Doctoral Degrees (Urology)

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    Penile allotransplantation for total phallic loss due to ritual circumcision: Proof of concept
    (Stellenbosch : Stellenbosch University, 2020-12) Van der Merwe, Andre; Moosa, Mohammed Rafique; Stellenbosch University. Faculty of Health Sciences. Dept. of Surgical Sciences: Urology.
    ENGLISH ABSTRACT:Ritual circumcision is an important tradition practiced by many African cultures in South Africa. These circumcisions occasionally result in severe penile mutilations, and many men are rendered aphallic as a result. Phalloplasty represents conventional treatment for these cases. However, this type of surgery has many challenges, which make it an undesirable treatment option, particularly in low- to middle-income settings, such as South Africa. Therefore, we considered alternatives to phalloplasty that were technically feasible and cost-effective. Penile allotransplantation was largely unexplored as a therapeutic option at the inception of the study in 2011, and it was uncertain if a penis transplant would restore all the functions of a normal penis. We undertook a proof of concept investigation and explored the feasibility of penile transplantation in our resource- constrained hospital setting. This is a prospective mixed-methods observational study. Following Human Research Ethics Committee approval, ritual circumcision related aphallic patients attending the Urology Clinic at Tygerberg Academic Hospital were invited to participate. Informed consent was obtained following the intense briefing of candidates over several visits. Various blood tests were conducted, after which selected patients werewaitlisted. The first donor became available in December 2014, and the most suitable recipient was selected based on blood group matching and a negative T-cell cross match. The donor penis was retrieved and transplanted by using the same basic principles of vascularised free flap surgery. Intense immunotherapy was initiated. Outcomes were recorded in terms of recovery from surgery, sexual function, standing to urinate, and general psychological recovery. In the first case-report at 24 months postoperatively, we used standardised pre-and post-surgery Short-Form (SF-36) health questionnaires as well as the International Index of Erectile Function (IIEF) scores to document erectile function outcomes. After that, we used lessons learned from the first case to construct a preliminary guidance manuscript on penile transplantation. We performed a second penile transplant case with 40 months follow-up using patient-reported outcomes as a measure of success in terms of erectile function, sexual satisfaction, and general well- being. We reviewed the ethics around penile transplantation in the context of our experience gained performing two penile transplantations and the societal and academic responses to these cases. Using a phenomenological approach, we conducted four in-depth interviews and performed a thematic analysis to describe study participants’ experiences of living with another person’s penis. Finally, we investigated the current state of penile transplantation by a review of the English literature using available primary databases. Additionally, we published two book chapters on penile transplantation and a manuscript of rebuttal to an argument against penile transplantation. These are attached as addenda to the current thesis. Patients with penile loss are suffering severely. Their self-image, as well as relationships, are destroyed with no effective treatment available to them. Penile transplantation offers hope for the restoration of their broken body image and relationships. Also, this study may pave the way for penile- or total genital transplantation in transmales.
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    The management of infertility secondary to azoospermia in a developing country: Is microsurgery a feasible solution?
    (Stellenbosch : Stellenbosch University, 2019-12) Zarrabi, Amir D; Kruger, Theunis; Van der Merwe, André ; Faculty of Medicine and Health Sciences. Dept. of Surgical Sciences. Division of Urology.
    ENGLISH ABSTRACT: The Introduction to this dissertation outlines the clear need that exists for addressing the limitations in male infertility treatment in South Africa (Zarrabi & Kruger. Nat Rev Urol 2018; 15(12):719-720). In this country we are faced with a burden of infertility surpassing that found in most developed countries, while at the same time struggling with inferior (in fact, often non-existent) access to skills, expertise, resources and training. This thesis provides evidence that this situation can be remedied. Chapter I provides an in-depth assessment of the current status of training and skills in male infertility and related microsurgery among urologists in South Africa. As expected, urology residents, academic urologists and consultant urologists in private practice in South Africa are in agreement that exposure to- and training in male infertility and –microsurgery is inadequate in the current residency programs. The majority opinion is that qualified urologist in private practice in South Africa are not adequately equipped to manage male patients with infertility and that the training which they received during their residency had been insufficient. A definite need for more focus on male infertility and -microsurgery in the urology residency training curriculum was clearly expressed by both trainees and qualified urologists. Chapter II is divided into 3 parts (IIa, IIb, IIc) and describes various aspects pertaining to the microsurgical management of obstructive azoospermia (OA): Chapter IIa looks at the outcomes which can be achieved in a developing country (South Africa) as part of the first dedicated service in male infertility microsurgery. Data from a total of 226 patients with OA operated on by a single surgeon, revealed surgical outcomes comparable to those achieved in developed countries. Chapter IIb further quantifies the success of microsurgery for OA by an analysis of the semen profiles, sperm quality and immunological factors in men after successful microsurgical reconstruction for OA. The data revealed that the optimum semen parameters were reached at 3 to 6 months after surgery but that the majority of men failed to reach normozoospermia according to WHO 2010 reference values. Not surprising, the type of reconstruction performed was found to significantly influence the semen profile. Patients who achieved pregnancy after surgical reconstruction had superior semen profiles when compared to those who failed to achieve pregnancy and a positive MAR test was associated with inferior sperm quality and lower pregnancy rates. Chapter IIc sheds some light on the factors which may be responsible for failure of microsurgery by in-depth examination of the histological findings at the anastomotic sites of failed reconstructive procedures performed for OA. While fibrosis was the most consistent histological finding at the anastomotic sites of failed microsurgical reconstructions, failure to address epididymal obstruction further contributed to surgical failures. Chapter III deals with the microsurgical management of non-obstructive azoospermia (NOA) and provides data on the outcomes which can be achieved with micro-TESE (microsurgical testicular sperm extraction) in a developing country (South Africa) as part of the first dedicated service in this surgical modality. Not only were sperm retrieval rates of micro-TESE found to be comparable to those reported internationally but - very importantly - mentorship in both the micro-TESE procedure and the in-theatre processing of biopsy material were shown to significantly improve the success of surgery. Chapter IV takes the need identified in Chapter I, leverages the successful outcomes proven in Chapter II and III and subsequently maps out the development of a training program and cost-efficient service delivery model for male infertility and - microsurgery in South Africa. Based on the model used in North America, it was found that the components essential to the development of a training program in male infertility and -microsurgery were available in South Africa: • A well-defined curriculum • Exposure to adequate numbers of clinical cases • Mentorship It is my sincere wish that this thesis will be the catalyst for providing care to infertile males in South Africa, which is on par with international standards, anchored in sound scientific evidence, delivered with compassion and is accessible to all.