40:1237-48. [PMID: 18589081 PMCID: PMC2692668 DOI: 10.1016/j.transproceed.2008.04.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. It is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed through 30 hand transplantation, 3 facial reconstructions, and vascularized knee, esophageal, and tracheal allografts. A major drawback for CTA is the requirement for lifelong immunosuppression. The toxicity of these agents has limited the widespread application of CTA. Methods to reduce or eliminate the requirement for immunosuppression and promote CTA acceptance would represent a significant step forward in the field. Multiple studies suggest that mixed chimerism established by bone marrow transplantation promotes tolerance resulting in allograft acceptance. This overview focuses on the history and the exponentially expanding applications of the new frontier in CTA transplantation: immunology associated with CTA; preclinical animal models of CTA; clinical experience with CTA; and advances in mixed chimerism-induced tolerance in CTA. Additionally, some important hurdles that must be overcome in using bone marrow chimerism to induce tolerance to CTA are also discussed.
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Affiliation(s)
- K V Ravindra
- Department of Surgery, University of Louisville, Louisville, Kentucky, USA
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