An estimated 250 men in South Africa have complications arising from ritualistic circumcisions that led to penile amputation.
Penile amputation exists in other regions of the world, however, it is rarely associated with circumcision rituals. Rather, it is often due to self-mutilation, assault, or accidental trauma.
This week in the Lancet
, van der Merwe and colleagues at the Stellenbosch University and Tygerberg Academic Hospital in South Africa published their findings from the world’s first successful penile transplant. It involved a young man who lost his penis due to a ritual circumcision made complicated by gangrene.
Prior to this transplant, there was one similar procedure performed in 2006 in China. While it was deemed a success, the penis was removed
2 weeks after surgery due to the severe psychological trauma experienced by the recipient and his wife.
Because of the psychological concerns that can arise from this variety of transplant, special care was taken to find the appropriate candidate at the South African hospital. The recipient chosen had lost his penis during a month-long camping event. Referred to as “going to the bushes,” the trip included young Xhosa men who have a circumcisionist remove the foreskin with a traditional spear. During the ritual, the cut penis is bandaged with buckskin or cloth and herbal leaves; the young man is then confined to a hut for 8 days, put on a strict diet, and given instructions by elders about the responsibilities of adulthood and family life.
As expected, the ritual raises serious health concerns, and penile amputation due to infection are common, as was the case for the recipient of the transplant. His penis was a casualty of gangrene setting in following the circumcision.
The patient was chosen by Dr. van der Merwe and colleagues at the Stellenbosch University following a screening to find recipients who were physically and psychologically prepared for the operation.
As the authors noted in their Lancet article, “we took particular care in selecting candidates for the waiting list who were proven to be compliant with treatment and clinic attendance and considered physically and psychologically suitable for penile transplantation. The participant selected to receive the transplant was counselled on the potential risks and benefits of the procedure for 2 years before transplantation.”
The transplantation took place in late 2014 when a donor became available and a 9-hour surgery transplanted the penis to the recipient.
Following the transplant, the patient was given immunosuppression treatment. Tadalafil (5 mg once per day) was given 1 week after the transplant and continued for 3 months. The patient was followed for 24 months with measurements of quality of life, erectile function and urine flow rates.
The recipient was discharged 1 month after surgery. Despite being warned to “take it easy,” he reported having a satisfactory sexual intercourse 1 week after discharge.
Sporadic skin infections and kidney injury were reported over the course of the 2 years but were manageable.
Quality-of-life scores were 25 preoperatively and climbed to 57 at 6 months and 46 at 24 months after surgery. At 24 months, urine flow and erectile function scores were normal.
The authors concluded that
“penile allotransplantation is feasible and can result in restoration of sexual function, penile sensation, and normal urination.” However, the authors warned that it is important to take precautions in choosing a transplant recipient and be mindful of their physical, emotional and psychological health.
Since this procedure, 2 more transplants have been successful, 1 in Boston and 1 by the South Africa team led by Dr. van der Merwe.
Videes by Dr. van der Merwe explaining the two transplants can be seen here
Van der Merwe A, Graewe F, Zühlke A. et al. Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up. Lancet. Published August 17, 2017 ahead of print.
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