By Rachel Nuwer From Smithsonian Magazine

The doctors who announced the first successful procedure last week had a particularly difficult time finding willing organ donors

Three years ago, an 18-year-old man checked himself into a South African hospital under grim circumstances. He had recently undergone a ritual circumcision, but the procedure had not gone well. His penis had been too tightly wrapped, causing it to undergo necrosis. Life-threatening gangrene soon set in. To save himself, the young man had come to the hospital that day to have his penis amputated.

His story has a happier ending than you might expect. Last week, doctors at Stellenbosch University and Tygerberg Hospital announced that the young man had become the recipient of the world’s first successful penis transplant. The procedure was performed in December, and the man now appears to have made a complete recovery and enjoys a fully functional penis. “This guy is now confident, he’s really back to being a man,” says operation leader Andre van der Merwe, head of the university’s division of urology. “The effect the transplant has had on this man proved to me that the project is really worthwhile.”

No one knows how many penis amputations occur each year in South Africa, but Western-style hospitals annually receive some 250 patients whose botched circumcisions ultimately lead to the loss of their organ. The true number, however, “must be in the thousands,” van der Merwe says, based on the cultural traditions behind the condition. “We are confident that this is only the tip of the iceberg, because initiates are not supposed to come to Western doctors.”

Ritual male circumcision, practiced by certain ethnic groups in South Africa, acts as a sort of rite of passage for young men. Traditionally, male teenagers attend circumcision schools where they are instructed in sex education and family values. At the end of that process, they are circumcised. “It is a positive thing, in its intended form,” van der Merwe says.

Problems started in recent years, however, as formerly close-knit communities began to degrade and old traditions fell away. Today, the people who perform the circumcisions often have little if any training. They charge exorbitant prices for the dangerous operation, which entails wrapping the penis at its base to stem the flow of blood before removing the foreskin. When the penis is wrapped too tightly, things go awry.

Sometimes, gangrenous penises fall off on their own. Each year, stories also hit the news of men who died from their infection after refusing to visit a Western hospital for fear of being ostracized. Some who do seek help are turned away by nurses who come from the same culture. Still others, unable to cope with the shame, commit suicide after losing their penis. Those who survive losing an infected penis oftentimes do not tell their relatives or even parents. Living with that secret means they must always be wary about using the bathroom or undressing in front of others, and it prevents them from pursuing romantic relationships. “These are guys who are 18 or 19 and who are now seen as failures in their own traditions,” van der Merwe says. “They are stigmatized in the heaviest way possible.”

Donors Wanted

Van der Merwe became interested in this problem back in 2010 and slowly built up a team of plastic surgeons, transplant coordinators, immunologists, anesthetists, theater nurses, ethicists and psychologists who also believed that penis transplants were worth investigating. They began by working with cadavers in the lab, making sure they understood all the ins and outs of this new type of transplant. All of the tests and ethical reviews went well, and they soon gained approval to begin a clinical trial with humans.

That’s when they hit a major roadblock: They simply could not find a donor. “I think there’s a lot of emotional gravity that goes with the organ,” van der Merwe says. “The psychology stretches deeper than we care to admit in everyday life.”

In South Africa, even if a man signs himself up as an organ donor, his family must give final written approval of that request following his death. Time and again, families flat-out refused to consider giving up the penis of a deceased father, brother, husband or son. “I cannot even count how many no’s we got. It was very frustrating,” van der Merwe says. “People just don’t want their relatives going to the grave without a penis.”

Then, an idea struck. Van der Merwe offered to fashion a faux penis out of a donor’s skin instead—a way to preserve the deceased’s dignity while also allowing him to do one final good deed. “People all of a sudden were thinking about the request, rather than just bluntly saying ‘no,’” van der Merwe says. On the fourth or fifth try—a year and a half after they began the search for a donor—one family finally said yes to a full penis donation.

Second Chance

As far as van der Merwe and his colleagues are aware, no one has previously performed a penis transplant that was successful in the long run. One report published in China several years ago detailed such an operation, but the penis apparently developed necrosis, possibly because the Chinese doctors warmed it with an infrared lamp immediately after the operation and increased its metabolic needs too quickly. Ultimately, that organ had to be removed. Other researchers have attempted transplants in rats, but never in a live human.

The young man in South Africa who received the transplant was not the first on the waiting list, but his blood group and immunology tests proved to be the closest match to the donor’s, meaning his risk of rejecting the organ was the lowest. The operation, which lasted nine hours and involved five surgeons, was straightforward but not without its close calls.

To perform the transplant, the surgeons opened up the man’s existing penile stump and surgically excised it to reveal the erectile bodies and the urethra within. It turned out that the patient’s own blood vessels had been completely destroyed by the severe infection following his circumcision, rendering them unusable for connecting the donor organ. But the surgeons improvised, drawing one of his abdominal arteries down to the penis and recruiting another that was nearby, and connecting them instead. Adding to the complications, in the first hours of the operation a blood clot developed in one of the arteries, but the surgeons caught and removed it before it could cause any damage.

After the operation, the team gave the patient medication to increase the blood supply to his new penis, which for some time after the operation was connected to a catheter and prevented from becoming erect. After a month in the hospital, the doctors sent the man home, and the team simply had to wait to see if his body would take to the new penis. At one point, the patient developed a hematoma—a collection of blood outside of a blood vessel—that the doctors had to evacuate. Some of the skin at the base of the penis also became infected and had to be removed. But overall, things went surprisingly well. “At this stage, the penis is incredibly well-tolerated,” van der Merwe says. The man can urinate, become erect and ejaculate normally.

That clinical evaluation applies psychologically, as well. “What’s so incredible about this particular guy is that he’s really just closed the door behind him and is looking forward,” van der Merwe continues. “He’s completely accepted this as his penis—he’s not even thinking that it belonged to someone else.” Van der Merwe adds that the young man’s girlfriend also appears to have accepted it. She is likely the only one who can celebrate the success, however; Van der Merwe does not think his parents ever even found out that he even had a problem with the original circumcision.

With this first success, van der Merwe hopes that the process of recruiting donors will become somewhat easier, and that more operations can soon be performed for the other men on the waiting list. He also believes that it will only be a matter of time before hospitals around the world try the procedure themselves. It could also potentially be used for female-to-male reassignment surgeries, but that would depend on figuring out how to properly attach the penis. Van der Merwe also wonders whether the clitoral stump would be able to generate sufficient blood flow to attain a full erection, though it could be possible to draw down extra arteries, as his team did for the young man.

For now, the procedure is most promising for men who have lost their penises to cancer, battle injuries or accidents. Indeed, since news broke about the operation, van der Merwe has received numerous messages from hopeful men. “One man from the U.S. emailed me and said his life is intolerable, he has a stump not much longer than those from [botched] ritual circumcision,” van der Merwe says. “I feel for people like him and think transplants should be done, should they accept the risk and be good candidates.”

Image: Members of the Xhosa tribe, like the young initiates seen here in Khayelitsha, are among the South African groups that practice ritual circumcision. The affiliation of the young man who received a transplant is not known. (Gideon Mendel/Corbis)
For more on this story go to: http://www.smithsonianmag.com/science-nature/trickiest-part-first-successful-penis-transplant-finding-donor-180954639/#h6sMRUAcBPRQshFq.99