The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

BACKGROUND

 Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated.

METHODS

 Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull.

RESULTS

 Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline.

CONCLUSION

 Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Importance of Breast Sensation After Mastectomy: Evidence from Three Sources

Background

Every year, more than 90,000 U.S. women undergo mastectomy. More than 40% have reconstruction. Following reconstruction, most women experience persistent partial or complete numbness of the reconstructed breasts, and many experience pain. Yet, breast reconstruction procedures focus largely on esthetic outcomes with mixed impact on sensory outcomes and little attention to pain. This study examines whether and how breast sensation is important to women.

Materials and Methods

Conventional content analysis of extant qualitative data from a clinical registry (29 women with prior breast surgery for cancer, 2008-2022), a volunteer community sample (qualitative interviews with 6 women with and 5 without breast cancer, 2019), and from a Twitter social media survey (N = 32, 2022).

Results

Functions of the breast identified by women with and without cancer include breastfeeding, sexual function, and femininity. Five interrelated themes on the importance of breast sensation emerged among women with breast cancer history: sexual function, experience of partnered sex or relationship with one's sexual partner, breast embodiment, effect of breast pain on sexual function, and importance to psychological wellbeing. Women, advocates, and clinicians described a lack of patient-physician communication in this domain that exacerbates the negative impact of breast sensation loss on health and wellbeing.

Conclusions

Breast sensation is important to women following mastectomy, yet a gap exists in patient-physician communication about the impact of mastectomy and reconstruction on breast sensory function. Lessons for physicians, scientists, and skeptics are conveyed about why the basic integrity of women's bodies matters for practice and science.

Expanding indications for urogenital transplantation: congenital and oncologic defects, and gender affirmation

PURPOSE OF REVIEW

Penile transplantation has become an emerging option for patients with severe genital defects. Only transplantation restores anatomy, sexual, and reproductive function of the penis. However, penile transplantation comes with important technical, psychosocial, ethical, and surgical challenges that must be considered for successful implementation. Indications for penile transplantation have yet to be clearly elucidated.

RECENT FINDINGS

Since 2006, only five penile transplants have been performed globally. Four of the five transplants have been performed following traumatic defects, and one was performed following a total penectomy from squamous cell carcinoma. Only two of the five penile transplants remain intact. However, long-term outcomes are encouraging with optimal surgical planning, patient selection, and immunologic compliance. Clinical implications and ethical considerations are discussed.

SUMMARY

Penile transplantation is a novel solution for penile defects not amenable to traditional reconstructive approaches. With an evidence-based surgical technique, potential advantages include improved urinary function, sensation, and cosmesis. While patient selection is challenging, there is an ongoing effort to identify potential candidates. Indications are discussed in this article.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

Ethical considerations regarding penis transplantation surgery in transgender men-an empirical ethics study

Background

The ongoing quest to surgically create the (nearly) ideal neophallus in transgender men has led to the continuous development of transgender medicine and the proposed introduction of penis transplantation. However, both technical and ethical issues arise when developing this treatment.

Aim

We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations.

Methods

Three semistructured focus groups, consisting of different stakeholders, were organized to participate in discussions of ethical considerations retrieved from the ethics literature of transplantation and transgender medicine. Analysis of the results was performed according to empirical ethics.

Outcomes

Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men.

Results

Nineteen people participated in this qualitative study. The main domains that emerged included arguments in favor of and arguments against penile transplantation. Although the participants expressed positive attitudes toward developing this care, with acknowledgement of the current limitations stakeholders of all groups were reluctant to endorse the introduction of penile transplantation for transgender men at this point.

Clinical Implications

Under the present circumstances, all groups expressed both a wide variety of ethical considerations as well as a tendency to prefer developing alternative treatment options or improving the results of currently available treatments in relation to penile transplantation for transgender men.

Strengths and Limitations

This study was the first (empirical) study to focus on this topic and included a diversity of stakeholder perspectives. Limitations included the hypothetical nature of the discussion as well as the clinical setting in which the topic has been studied.

Conclusion

Introducing penile transplantation for transgender men, under the current circumstances, comes with a wide range of ethical considerations, which deal with personal identity, autonomy, medical risks, risk for transgender support and donor willingness, and issues regarding equality. Despite the present hesitancy to use penile transplantation, should the technical side of this treatment option develop, further research in the ethical field of penile transplantation for transgender men is recommended.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

BACKGROUND

 Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated.

METHODS

 Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull.

RESULTS

 Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline.

DISCUSSION/CONCLUSION

 Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study

PURPOSE

Gender affirmation in trans men requires multiple staged procedures. The final masculinizing step involves phalloplasty or metoidioplasty and further incorporation of penile and testicular prostheses. However, these are functionally suboptimal and associated with high complication rates. Therefore, we sought to investigate the anatomical feasibility of one-stage genitourinary vascularized composite allotransplantation (GUVCA) for such gender-affirming surgeries.

METHODS

Twenty fresh cadaveric dissections were performed to delineate the neurovascular anatomy of the proposed GUVCA. Specifically, in donors (n = 14), besides the penis and scrotum, the GUVCA included an inferior bladder patch with the urinary sphincter, prostate, seminal vesicles, as well as a strip of the pubic bone. In trans men recipients, osteotomies of the pubic bone to match that of the donor GUVCA were required. Five cadaveric GUVCA transplants were then performed to simulate one-stage gender affirmation surgery.

RESULTS

The GUVCA required (1) vascular anastomoses between the recipient's deep inferior epigastric, external pudendal, and superficial circumflex iliac (or superficial inferior epigastric) vessels to the donor's internal pudendal, external pudendal and genitofemoral vessels respectively; (2) neurosynthesis between the recipient pudendal and dorsal clitoral nerves to the donor pudendal and genitofemoral nerves; and (3) urinary bladder anastomosis at the bladder neck, upstream of the urinary sphincter. Average donor measurements (length (cm), diameter (mm)) were: external pudendal artery (2.5, 2.0) and vein (2.0, 3.5), internal pudendal artery (15.0, 4.0), pudendal (15.0, 3.0) and genitofemoral nerves (8.0, 2.0).

CONCLUSIONS

We have described the anatomical basis for a one-stage GUVCA in trans masculine genitourinary reconstruction.

Inequities in organ and tissue donation and transplantation for sexual orientation and gender identity diverse people: A scoping review

Sexual orientation and gender identity (SOGI) diverse populations experience discrimination in organ and tissue donation and transplantation (OTDT) systems globally. We assembled a multidisciplinary group of clinical experts as well as SOGI-diverse patient and public partners and conducted a scoping review including citations on the experiences of SOGI-diverse persons in OTDT systems globally to identify and explore the inequities that exist with regards to living and deceased OTDT. Using scoping review methods, we conducted a systematic literature search of relevant electronic databases from 1970-2021 including a grey literature search. We identified and screened 2402 references and included 87 unique publications. Two researchers independently coded data in included publications in duplicate. We conducted a best-fit framework synthesis paired with an inductive thematic analysis to identify synthesized benefits, harms, inequities, justification of inequities, recommendations to mitigate inequities, laws and regulations, as well as knowledge and implementation gaps regarding SOGI-diverse identities in OTDT systems. We identified numerous harms and inequities for SOGI-diverse populations in OTDT systems. There were no published benefits of SOGI-diverse identities in OTDT systems. We summarized recommendations for the promotion of equity for SOGI-diverse populations and identified gaps that can serve as targets for action moving forward.

Lessons learned from the first 15 years of penile transplantation and updates to the Baltimore Criteria

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.

Vascularized composite allotransplantation of the penis: current status and future perspectives

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.

Addressing ethical confusion in deceased donation and transplantation research: the need for dedicated guidance

Innovative research in deceased donation and transplantation often presents ethical challenges for researchers and those responsible for ethical governance of research. These challenges have been recognized as potential barriers to the conduct of research. We review the literature to identify and describe ethical considerations that may cause confusion or uncertainty in the context of research involving potential deceased donors or deceased donor transplantation. We normatively examine these considerations and discuss their implications for the ethical conduct of research. In addition to the complexities of research involving critically ill, dying or recently deceased individuals, uncertainty may arise regarding the ethical status of various individuals who may be involved in research aimed at improving availability and outcomes of organ transplantation. Consequently, routine ethical guidelines for clinical research may fail to provide clear guidance with regards to the design, conduct and governance of some deceased donation or transplantation studies. Ethical uncertainty may result in delays or barriers to research, or neglect of important ethical considerations. Specific ethical guidance is needed to support research in deceased donation and transplantation as the ethical considerations that arise in the design and conduct of such research may not be addressed in the existing guidelines for human research.

Limitations and limits and of vascularized composite allotransplantations: can we reach the holy grail?

PURPOSE OF REVIEW

In recent times, vascularized composite allotransplantation (VCA) have been gaining more attention and applications. Currently, VCA are at the highest level of the reconstruction pyramid, and thus the effects expected after them are intended to outweigh what the 'classical' reconstructive surgery can offer us, including even the most advanced microsurgical techniques.

RECENT FINDINGS

Over 40 patients have received a partial or full-face transplant. Others have received penis, uterus, larynx, abdominal wall, and lower extremity transplants. Each type of VCA has its own problems and limitations. However, resolving the limits defined by immunosuppression and improved donor selection would revolutionize all of them.

SUMMARY

Defining the limits and limitations of given procedures will not only allow for better preparation of transplant teams but will also help in determining the direction of future research.

Ethical and societal challenges in penis transplantation

PURPOSE OF REVIEW

To review the current understanding of the ethical and societal difficulties of penile transplantation.

RECENT FINDINGS

Penile transplantation, as with other forms of vascularized composite allotransplantation, has increasing acceptance in society but is still not entirely accepted. Guidelines aiming to help guide future penile transplant programs in an ethical and scientific safe manner were created. Controversies regarding the economic impact, patient safety, and the rights of the patients choosing penile transplant remains.

SUMMARY

Penile transplantation has excellent functional and cosmetic results in the short-term and medium-term. The penis, similar to the face in facial transplantation, carries emotional gravity that relates to visible body parts of another that live forth in a tangible manner contributing to psychological and ethical challenges for both the individual and society more broadly, healthcare administrators, and healthcare workers. In the context of these challenges, controversies emerge related to issues of judgment about what society can and wants to afford. Effects of toxic immunosuppression in a nonlife saving life-enhancing procedure, as well as costs, become arguments that have to be considered in the context of ethical and societal challenges.

[Gender reassignment from female to male : Phalloplasty]

BACKGROUND

The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals.

OBJECTIVE

The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty.

MATERIAL AND METHODS

Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years.

RESULTS

Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%.

CONCLUSION

Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.