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Kodali NA, Janarthanan R, Sazoglu B, Demir Z, Dirican O, Zor F, Kulahci Y, Gorantla VS. A World Update of Progress in Lower Extremity Transplantation: What's Hot and What's Not. Ann Plast Surg 2024; 93:107-114. [PMID: 38885168 DOI: 10.1097/sap.0000000000004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
ABSTRACT The field of vascularized composite allotransplantation (VCA) is the new frontier of solid organ transplantation (SOT). VCA spans life-enhancing/life-changing procedures such as upper extremity, craniofacial (including eye), laryngeal, tracheal, abdominal wall, penis, and lower extremity transplants. VCAs such as uterus transplants are life giving unlike any other SOT. Of all VCAs that have shown successful intermediate- to long-term graft survival with functional and immunologic outcomes, lower extremity VCAs have remained largely underexplored. Lower extremity transplantation (LET) can offer patients with improved function compared to the use of conventional prostheses, reducing concerns of phantom limb pain and stump complications, and offer an option for eligible amputees that either fail prosthetic rehabilitation or do not adapt to prosthetics. Nevertheless, these benefits must be carefully weighed against the risks of VCA, which are not trivial, including the adverse effects of lifelong immunosuppression, extremely challenging perioperative care, and delayed nerve regeneration. There have been 5 lower extremity transplants to date, ranging from unilateral or bilateral to quadrimembral, progressively increasing in risk that resulted in fatalities in 3 of the 5 cases, emphasizing the inherent risks. The advantages of LET over prosthetics must be carefully weighed, demanding rigorous candidate selection for optimal outcomes.
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Affiliation(s)
- Naga Anvesh Kodali
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Ramu Janarthanan
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Bedreddin Sazoglu
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Zeynep Demir
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Omer Dirican
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Fatih Zor
- Department of Plastic Surgery, Indiana University, Indianapolis, IN
| | - Yalcin Kulahci
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
| | - Vijay S Gorantla
- Department of Surgery, Wake Forest School of Medicine, Winston Salem, NC
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Dergamoun H, Lakssir J, Gdaouni AEL, Jalal O, Saouli A, Ziouziou I. A microsurgical approach to post-traumatic penile amputation: Towards standardizing the technique - A case report. Int J Surg Case Rep 2024; 116:109384. [PMID: 38350376 PMCID: PMC10943986 DOI: 10.1016/j.ijscr.2024.109384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Penile amputation is an unusual situation reported globally as isolated cases and small series. It constitutes a urological emergency which requires microsurgical skills for the repair of the penis. We present a case of a penile amputation and discuss the management of this challenging condition. CASE PRESENTATION A 47-year-old patient presented to the emergency room with total amputation of corpora cavernosa of the penis resulting from knife aggression. The patient underwent successful microsurgical replantation, demonstrating positive progression and satisfactory results. CLINICAL DISCUSSION Microneurovascular repair of penile amputation is the gold standard. Recommendations include a meticulous anastomosis, and a focus on vein anastomoses for optimal outcomes as well as associating a psychiatric approach. The PENIS score classifies the severity of lesion and predict postoperative complications and main outcomes. CONCLUSION Penile amputation presents a distinctive challenge, necessitating microsurgical anastomosis, meticulous tissue management, and adherence to established protocols are imperative for effectively managing such intricate cases. Even in cases of posttraumatic partial penile amputation after a long period, can yield satisfactory morphofunctional outcomes.
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Affiliation(s)
- Hamza Dergamoun
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
| | - Jihad Lakssir
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
| | - Aziz E L Gdaouni
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
| | - Ossama Jalal
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
| | - Amine Saouli
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
| | - Imad Ziouziou
- Department of Urology, Souss Massa University Hospital, Faculty of Medicine and Pharmacy of Agadir, Ibn Zohr University, Agadir, Morocco.
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Lopez CD, Yusuf CT, Girard AO, Lake IV, Cooney DS, Redett RJ. Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study. J Reconstr Microsurg 2024; 40:96-101. [PMID: 37142254 DOI: 10.1055/a-2085-9943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.
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Affiliation(s)
- Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia T Yusuf
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alisa O Girard
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Isabel V Lake
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ruiz F, Cetrulo CL, Timsit MO, Lantieri L, Lellouch AG. Modified Surgical Model for Genitourinary Vascularized Composite Allotransplantations: An Anatomical Study. Plast Reconstr Surg 2023; 152:468e-471e. [PMID: 36735818 DOI: 10.1097/prs.0000000000010263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
SUMMARY Total penile reconstruction represents a surgical challenge. Autologous reconstructions offer limited aesthetic results and variable urinary function recovery. To date, five genitourinary vascularized composite allotransplantations have been performed worldwide. However, in all cases, vascular complications have been reported. The objective of this study was to develop a modified surgical model for penile allotransplantation to limit the number of microsurgical anastomoses and ensure vascular reliability. The authors studied penile allotransplantation by performing dissections on 12 subjects. The study was carried out to ensure the vascularization of the entire penis shaft while limiting the number of anastomoses. The penis vasculature includes numerous angiosomes between its different subunits. The penile skin envelope is supplied by both external and internal pudendal vessels. The cavernous and spongy bodies are supplied by terminal branches of the internal pudendal vessels. The anterior pubic osteotomy approach allows access to the root of the cavernous bodies and to the Alcock ducts. This modified surgical model for penile allotransplantation could help future teams involved in genitourinary vascularized composite allotransplantations to improve urinary and sexual function. CLINICAL RELEVANCE STATEMENT The authors introduce an improved surgical technique for penile transplantation that enhances vascularization and graft viability. This innovative procedure optimizes blood flow through meticulous microsurgical anastomosis, resulting in improved functional outcomes. Its potential to revolutionize penile transplantation warrants further exploration and validation within the surgical community.
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Affiliation(s)
- François Ruiz
- From the Departments of Plastic, Reconstructive and Aesthetic Surgery
| | - Curtis L Cetrulo
- the Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
| | - Marc-Olivier Timsit
- Urology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris
| | - Laurent Lantieri
- From the Departments of Plastic, Reconstructive and Aesthetic Surgery
| | - Alexandre G Lellouch
- From the Departments of Plastic, Reconstructive and Aesthetic Surgery
- the Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School
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Maimaitiming ABLT, Mulati YLSD, Apizi ART, Li XD. Self-strangulation induced penile partial amputation: A case report. World J Clin Cases 2023; 11:5373-5381. [PMID: 37621600 PMCID: PMC10445066 DOI: 10.12998/wjcc.v11.i22.5373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/20/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Traumatic amputation of the penis is a rare surgical emergency, usually caused by self-mutilation, accidents, circumcision, assault and animal attacks. This study aimed to summarize our treatment experience involving penile reconstruction in a rare case of a self-strangulation induced chronical penile partial amputation. CASE SUMMARY A 22-year-old man presented with self-strangulation induced chronical penile partial amputation for 3 mo where the penile proximal part was 1 cm far from the pubis. Reconstruction methods included end-to-end anastomosis of the urethral mucosa, proximal anastomosis of the corpus cavernosum and tunica albuginea of the penis, anastomosis of the deep dorsal vein, dorsal artery, and superficial dorsal vein. Patient urinated smoothly after the catheter was removed on day 21. 3 mo after the surgery, the patient's penile preliminary cosmetic appearance was satisfactory, with occasional morning erections. Distal penile sensation was preserved, yet erection hardness of the distal penis was not satisfactory. CONCLUSION Complete preoperative assessment and prompt surgical intervention decreases loss of residual penile functions.
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Affiliation(s)
- A-Bu-Lai-Ti Maimaitiming
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Ye-Li-Su-Dan Mulati
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Ai-Re-Ti Apizi
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Xiao-Dong Li
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
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Maimaitiming ABLT, Mulati YLSD, Apizi ART, Li XD. Self-strangulation induced penile partial amputation: A case report. World J Clin Cases 2023; 11:5367-5375. [DOI: 10.12998/wjcc.v11.i22.5367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/20/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Traumatic amputation of the penis is a rare surgical emergency, usually caused by self-mutilation, accidents, circumcision, assault and animal attacks. This study aimed to summarize our treatment experience involving penile reconstruction in a rare case of a self-strangulation induced chronical penile partial amputation.
CASE SUMMARY A 22-year-old man presented with self-strangulation induced chronical penile partial amputation for 3 mo where the penile proximal part was 1 cm far from the pubis. Reconstruction methods included end-to-end anastomosis of the urethral mucosa, proximal anastomosis of the corpus cavernosum and tunica albuginea of the penis, anastomosis of the deep dorsal vein, dorsal artery, and superficial dorsal vein. Patient urinated smoothly after the catheter was removed on day 21. 3 mo after the surgery, the patient's penile preliminary cosmetic appearance was satisfactory, with occasional morning erections. Distal penile sensation was preserved, yet erection hardness of the distal penis was not satisfactory.
CONCLUSION Complete preoperative assessment and prompt surgical intervention decreases loss of residual penile functions.
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Affiliation(s)
- A-Bu-Lai-Ti Maimaitiming
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Ye-Li-Su-Dan Mulati
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Ai-Re-Ti Apizi
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
| | - Xiao-Dong Li
- Department of Urology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang Clinical Research Center for Genitourinary System, Urumqi 830011, Xinjiang Uygur Autonomous Region, China
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Lopez CD, Girard AO, Lake IV, Oh BC, Brandacher G, Cooney DS, Burnett AL, Redett RJ. Lessons learned from the first 15 years of penile transplantation and updates to the Baltimore Criteria. Nat Rev Urol 2023; 20:294-307. [PMID: 36627487 PMCID: PMC9838304 DOI: 10.1038/s41585-022-00699-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 01/11/2023]
Abstract
Since 2006, five penis transplants have been performed worldwide. Mixed outcomes have been reported, and two of the five penile transplants have required explantation. However, the long-term outcomes have been encouraging when compliance is implemented, whether standard induction and triple therapy maintenance, or single therapy maintenance. Follow-up monitoring of transplant recipients has enabled a synthesis of technical considerations for surgical success and has shown stable leukocyte counts and renal function after a donor bone-marrow-based immunomodulatory regimen followed by tacrolimus monotherapy as long as 3 years post-transplant, as well as continuous nerve regeneration of penile allografts 3 years post-transplant. Areas of uncertainty include the ethics of donor-recipient colour mismatch, surveillance for sexually transmitted infections and how to optimize patient compliance. Questions also remain with respect to the long-term immunological sequelae of penile tissue, functional outcomes, psychosocial implications and patient selection. Patient counselling should be modified to mention the possibility of long-term improvement in nerve regeneration and sufficient renal function with single-therapy maintenance, and to build a longitudinal dialogue and partnership between the patient and the multidisciplinary care team regarding the risks of sexually transmitted infection instead of surveillance.
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Affiliation(s)
- Christopher D. Lopez
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Alisa O. Girard
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Isabel V. Lake
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Byoung Chol Oh
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Gerald Brandacher
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Damon S. Cooney
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Arthur L. Burnett
- grid.21107.350000 0001 2171 9311Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MA USA
| | - Richard J. Redett
- grid.21107.350000 0001 2171 9311Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MA USA
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Akhoondinasab MR, Farahmand HR, Zahedi A, Saraee A. Successful Microsurgical Replantation of Amputated Penis: A Case Report and Review of Literature. World J Plast Surg 2023; 12:18-23. [PMID: 38226201 PMCID: PMC10788100 DOI: 10.61186/wjps.12.3.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/08/2023] [Indexed: 01/17/2024] Open
Abstract
This study aims to explain microscopic replantation in a rare case of a wholly amputated penis after prolonged ischemia. A 36-year-old patient underwent microscopic replantation of the penis after 9 hours. The penis was completely amputated due to self-mutilation. Microvascular replantation was performed after pre-operative preparation. On the second day after surgery, congestion was observed in the penis, and three sessions of leech therapy were conducted each time the leeches were placed for 30 minutes and then detached by themselves. The patient was referred to a psychiatrist to continue treatment after discharge from the hospital. Penile amputation is a rare situation and has different causes. There are various treatments to repair the amputated penis, which are both microvascular and microvascular. The microsurgery methods have shown the best results. In the present case, due to microsurgical artery repair and the early start of leech therapy, there was limited and predictable necrosis in the area of the penoscrotal junction flap, which underwent debridement and skin graft. Complete amputation of the penis is a rare phenomenon. Efforts should be made to perform the replantation surgery as soon as possible. The venous outflow is an essential factor in the success of penile re-implantation, and completely restored vascular and sensory function in this case. Early initiation of psychological care to control underlying disease leads to further cooperation of the patient to handle complications and avoid the recurrence of self-injury.
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Affiliation(s)
- Mohammad-Reza Akhoondinasab
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Afshin Zahedi
- Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Saraee
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Liu J, Song B. Review and Clinical Progress of Allograft Penis Transplantation. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03292-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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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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Selvaggi G, Manner K, Sakinis A, Olausson M. A pilot retrospective CT angio study of the internal pudendal arteries in male bodies, for the purpose of penis transplantation to trans men. J Plast Surg Hand Surg 2021; 56:63-68. [PMID: 34010105 DOI: 10.1080/2000656x.2021.1927058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Literature reports four successful cases where penile transplantation has been performed for cis men. To date, no penis transplantation has ever been attempted for trans men. Modern surgical techniques for penis reconstruction for (trans) men with gender incongruence present multiple drawbacks, and sometimes fail to meet patients' expectations. Penis transplantation could represent an alternative solution. With the aim of planning penis transplantation to trans men, a previous study from our same group suggested a surgical technique for explantation of penis and associated vessels, nerves and urethra en-bloc from a cadaver: further radiographic imaging of vascular anatomy was recommended. To measure length and diameter of the internal pudendal arteries at three set points in biological males, in order to confirm its viability for transplantation. A retrospective examination of existing CT images visualizing the internal pudendal arteries in 12 bodies, assigned male at birth, was performed. Diameters were measured in three points: 1. the take off of the artery; 2. distal to its rectal branch; and, 3. at the bifurcation of the two terminal branches of the artery, i.e. the bulbourethral artery and the dorsal artery of the penis. Mean diameters of the selected points were 2.4 mm, 1.9 mm, and 1.5 mm on both sides. Mean lengths of internal pudendal arteries were 111.2 mm on the left, and 120.1 mm on the right side. Diameters of the internal pudendal artery is sufficient for arterial anastomosis at all measured points. Lengths are sufficient to reach recipient vessels.
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Affiliation(s)
- Gennaro Selvaggi
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kristiina Manner
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Augustinas Sakinis
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Michael Olausson
- Department of Transplantation Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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12
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Klingsor Syndrome—Microvascular Replantation of Penis After Self-Mutilation in Schizophrenia. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02941-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Staud CJ, Zaussinger M, Duscher D, Radtke C, Wenny R, Schmidt M, Huemer GM. A modified microvascular "Tube-in-Tube" concept for penile construction in female-to-male transsexuals: Combined radial forearm free flap with anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2021; 74:2364-2371. [PMID: 33622542 DOI: 10.1016/j.bjps.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/24/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Phalloplasty is a complex surgical task and remains a significant challenge in plastic surgery. To date, there are various techniques; however, complication rates are still not satisfactory. Here, we present our surgical approach of a modified tube-in-tube concept combining a radial forearm free flap and an anterolateral thigh flap and assess its outcome in a series of female-to-male transsexuals. PATIENTS AND METHODS In this report, 21 female-to-male transsexual patients were included. The first surgical step includes colpectomy and elongation of the fixed part of the urethra with a full-thickness skin graft. Subsequently, a radial forearm free flap was adapted to build the inner tube which represents the neourethra. For the last step, a free anterolateral thigh flap is utilized as the outer tube of the neophallus. All patients were evaluated regarding aesthetic and functional outcomes as well as postoperative complications and revision surgeries. RESULTS Our results showed a 100% flap survival rate with a mean follow-up of 4.4 years (range, 2.7-6). Three radial forearm free flaps and one free anterolateral thigh flap presented with partial flap necrosis. Generally, complications occurred in 11 patients (52.4%). The most common complications were related to urethral reconstruction including fistula formation (n = 8) and stenosis (n = 5). All except one patient obtained the ability to void while standing. CONCLUSION Despite the complexity, the initial results are very promising for a single-stage phalloplasty with complete functional creation of a neophallus. Further improvements have to be implemented for reduction of postoperative complications particularly regarding urethral reconstruction. LEVEL OF EVIDENCE IV (Therapeutic).
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Affiliation(s)
- Clement J Staud
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Maximilian Zaussinger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Dominik Duscher
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria; Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Germany
| | - Christine Radtke
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Raphael Wenny
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Manfred Schmidt
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Georg M Huemer
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria.
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Redett RJ, Etra JW, Brandacher G, Burnett AL, Tuffaha SH, Sacks JM, Shores JT, Bivalacqua TJ, Bonawitz S, Cooney CM, Coon D, Pustavoitau A, Rizkalla NA, Jackson AM, Javia V, Fidder SAJ, Davis-Sproul J, Brennan DC, Sander IB, Shoham S, Sopko NA, Lee WPA, Cooney DS. Total Penis, Scrotum, and Lower Abdominal Wall Transplantation. N Engl J Med 2019; 381:1876-1878. [PMID: 31693813 DOI: 10.1056/nejmc1907956] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Devin Coon
- Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | | | - Vidhi Javia
- Johns Hopkins School of Medicine, Baltimore, MD
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15
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Ngaage LM, Elegbede A, Sugarman J, Nam AJ, Cooney CM, Cooney DS, Rasko YM, Brandacher G, Redett RJ. The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline. Transpl Int 2019; 33:471-482. [PMID: 31646681 DOI: 10.1111/tri.13545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 12/20/2022]
Abstract
Significant advances and increasing acceptance of vascularized composite allotransplantation (VCA) have contributed to emerging success of penile transplantation. The aims of penile transplantation are fourfold: adequate urinary function, enabling natural erections, restoration of erogenous sensation and appearance of external male genitalia. Successful penile transplantation also requires limiting risks and managing complications of lifelong immunosuppression. Given the limited experience with this procedure, potential recipients must understand that penile transplantation is not currently standard of care and long-term functional outcomes are unknown. Moreover, these transplants are associated with complex ethical issues. Nevertheless, as the efficacy and safety of penile transplantation are being evaluated, clear indications for transplant are needed. Although preliminary recommendations have been proposed, a more comprehensive framework is needed. We performed a literature review for English language publications related to penile transplantation and ethics. Based on the results of the search, a review of prior recommendations, and our experience performing the first whole male genital allotransplantation including penis, scrotum and abdominal wall; screening and identifying potential donors and recipients for the procedure; and addressing the associated ethical issues, we propose guidelines for responsible penile transplantation: The Baltimore Criteria for an Ethical Approach to Penile Transplantation.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adekunle Elegbede
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy Sugarman
- Department of Medicine, Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Arthur J Nam
- Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- 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
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- 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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Abstract
Penile inversion vaginoplasty is a technique of gender-affirming genital surgery that uses primarily genital skin to construct the vulva and neovagina for patients assigned male sex at birth. This article presents present the authors' techniques and other contemporary techniques for this surgery, with particular attention to neovaginal canal construction, neoclitoral construction, and urethroplasty.
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Affiliation(s)
- Poone Shoureshi
- Department of Urology, Oregon Health & Science University, 3303 Southwest Bond Avenue, CH-10-U, Portland, OR 97210, USA
| | - Daniel Dugi
- Department of Urology, Transgender Health Program, Oregon Health & Science University, 3303 Southwest Bond Avenue, CH-10-U, Portland, OR 97210, USA.
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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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Hawksworth DJ, Cooney DS, Burnett AL, Bivalacqua TJ, Redett RJ. Penile Allotransplantation: Pushing the Limits. Eur Urol Focus 2019; 5:533-535. [DOI: 10.1016/j.euf.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
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Zor F, Sengezer M, Davis MR. Penile Reconstruction Versus Transplantation: Which One Is Ideal? CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0215-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis. Plast Reconstr Surg 2018; 142:535e-540e. [PMID: 30252820 DOI: 10.1097/prs.0000000000004818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microsurgical anastomosis of the dorsal artery of the penis either with or without anastomosis of the cavernosal artery is the preferred technique for penile replantation. However, postoperative penile skin necrosis is commonly reported with this technique. This study aimed to characterize the anatomy of the vascular supply of the penis pertinent to penile replantation surgery and to report a successful case of penile replantation without postoperative necrosis using anastomosis of the inferior external pudendal artery. METHODS The authors dissected 15 penises of fresh cadavers under acrylic dye injection by means of the inferior external pudendal and dorsal arteries of the penis to identify vascular anastomoses between arteries supplying the penis and to measure other parameters of the arteries. RESULTS Mean diameters at the base of the penis of the inferior external pudendal, dorsal, and cavernosal arteries were 0.94, 1.43, and 0.80 mm, respectively. Penile skin is mainly supplied by the inferior external pudendal artery under three patterns with anastomoses across the midline. Preputial skin receives additional blood supply from perforators of the dorsal artery without visible anastomosis between the perforators and the inferior external pudendal artery. Deep structures receive blood supply from the dorsal, cavernosal, and urethral arteries, with visible anastomoses between the arteries. In a patient with amputated penis, the inferior external pudendal artery diameter was 0.7 mm, which was sufficient for microsurgical anastomosis. No postoperative necrosis developed, and patency of the inferior external pudendal artery was confirmed with duplex ultrasound. CONCLUSION The diameter of the inferior external pudendal artery at the base and midshaft of the penis is sufficiently large for microsurgical anastomosis, and additional vascular anastomosis of at least one inferior external pudendal artery may help to prevent postoperative penile skin necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Szafran AA, Redett R, Burnett AL. Penile transplantation: the US experience and institutional program set-up. Transl Androl Urol 2018; 7:639-645. [PMID: 30211053 PMCID: PMC6127561 DOI: 10.21037/tau.2018.03.14] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Penile transplantation using vascularized composite allografts is an emerging technique to treat genital loss. In the United States, this procedure has been performed successfully at Massachusetts General Hospital in a patient who had previously undergone treatment for penile cancer. The Johns Hopkins Medical Institutions has developed a research protocol to perform penile transplantation in patients with genital loss secondary to trauma. The process of selecting the appropriate candidate for genitourinary (GU) vascularized composite allograft surgery is rigorous including extensive physical examination, laboratory testing, imaging and psychological evaluations. After transplantation, limiting the potential complications associated with immunosuppression is critical given that the procedure is intended to improve quality of life and is not life-saving. Ultimately, penile transplant is a surgical intervention which may have numerous applications. Optimization of the pre-operative screening process, surgical technique, and immunosuppressive protocol is required to establish this method as the standard treatment for patients with genital loss and limited reconstructive options.
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Selvaggi G, Wesslen E, Elander A, Wroblewski P, Thorarinsson A, Olausson M. En Bloc Surgical Dissection for Penile Transplantation for Trans-Men: A Cadaveric Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6754030. [PMID: 29854779 PMCID: PMC5964499 DOI: 10.1155/2018/6754030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/01/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The surgical techniques currently available for penile reconstruction for trans-men with gender dysphoria present with multiple drawbacks and often fail to meet patients' expectations. Literature reports three cases where penile transplantation has been performed for cis-men, with the last two cases being considered successful. AIM To determine whether an en bloc surgical dissection can be performed in a male cadaver, in order to include structures necessary for penile transplantation (from a deceased donor male) to a recipient with female genitalia in gender affirmation surgery. METHOD The study was conducted in the form of explorative dissections of the genital and pelvic regions of three male cadavers preserved in phenol-ethanol solution. RESULTS The first two dissections failed to explant adequately all the relevant structures. The third dissection, which was performed along the pubic arch and through the perineum, succeeded in explanting the relevant structures: it, in fact, allowed for identification and adequate transection of urethra, vessels, dorsal nerves, crura of corpora cavernosa, and bulb of corpus spongiosum, in en bloc explantation of male genitalia. CONCLUSIONS It is possible to explant the penis and associated vessels, nerves, and urethra en bloc from a cadaver. This study suggests a surgical technique for en bloc explantation aiming for transplantation of the penis from a cadaveric donor male to a recipient with female genitalia.
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Affiliation(s)
- Gennaro Selvaggi
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Erica Wesslen
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Peter Wroblewski
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Andri Thorarinsson
- Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Michael Olausson
- Department of Transplantation Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden
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Yao A, Ingargiola MJ, Lopez CD, Sanati-Mehrizy P, Burish NM, Jablonka EM, Taub PJ. Total penile reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2018; 71:788-806. [PMID: 29622476 DOI: 10.1016/j.bjps.2018.02.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Phalloplasty poses a unique challenge to the plastic and reconstructive surgeon. The development of advanced microsurgical techniques has greatly augmented the range of surgical approaches available. METHODS A systematic review of the MEDLINE and Cochrane databases was performed to identify clinical studies of total penile reconstruction published within the last 10 years using the search algorithm: "(phallus or penis or penile) and (reconstruction or phalloplasty or transplant)". RESULTS The primary literature search retrieved 1400 articles. After applying inclusion and exclusion criteria, 30 studies were selected for review. The radial forearm free flap is the preferred technique for total phalloplasty; however, other techniques including the fibular osteocutaneous flap, anterolateral thigh flap, latissimus dorsi flap, scapular free flap, and abdominal flap are described. Background, indications, and preoperative and postoperative care are also discussed. CONCLUSIONS Total penile reconstruction can provide functional, aesthetic, and psychosocial benefits to the patient. Use of the radial forearm free flap has been proposed as the gold standard; however, the wide range of potential complications associated with phalloplasty warrants an individualized approach to each patient.
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Affiliation(s)
- A Yao
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - M J Ingargiola
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - C D Lopez
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - P Sanati-Mehrizy
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - N M Burish
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - E M Jablonka
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - P J Taub
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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25
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Successful Second Microsurgical Replantation for Amputated Penis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1512. [PMID: 29062672 PMCID: PMC5640378 DOI: 10.1097/gox.0000000000001512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
Penile amputation is a rare emergency, but the best method for its repair is required due to the organ's functional and societal role. Since the first successful microsurgical replantation of the amputated penis, microsurgical techniques have matured and become the standard treatment for the penile replantation. However, the successful second microsurgical replantation for amputated penis has been rarely reported. We present the case of a 40-year-old man with schizophrenia who had a past history of penile self-mutilation and successful replantation at another hospital 2 years ago. After stopping oral medication for schizophrenia, he again cut his penis with a kitchen knife. We successfully replanted the amputated penis by anastomosing both circumflex arteries, the superficial dorsal vein, and the deep dorsal vein using microsurgical techniques. Postoperatively, the foreskin of the replanted penis gradually developed partial necrosis, requiring surgical debridement. The aesthetic and functional results were satisfactory and retrograde urethrography showed no evidence of leakage and stricture of the urethra. Although skin necrosis after penile replantation has been reported as an unavoidable process owing to the nature of injury, the rate would be higher after secondary replantation because of scar formation due to the previous operation. Therefore, our case of successful secondary replantation suggests that skin necrosis would be a predictable postoperative complication and the debridement timing of the devitalized foreskin should be closely monitored, and also secondary amputation is not a contraindication of replantation.
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Sopko NA, Tuffaha SH, Lough D, Brandacher G, Lee WPA, Bivalacqua TJ, Redett RJ, Burnett AL. Penile Allotransplantation for Complex Genitourinary Reconstruction. J Urol 2017; 198:274-280. [PMID: 28286074 DOI: 10.1016/j.juro.2016.10.134] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 01/31/2023]
Abstract
PURPOSE Reconstruction of complex functional structures is increasingly being performed with vascularized composite allotransplantation. Penile transplantation is a novel vascularized composite allotransplantation treatment option for severe penile tissue loss and disfigurement. Three allogeneic human penile transplantations have been reported. We review these cases as well as penile transplant indications, preclinical models and immunosuppression therapy. MATERIALS AND METHODS We performed a comprehensive literature review for the years 1970 to 2016 via MEDLINE®, PubMed® and Google with the key words "penis transplantation," "penile rejection," "penile replantation," "penile tissue loss" and "penis vascularized composite allotransplantation." Relevant articles, including original research, reviews and nonscientific press reports, were selected based on contents, and a review of this literature was generated. RESULTS Three human allogeneic penile transplantations have been performed to date, of which 1 was removed 14 days after transplantation. The second recipient reports natural spontaneous erections and impregnating his partner. All 3 patients were able to void spontaneously through the graft's urethra. The complexity of the transplant is determined by how proximally the penile shaft anastomosis is performed and additional pelvic tissue may be transplanted en bloc if needed. CONCLUSIONS Penile transplantation is a technically demanding procedure with significant ethical and psychosocial implications that can provide tissue and functional replacement, including urinary diversion and natural erections. It is unclear how rejection and immunosuppression may affect graft function. Better models and more preclinical research are needed to better understand and optimize penile transplantation.
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Affiliation(s)
- Nikolai A Sopko
- The James Buchannan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Denver Lough
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Trinity J Bivalacqua
- The James Buchannan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arthur L Burnett
- The James Buchannan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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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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Merwe AVD, Zarrabi A, Zühlke A, Barsdorf N, Moosa R. Lessons learned from the world's first successful penis allotransplantation. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:27. [PMID: 28074434 DOI: 10.1007/s10856-016-5836-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/16/2016] [Indexed: 06/06/2023]
Abstract
We performed a successful penis allotransplantation on 11 December 2014. Sharing the lessons learned might help more patients in need to be treated this way. We divided the project into manageable segments that was each overseen by an expert. The ethical review and conduct paved the way for a publically acceptable and successful project. Screening for a psychological stable recipient is important. The most difficult part of the project was finding a donor penis. This was successfully negotiated with the family of a brain dead donor by creating a neo-phallus for the donor, thereby maintaining the dignity of the donor. Working with transplant coordinators that are sympathetic to aphallic men is crucial. Surgeons versed in microvascular techniques is a critical part of the team. Transplant immunologists have to adapt to treat composite tissue transplantation patients.
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Affiliation(s)
- Andre van der Merwe
- Division of Urology, Department of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa.
| | - Amir Zarrabi
- Division of Urology, Department of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Alexander Zühlke
- Division of Plastic and Reconstructive surgery, Department of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Nicola Barsdorf
- Health Research Ethics, Division of Research Development and Support, Department of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Rafique Moosa
- Division Nephrology and Renal Transplantation, Department of Internal Medicine, Department of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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Bickell M, Beilan J, Wallen J, Wiegand L, Carrion R. Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer. Urol Clin North Am 2017; 43:545-559. [PMID: 27717440 DOI: 10.1016/j.ucl.2016.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually. Techniques and discussion for penile cancer reconstruction include Mohs surgery, glans resurfacing, partial and total glansectomy, and phalloplasty. Included in the penile cancer reconstruction section is the use of penile prosthesis in phalloplasty patients after penectomy, tissue engineering in phallic regeneration, and penile transplantation. Reconstruction following treatment of primary urethral carcinoma and current techniques for scrotal cancer reconstruction using split-thickness skin grafts and flaps are described.
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Affiliation(s)
- Michael Bickell
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Jonathan Beilan
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Jared Wallen
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Lucas Wiegand
- Department of Urology, University of South Florida, Tampa, FL, USA
| | - Rafael Carrion
- Department of Urology, University of South Florida, Tampa, FL, USA.
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Penis Allotransplantation in Beagle Dog. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1489204. [PMID: 26977412 PMCID: PMC4761661 DOI: 10.1155/2016/1489204] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/30/2015] [Accepted: 12/10/2015] [Indexed: 11/17/2022]
Abstract
This is an original research of penis allotransplantation. The paper presents an experiment allogenic penis transplantation model in Beagles, with a focus on recovery of blood supply and changes in tissue architecture. Twenty adult Beagles were allocated to 10 pairs for penile transplantation. After operation, the skin and glans were observed. If adverse symptoms occurred, the transplanted penis was resected and pathologically examined. Frequency of urination, urinary stream, and patency level were recorded 7 days after transplantation. Cystourethrography was performed on Day 10. The transplanted penises were resected on Day 14 for pathological examination. The research showed that transplanted penises survived after allotransplantation, and the dogs regained urination ability. Penis autotransplantation in Beagles is feasible. This preliminary study shows a potential for application of this new procedure for penis transplantation in humans.
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Microsurgical Penile Replantation after Self-inflicted Amputation in a Schizophrenic Patient: 5-year Follow-up. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e319. [PMID: 25878930 PMCID: PMC4387141 DOI: 10.1097/gox.0000000000000172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/10/2014] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. In this article, we report on the long-term follow-up of a microvascular penile replantation resulting from self-inflicted amputation in a schizophrenic patient. An interdisciplinary approach with the involvement of urology, plastic surgery, endocrinology, and psychiatry is imperative for optimal treatment of these catastrophic injuries.
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