In the past year, medicine has made some impressive advances pertaining to sex organs: Last April, doctors at Wake Forest performed successful implants of lab-grown vaginas; months later, the same center announced that lab-grown penises could soon be ready for human implantation. And now a South African urologist has performed the world’s first successful penis transplant.
Earlier this month, Andre van der Merwe became the first doctor to transplant a donor penis, as part of a pilot program at the University of Stellenbosch and Tygerberg Hospital in Cape Town. The nine-hour surgery took place back in December, but Dr. van der Merwe wanted to wait to make sure the procedure was a total success before announcing it to the public. He’s now happy to report that the recipient — a 21-year-old man whose penis was amputated after a ritual circumcision (performed among a group in the Eastern Cape province) left his genitals mutilated — is happy and healthy, and making good use of his new penis.
Since the news broke, Dr. van der Merwe has been surprised by the overwhelming amount of interest in the surgery. For a relatively small organ, it seems the penis has outsize cultural baggage. "I didn’t see this as a high-profile surgery, but I think the hype of the operation is a reflection on us as a society," he said, going on to discuss the effect of such a transplant on self-image and ego. "Why is the penis so important to us? I'm not sure, but it is, " he said.
The Cut spoke to Dr. van der Merwe—now "Dr. Dick," in the South African press—about the procedure.
You conceived of the pilot program that led to this surgery. Why did you believe it was an important procedure?
In this part of the world, because of the importance of the circumcision ritual, I see young men come into the hospital for treatment and leave without a penis. They always ask, “When is it going to grow back?” And then you have to tell them “It’s not going to grow back. You’re 19 years old and you haven’t got a penis and that’s just the way it’s going to be." So, it’s the devastation on those guys' faces — who thought they were going to be men, they’re going to have sexual intercourse, they’re going to marry — all of those things are gone for them. I run the transplant program here and after harvesting the kidneys and seeing some of these donors just going to the mortuary with a penis on, I thought, Why don’t we just take the penis and harvest it and attach it? I just thought one should be able to do it. That was in 2010, more or less. And then we looked up the literature and saw it had been tried once and failed. And then the project started.
What was life like without a penis for your patient?
Life was just hell — there is no other way to describe it. When it comes to these ritual ceremonies, the penis is almost a holy thing in the community and culture. It’s supposed to be a watershed event between manhood and boyhood. The stress that people might find out and they will be stigmatized is ruining their lives. Young guys are committing suicide because they’re feeling completely depressed and deprived of manhood.
What about medically?
Him and a lot of the others on the list had gangrene of the penis and it became infected. So they have varying degrees of kidney failure. One [patient] got septic arthritis. They lie in the ICU, being ventilated with multi-organ failure, some of the guys awaiting this surgery. The fact of the matter is, medically, if you lose your penis from this, it’s not the only thing that’s gone wrong — you’d be lucky to survive with your life.
Before this, what were options for men who had lost their penis?
In South Africa, what we can do is a forearm flap. So, you take muscle and skin from the forearm and then you fashion it, in a double-tube fashion, into a penis. And then you’ve got something that looks very good — or, it can look potentially very good. It can also have full sensation if you connect the peripheral nerve well. But it doesn’t have the same function of a penis, and what you find with those flaps, if you look at the literature, is that the flaps atrophy in up to 40 percent of patients — they get smaller. You can’t have a prosthesis put into them because they are just not big enough after a while. Then of course the problem with the prosthesis — it’s a hard rod implanted inside the penis that you either inflate to be hard, or it is a malleable rod — is that the prosthesis extrudes if you have frequent sexual intercourse. It pushes through the penis.
It’s very, very expensive. A forearm-flap penis costs about $120,000, and then an additional 10,000 to 12,000 U.S. dollars for one of those inflatable things. And then you tell the guy he can only have sex once in a week or once in two weeks because otherwise these things aren’t going to work? And then because you’re connecting different tissues, the flaps often leak urine, so men have to sit down to urinate. So, yes, it’s better than nothing but certainly it doesn’t have the same function as the real organ. Not by a far chance.
How’s the patient doing in his post-op life?
He’s doing very well. I looked at the transplant a couple of days ago and it looks absolutely normal. There’s absolutely no sign of rejection. He’s only 21 and we know from the kidney transplant program that this age group is not the most reliable with immunosuppressant drugs, but this guy is very solid. I think he’s a model patient.
You have a waiting list of candidates hoping for this surgery. Is it more challenging to find a donor penis than it is to find, say, a heart?
The big hurdle with this kind of surgery was to get a donor — even after the ethics committee approved it, you have to ask someone to donate a penis. The family members are feeling too bad to donate the relative’s penis. You know, you’re taking their dignity away. And it occurred to me I should do something to restore dignity for the cadaver — it’s not difficult to make something that looks like a penis. Then, we started asking with that in mind, knowing we could make a skin penis, and I think the first four cases still said no, but they were thinking about it, but then the fifth one said yes.
And everything works? He can have kids? Have sex?
Of course he can have kids. And he’s already sexually active, much earlier than I expected honestly. If you look at penis-replant studies, where the penis has been cut off and you put it back on, those take about two years to recover full function. So I was aiming for two years.
Was there any concern that he was having sex so much earlier than you expected?
Intercourse at five weeks was really scary, because I didn’t think there was a way that his body could have healed completely at the suture line. I was so scared of a rupture at that suture line. We did tell him, because of the way his blood supply comes to the penis, if he had intercourse, especially in the early days, to make absolutely sure that the female should not be on top, putting pressure continuously on that artery. I was absolutely scared that if that happened that the artery would block off. But everything seems to be fine.
What, if any, are the long-term issues he’ll have to deal with?
This guy had to be prepared for all the side effects and things. I mean, a lot of things can go wrong in the long-term, being on immunosuppressants. Infection is the biggest problem. He can have pneumonia or the flu, for instance, at a higher rate than anyone else. Or he can have skin infections, he could have bladder infections, he could have septicemia. Those sorts of things are all real risks. So we treat him the same as we do for our kidney transplant patients
What about psychological issues?
We looked a lot into the facial transplant literature to see what the psychological effect would be on the patient having received a face and I think the penis is very similar; it really effects the understanding of self-image and ego. When you add an organ, you break what used to be stable and solid — your whole image becomes more liquid. It can induce psychosis or depression. He could avoid the organ, or he can stop taking his medication. We didn’t really know what to expect. The other thing is the primitive guilt, he’s now feeling guilty that he’s walking with somebody else’s penis and that guy’s in the grave — but the primitive guilt is seemingly not a problem for this guy.
I know there was an attempt in China in 2006, but the patient had to have the penis removed due to psychological trauma.
I was so scared that he was going to wake up and, much like the very first case in China, that he was not going to accept the penis. But I think because he’s a very solid young man, I think that played a part in it. We prepared him very well, you know, explaining that he’s going to feel strange about the penis and it’s going to be funny to have somebody else’s penis attached to your body, but he has seemed to have put that behind him very quickly.
We had his penis stapled onto his body with staples and a sponge, and he couldn’t see his penis and he’s never seen his penis until then. So we were taking the staples out of the skin and cleaning up the sponge and he couldn’t keep it in — “I want to see my penis” — you know, and that immediately made it clear to me that this guy is accepting it, as "my" penis. Personally, I don’t think he wants to be reminded that it belonged to somebody else at some stage. I think he basically just wants to carry on with his life and not look back. Because he’s been through a terrible time. I think he’s closed the door in a fantastic sort of way.
Who else might be a candidate for a penis transplant surgery?
People who have cancer of the penis. It’s not as uncommon as you may think to have cancer of the penis and have the penis be removed. People who are born with congenital abnormalities. I received an email from someone who was born without a penis — we call it aphallia — who was wondering if he might be a candidate. Or someone who suffers from epispadias, a condition where you have a very short and stubby penis that is sometimes adequate for sexual intercourse and sometimes not. I think a short stubby penis would be a perfect landing place to put a transplanted penis on. And then across the world there are people who lose their penises from trauma, from violence, gunshots. Maybe people with erectile dysfunction who have exhausted every option and they’ve had prosthesis in and they’re still young. But I have to say, this is not the first line of treatment at all. This is end-of-the-line treatment.
So, you don’t think there is space for this to be a purely cosmetic surgery?
I really do not think this is for cosmetics. I think we have to shy away from the cosmetic application. If you just want something that looks good, you can use a forearm flap. It doesn’t look bad. I mean, you can have a big voluminous forearm flap. But I think this is for severe — I want to call it life-threatening problems, because for our group of young men it is certainly life threatening. They don’t have a life the way they are.
You mentioned in an article that you’ve had people reach out to volunteer to be donors. Is that something you could consider?
Yes, they emailed and said, “I don’t want a penis anymore,” and will we take the penis? I think probably not! It’s something I won’t do easily because maybe in a year or two the guy changes his mind and then he’s got no penis and he goes and hunts down the person who has his penis or something. Those people have offered and I am grateful for their attitude. It’s very kind to offer, but I prefer to have a cadaver who has been fully worked up as part of the transplant setting.
This interview has been condensed and edited.