Penile allotransplantation for total phallic loss due to ritual circumcision: Proof of concept
Thesis (PhD)--Stellenbosch University, 2020.
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.