Penile Transplantation Research Articles

Future directions in transmasculine genital gender-affirming surgery: tissue substitutes and transplant.

The present study reviews contemporary literature focused on transplantation and tissue substitutes for the purposes of masculinizing genital gender affirming surgery. Additional background is provided for both topics to provide a more comprehensive understanding of the modern applications. Genitourinary vascularized composite allotransplantation has become a reality in recent years with several cases reported worldwide in cisgender men with promising reports of urinary and sexual function. A natural extension might be to apply these techniques to gender affirming surgery (GAS). Technical barriers include anatomic differences between vasculature supporting penoscrotal and vulvovaginal anatomy as well as size discrepancies between the corporal bodies which complicate the required anastomoses. Whether the smaller caliber of biologic female pelvic vasculature can support erection of a neophallus is another obstacle. Ethically, resource allocation, elective immunosuppression, society response to organ donation and gender identity, as well as the psychosocial safety of the patient given charged public opinion must all be considered.Tissue substitutes have long been used in urologic reconstruction but more recently applied to masculinizing gender affirmation surgery which has traditionally relied on autografting. The focus has been on restoring form and function to the donor site as well as facilitating treatment of urethral stricture and wound complications after phalloplasty. Furthermore, aesthetic applications have also been described, most recently for glans atrophy. The field of masculinizing gender affirmation surgery represents an exciting frontier for surgeons and patients alike. Given the relative nascency of the specialty and its propensity to draw techniques from various surgical disciplines there exists a unique opportunity for rapid innovation to overcome challenging problems posed by these complex procedures as evidenced by discussions around applying penile transplantation and the use of novel tissue grafting techniques.

Incorporating Trauma-informed Approaches to Care in Vascularized Composite Allotransplantation.

Since 1998, vascularized composite allotransplantation (VCA) has been a growing area of research in the field of reconstructive surgery. Although conditions treated with VCA often result from a traumatic injury, there has been limited emphasis on incorporating trauma-informed care (TIC) models in VCA. Considering the importance of psychosocial well-being in VCA candidates and recipients, applying best practices in TIC to the face, upper extremity, and penile transplantation may be critical in minimizing retraumatization throughout the perioperative process. There are six main principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical, and gender issues, which may be further incorporated in care for VCA patients. Evaluating for PTSD and incorporating TIC may have substantial benefit to postoperative outcomes.

A Cadaveric Study of the Deep and Superficial Dorsal Veins for Penile Transplant

A Cadaveric Study of the Deep and Superficial Dorsal Veins for Penile Transplant

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

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. We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations. 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. Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men. 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. 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. 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. 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.

Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study.

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. This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. 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. Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.

MP02-01 CADAVERIC PENILE DISSECTION AND ITS IMPACT ON LIVE DONOR PENILE TRANSPLANTATION: A PRELIMINARY STUDY

You have accessJournal of UrologyCME1 Apr 2023MP02-01 CADAVERIC PENILE DISSECTION AND ITS IMPACT ON LIVE DONOR PENILE TRANSPLANTATION: A PRELIMINARY STUDY Borko Stojanovic, Bojana Radnic, Marta Bizic, Milenko Bogdanovic, Sinisa Ducic, Vesna Popovic, Tatjana Atanasijevic, and Miroslav Djordjevic Borko StojanovicBorko Stojanovic More articles by this author , Bojana RadnicBojana Radnic More articles by this author , Marta BizicMarta Bizic More articles by this author , Milenko BogdanovicMilenko Bogdanovic More articles by this author , Sinisa DucicSinisa Ducic More articles by this author , Vesna PopovicVesna Popovic More articles by this author , Tatjana AtanasijevicTatjana Atanasijevic More articles by this author , and Miroslav DjordjevicMiroslav Djordjevic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile transplantation presents an ideal treatment for penile agenesis, traumatic penile amputation, penile cancer or gender dysphoria in transmen. Until now, all four reported cases underwent cadaveric penile transplantation. We evaluated possibilities for using all penile entities after their removal in transfemale gender affirming surgery for live donor penile transplantation. Main goal of this cadaveric study was to develop techniques for anatomical harvesting of the penile entities (corpora cavernosa with distal urethra and glans) that could be used for safe and successful donor penile transplantation. METHODS: Between January and September 2022, penile dissection was performed in 18 male cadavers, aged from 19 to 51 years (mean 38.5 years). Dissection was based on penile disassembly principles: corpora cavernosa with urethra, glans with neurovascular bundle and penile skin. Penile skin with small piece of the glans and proximal urethra were separated as a tissue for creating the female genitalia. This way completely preserved cavernosal bodies, distal urethra and largest part of the glans were precisely measured with associated blood vessels and nerves. RESULTS: Mean penile length was 10.5 cm (from 6 to 13 cm) in flaccid and 15 cm (from 12 to 18 cm) in stretched state, and mean circumference 8 cm (from 7 to 9 cm). Neurovascular bundle had regular anatomy in 16 cases, while in remaining 2 anatomical variations were detected: single penile artery in one and a common trunk of both penile arteries in another case. Mean diameters of deep dorsal vein, right and left left artery were measured 2.9 mm, 2.5 mm and 2.2 mm, respectively. Penile nerves were found in all cases with anatomical distribution. A circumflex branches and perforators of the blood vessels were detected in all cases. Mean length and girth of cavernosal bodies were 20 cm (from 18 to 24 cm), and 7.4 cm (from 6.5 to 11 cm), respectively. Both crural arteries are identified in all cases. Mean length of the distal urethra was 11.4 cm (from 9.5 to 14 cm) without registered anomalies. The mean volume of the remaining glans after creation of the neoclitoris was 87% (from 85 to 90%). All dissections were finished successfully, and all entities were joined again in all cadavers. CONCLUSIONS: Preliminary results of cadaveric penile dissection confirm feasibility of using all remaining entities such as corpora cavernosa, minimally reduced glans, distal urethra and preserved neurovascular elements during transfemale gender affirming surgery for possible penile transplantation. Surgical technique is suggested and will be established with further research. Source of Funding: Science Fund of the Republic of Serbia, Project IDEAS © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e10 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Borko Stojanovic More articles by this author Bojana Radnic More articles by this author Marta Bizic More articles by this author Milenko Bogdanovic More articles by this author Sinisa Ducic More articles by this author Vesna Popovic More articles by this author Tatjana Atanasijevic More articles by this author Miroslav Djordjevic More articles by this author Expand All Advertisement PDF downloadLoading ...

Modified Surgical Model for Genitourinary Vascularized Composite Allotransplantations: An Anatomical Study.

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. 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.

Penile transplantation: Past, present and future

Penile transplantation: Past, present and future

Cadaveric penile dissection and its impact on live donor penile transplantation: A preliminary study

Cadaveric penile dissection and its impact on live donor penile transplantation: A preliminary study

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.

NEW PERSPECTIVES IN PENILE CANCER MANAGEMENT: HOW TO RETAIN FUNCTIONAL OUTCOMES

Penile cancer is a rare malignancy and a debilitating condition in most industrialized nations that often requires aggressive surgical or multimodal treatment with significant anatomical, functional, and psychosocial impact on patients’ quality of life. Total or partial penile amputation has been considered the standard of treatment according to locoregional clinical staging and risk stratification. However, these surgical options are associated with significant negative functional and psychological outcomes in terms of body image, self-esteem, and manhood resulting in loss of sexual function and inability of upright voiding. Recently, a critical paradigm shift has taken place in the clinical management of penile malignancy, that is, the implementation of alternative, less-invasive surgical strategies to deal with the primary malignancy. These sparing approaches of penile anatomy aim to retain penile and urinary functions and overall quality of life and thus interfering as little as possible with functional anatomy. This paradigm shift has been made possible by advances in surgical and technological developments which have resulted in organ-preserving strategies with gratifying psychosocial and functional outcomes simultaneously without compromising final cancer control. This spectrum of novel surgical strategies includes local excision, glansectomy, and partial penectomy followed by surgical reconstructive procedures consisting of primary closure of the resulting defect, closure with skin flaps or split- thickness skin grafts, penile lengthening and/or enhancing procedures, neophalloplasty, and, more recently, penile transplantation fostered by limitations of conventional reconstruction. This review discusses the complexities of surgical reconstruction following penile cancer treatment including the burgeoning field of penile transplantation.

Psychosocial and bioethical challenges and developments for the future of vascularized composite allotransplantation: A scoping review and viewpoint of recent developments and clinical experiences in the field of vascularized composite allotransplantation.

Vascularized Composite Allotransplantation (VCA) has evolved in recent years, encompassing hand, face, uterus, penile, and lower extremity transplantation. Accordingly, without centralized oversight by United States Organ Procurement and Transplantation Network (OPTN) or European Programs, centers have developed their own practices and procedures that likely vary, and accordingly, present different levels of rigor to the evaluation process, internationally. The importance of psychosocial factors in the selection process and treatment course has been widely recognized, and therefore, several approaches have been developed to standardize and guide care of VCA candidates and recipients. We propose to develop an international multidisciplinary platform for the exchange of expertise that includes clinical, patient, and research perspectives. Patient perspectives would derive from peer education and the assessment of patient-reported outcomes. To establish a foundation for such a platform, future research should review and combine current VCA protocols, to develop the ethical framework for a standardized psychosocial evaluation and follow-up of VCA candidates and recipients. This review presents a comprehensive overview of recent results in the field of VCA, developments in structural aspects of VCA, and provides viewpoints driven from clinical experience.

Capacitating militarised masculinity: Genitourinary injuries, sex/sexuality, and US military medicine

AbstractThis article examines the soldiering body in relation to the increasing prevalence of genitourinary injuries in military personnel. Feminist scholars have demonstrated that the idealised masculine soldiering body are central to the workings of international politics. The article shows that US militarised masculinity operates through the selective distribution of bodily capacities. The article draws upon critical disability studies, particularly Jasbir Puar's work on capacity and debility, to argue that treatments for genitourinary injuries revolve around the production of seminal capacity. Queer and trans bodies are debilitated in these arrangements through the denial of heterosexual and cisgender capabilities to them. To unpack this argument the article analyses treatments for genitourinary injuries. The article shows that genitourinary injuries destabilise the gender identity of US service members. Through an exploration of surgical treatments, including penis transplants and reconstructive surgeries, and fertility treatments, the article shows how masculine capacitation is achieved for some US service members through the debilitation of others; in particular, queer and trans bodies, and the bodies of Iraqi and Afghan civilians.

A Reliable Porcine Fascio-Cutaneous Flap Model for Vascularized Composite Allografts Bioengineering Studies.

Vascularized Composite Allografts (VCA) such as hand, face, or penile transplant represents the cutting-edge treatment for devastating skin defects, failed by the first steps of the reconstructive ladder. Despite promising aesthetic and functional outcomes, the main limiting factor remains the need for a drastically applied lifelong immunosuppression and its well-known medical risks, preventing broader indications. Therefore, lifting the immune barrier in VCA is essential to tip the ethical scale and improve patients' quality of life using the most advanced surgical techniques. De novo creation of a patient-specific graft is the upcoming breakthrough in reconstructive transplantation. Using tissue engineering techniques, VCAs can be freed of donor cells and customized for the recipient through perfusion-decellularization-recellularization. To develop these new technologies, a large-scale animal VCA model is necessary. Hence, swine fascio-cutaneous flaps, composed of skin, fat, fascia, and vessels, represent an ideal model for preliminary studies in VCA. Nevertheless, most VCA models described in the literature include muscle and bone. This work reportsa reliable and reproducible technique for saphenous fascio-cutaneous flap harvest in swine, a practical tool for various research fields, especially vascularized composite tissue engineering.

Penile Transplantation: Lessons Learned and Technical Considerations.

Penile vascularized composite allotransplantation is a powerful tool for penile reconstruction. Traditional methods of reconstruction utilizing free tissue and prostheses have well-known complications, can require reoperation and cannot truly emulate the natural form or function of the penis. While vascularized composite allotransplantation may alleviate these difficulties, penile transplantation carries its own ethical, surgical and medical complications. To date, the procedure has only been attempted 5 times. Broader use of this procedure requires unique surgical considerations. We present the first comprehensive, detailed review of this procedure in order to present lessons learned from both our own and the global experience. A review of published reports of penile transplant methods and outcomes was conducted to compile lessons learned from these cases. Five penile transplant cases have been reported in literature, 4 with published methodology and outcomes data. All 4 detailed unique surgical approaches and postoperative immunosuppressive regimens. Three of these cases resulted in successful sensory and functional outcomes. Though all 4 analyzed cases employed unique anastomotic and immunosuppressive approaches, 3 resulted in successful recovery of penile urinary and sexual function. Still, specific approaches used by different teams circumvented otherwise common complications, and these differences should guide future research and penile transplant cases.

Review and Clinical Progress of Allograft Penis Transplantation

Review and Clinical Progress of Allograft Penis Transplantation

“Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?”

The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. Sexual orientation, gender, and age were independent predictors of interest in interventions. There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations.

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.

Living with someone else's penis: The lived experiences of two South African penile allograft recipients: A descriptive phenomenological study

BackgroundIn South Africa, penile loss is a recognised complication of ritual circumcision which has a profoundly negative effect on these men's psyches and their everyday lives. The purpose of this paper was to investigate the experiences of the first two South African penile allograft transplantation recipients in order to assess the psychosocial impact of this surgery. Materials and methodsA qualitative descriptive phenomenology approach was used. A total of four in-depth interviews were conducted with the two South African penile transplant recipients. The interviews were transcribed verbatim while adding the field and observational notes. Thematic analysis was used to derive meaning from the collected data. ResultsAfter the penile loss, both participants reported feeling suicidal for the following reasons: their communities shunned them and regarded them as ‘dead,’ they felt severely ashamed of their disfigured bodies, they were unable to develop intimate relationships and could not have children. Transplantation gave them a fully functional penis, which resolved the majority of these issues. The participants were able to build relationships and satisfy their own and their partners' sexual and relationship needs. The transplant led to complete restoration of their self-image and manhood. They were, however, still persecuted by their traditional communities as they had not successfully completed the ritual circumcision ceremony. ConclusionThis study emphasises the necessity of offering penile transplantation as treatment for penile loss as this is not only life enhancing but lifesaving, especially within the South African context.

A pilot retrospective CT angio study of the internal pudendal arteries in male bodies, for the purpose of penis transplantation to trans men

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.