What to Expect From a Penis Transplant

A penis transplant is a rare and complex procedure that has only seen a few successes. While still being considered experimental, research is progressing.

In 2006 a penis transplant was performed in China, but it was considered unsuccessful because the transplant recipient’s body rejected the organ. The first successful penis transplant was performed in South Africa in 2014, involving a 21-year-old recipient who lost his penis due to a failed circumcision. After the 2014 procedure proved successful, other transplants were performed, one in the U.S. in 2016 and another in South Africa in 2017.

In 2018, a veteran who experienced a traumatic loss from his tour in Afghanistan underwent a 14-hour procedure to transplant a donated penis and scrotum at Johns Hopkins Medical Center. He is said to be able to gain near-normal functioning (reproductively and urologically). The transplant recipient—who chose to maintain his anonymity—also lost both of his legs in the explosion (from an improvised explosive device) during the time he was serving in the armed forces in Afghanistan.

A statement by the surgeon Richard Redett explained, “Our transplant is different [from previous ones] because it is a much larger piece of tissue. An improvised explosive device typically hits the pelvic region. We were able to design a transplant that would include all the tissue to replace the entire defect.”

Reasons for a Penis Transplant

The successful procedure at Johns Hopkins in 2018 involves the hospital’s special program for wounded soldiers. Johns Hopkins names those who are eligible for consideration as people with “75% genital loss from combat injuries with limited reconstructive options.”

In addition to those who have experienced traumatic injuries resulting in the loss of the male reproductive organs, other transplants have been performed, including a man who underwent treatment for penile cancer (which resulted in the loss of his penis).

Who Is Not a Good Candidate?

Those who are not deemed stable (emotionally or physically) after undergoing extensive evaluations during the screening process are not eligible for a penile transplant.

The Johns Hopkins Medical Center program explains the transplant procedure is not yet intended to be available for transgender individuals who are considering gender reassignment surgery. In the future, the genitourinary (penis and urinary structures) transplant procedure may be available for many other recipients, including:

• Those with congenital conditions resulting in a small or abnormal phallus
• Individuals transitioning from female to male gender

Who Is a Candidate?

Reconstructive penile transplant procedures are for adults who have suffered severe trauma resulting in the loss of the structure or function of the penis. At Johns Hopkins, those who have lost most function and are not a candidate for conventional reconstructive surgery may be considered for a penis transplant.

A recipient of a penis transplant must be considered stable mentally, and be deemed stable in the following categories:

• General cognitive function
• Good coping mechanisms
• Ability to deal with the impact of penile trauma and with receiving the penile graft
• The partner must also be evaluated if the candidate is married or in a relationship.

Psychological Testing

To ensure that a candidate is mentally able to understand all that is involved in the penile transplant (such as the risks, psychological impact and more), many different types of psychological tests are administered, including:

• The Mini-Mental Status Exam
• The Hopkins Adult Reading Test (to ensure a candidate can comprehend written consent forms and other written material)
• The Hopkins Verbal Learning Test

In addition, questionnaires on self-esteem, psycho-sexual quality of life (and more) are given by the transplant social worker, who helps with the overall psychological assessment. These tests are given to ensure that the candidate for a penis implant will have a solid base of support after the procedure.

Eligibility

After a successful meeting with the transplant team, the list of criteria for a penile transplant at Johns Hopkins Medical Center include:

• Males of any color, race, or ethnicity
• Age 18 to 69
• U.S. citizen
• A penile injury that occurred six months ago or longer
• Injury resulted in loss of 75% or more of the phallus
• No history of HIV or hepatitis
• No history of cancer (for at least the past five years)
• The ability to take immunosuppressive drugs

Types of Penis Transplant Procedures

In one successful penis transplant procedure, only the penis was transplanted, but in the 2018 procedure at Johns Hopkins, the penis, scrotum, and part of the abdominal wall were transplanted; this complex procedure is called a vascularized composite allotransplantation (VCA) which is sometimes referred to as composite tissue allotransplantation (CTA).

VCA/CTA is an umbrella term that refers to transplant procedures involving several different types of tissue (such as skin, muscle, bone, nerves and blood vessels) being transplanted as a structural unit from a human donor.

A VCA (or CTA) is a solid organ transplant involving the following criteria:

• Requires blood flow by surgical connection of blood vessels
• Contains more than one type of tissue
• Is from a human donor and is recovered as a structural unit
• Is transplanted to the recipient as a structural unit
• Is minimally manipulated

There have been several types of human CTA procedures done, including hand, arm, face, knee and more recently, penile transplants.

Donor Recipient Selection Process

The process of surgical transplantation of an organ is not considered a quick or easy fix. It begins with a search to find a matching donor organ (often from a deceased person) and involves getting permission from the donor’s family members.

Understandably, it may be very challenging to locate a viable donor for a penis transplant. When a person checks the box on the driver’s license, signing up to be a tissue donor for all body tissues, the penis and scrotum are not on the list. What this means is that the family must be approached when there is a potential donor. The family members must be the ones to make the hard decision, attempting to anticipate what their deceased loved one would have chosen.

The donor must be a match in several categories include:

• Skin tone
• Skin color
• Gender
• Ethnicity
• Race
• Size of penis

Once the donor is located—utilizing a computerized organ donor matching system—the surgery can be scheduled. A person waiting for a penis donor may be called into surgery at a moment’s notice.

Types of Donors

The donor is typically a human whose family agreed to organ donation due to imminent death. Researchers have grown rabbit penises artificially in a lab and successfully transplanted them, developing techniques that may hold promise in the future for human organs.

Before Surgery

Before a person undergoes a penis transplant procedure, a very rigorous screening process is performed. The process includes lab testing and in-depth psychological evaluations, as well as comprehensive imaging to evaluate the persons’ physical anatomy (such as the blood vessels and nerves) before surgery.

Preoperative lab tests may include:

• CBC (complete blood count)
• Metabolic panel
• Evaluation of blood clotting factors
• Liver function tests
• Electrolytes
• Blood typing
• Infectious disease studies (for HIV, Epstein-Barr, Cytomegalovirus, Herpes simplex virus, syphilis and more).
• Imaging studies (CT scans, EKG’s, pulmonary function tests, X-rays, and more)

In addition, a consultation and examination will be conducted by the following specialists:

• A urologist
• A psychiatrist
• An ophthalmologist
• A cardiologist
• An infectious disease specialist
• A dentist

Surgical Process

The Johns Hopkins plastic surgery team involved nine plastic surgeons and two urological surgeons. Those that performed the penis transplant at Johns Hopkins Hospital included W.P. Andrew Lee, Richard Redett, Damon Cooney, and Gerald Brandacher. These surgeons were also part of the team that performed the first bilateral (on both sides) arm transplant in 2012 at Johns Hopkins Hospital.

 A penis transplant procedure is much more complex than many other types of transplants. Experienced surgeons, trained to perform the procedure under a microscope, work to transplant skin, muscles and tendons, while connecting a vast network of very small blood vessels and nerves.

Interestingly, the testicles were not included as part of the penis and scrotum transplant. this was because, according to the experts, the sperm-generating tissue in the donor’s testicles would possibly cause the recipient’s reproduction system to involve genetic material from the donor. This could result in a possible pregnancy involving the donor as the biological father of future offspring. To avoid the ethical complications involved, the testicles were not transplanted.

A recent discovery in the transplant procedure involves a final step; taking a bone marrow sample from the donor and infusing it (along with a low dose of immunosuppression medication) into the recipient’s body to modulate the immune response. This procedure lowers the risk of rejections of the new organ being transplanted. The bone marrow infusion procedure (before transplant surgery) was first performed by a team of specialists at Johns Hopkins Medical Center.

Complications

Perhaps the most common and serious complication from a penile transplant (or any other type of transplant) is the risk of the body attacking the donor tissue, a condition called “rejection.” It’s the immune system’s response to identifying the newly transplanted tissue as a foreign invader (much like a virus). To combat the risk of rejection, (even for those who received a donor bone marrow infusion) immunosuppressant medications must be given. These medications leave a person at high risk for infections because they suppress the immune system.

After Surgery

The normal recovery time after a penis transplant can take several weeks, up to six months, or longer. But even after recovery, transplant recipients will be followed by the transplant team their entire life, according to Johns Hopkin’s Medicine. Follow up procedures include:

• Blood tests
• Screening for signs of possible rejection
• Tests for urinary flow
• Erection Hardness Scale test
• Questionnaires to evaluate the function of the GU (genitourinary system including the organs of the reproductive and urinary system)

Prognosis

There are several goals of penile transplant that are evaluated as part of a successful prognosis, these include:

• Normal urination
• Restoration of sexual function
• Restoration of the recipient’s sense of wholeness and self
• A normal appearance and function of the penis (including the ability to become erect, or be compatible with a penile prosthesis, perform sexual intercourse).

Because of the limited number of penis transplant procedures that have been performed, there are no statistics on the prognosis of the procedure yet. However, the 2018 penis transplant procedure performed at Johns Hopkins is considered a success. According to Penn State Hershey, “About 18 months after the transplant, the patient was able to urinate without problems, have normal sensation in the penis, and have "near-normal" erections and the ability to achieve orgasm. With the help of limb prostheses to replace his amputated legs, he is now living independently and in school full-time."

Support and Coping

Perhaps more than other types of transplant surgery, the emotional and psychological burden of having a penis transplant can be significant. The procedure is still considered experimental and the risk of allograft failure and rejection is considerable. Candidates for transplant procedures must be able to show (through psychological testing) that they can handle these risks.  In addition, there have been cases in which transplant recipients had adjustment problems after the procedure, struggling to accept the donor transplant as their own. 

Because of these and many other psychosocial related issues linked with having a penis transplant, a recipient must continue to be open to ongoing mental health evaluations and support from professionals, as well as from their family members and/or friends. More specially, experts advise that psychological support should be provided daily during the first month after the procedure and two times per week for the next four months, followed by once a month (or at the request of the transplant recipient). The recipient’s romantic partner or spouse should also be involved in professional counseling, and peer support groups are highly advisable.