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Page 14 of 17 Khavanin et al. Plast Aesthet Res 2020;7:47 I http://dx.doi.org/10.20517/2347-9264.2020.63

locoregional recurrence should be negligible. We also believe that criteria for transplantation should be
expanded to include men with congenitally ambiguous genitalia or true micropenis. To date, even the most
sophisticated techniques for conventional penile reconstruction are fraught with urinary complications
and issues related to penile prosthesis [3,19] . Although there are greater risks with penis transplantation, this
may be outweighed by the improved function and aesthetics of transplanted phallus. At this time, further
deliberation on the use of penile transplantation in transgender men is needed as the lack of proximal
corpora would preclude the ability to achieve an erection with the transplanted penis.

Technical considerations
Donor selection
[60]
Limited donor availability represents a major hurdle for any kind of transplantation . In addition to HLA
matching and screening for a healthy donor phallus that is without vascular disease, sexually transmitted
infection, and/or complications of diabetes, attention should be paid to recipient aesthetic preferences. The
appearance of donor phallus must be inline with the recipient’s desired appearance and discussed frankly
before listing, in an attempt to limit psychological stresses.

Surgical planning
Given the anatomical complexity, penile transplantation presents unique challenges including how
proximally the graft will need to be harvested. Anastomosing a distal portion of the penis requires fewer
structural anastomoses than transplantation of the entire penis with portions of the pelvic floor. Larger
grafts may be required to address wartime injuries when extensive damage to the genitalia, pelvic floor,
and abdominal tissues can occur from the upward blast of an improvised explosive device. In congenital
anomalies, there may be insufficient tissue development to provide adequate proximal corpora to be
anastomosed.

[21]
The penis has three main vascular perfusion territories that have been previously described in detail .
The first includes the shaft skin, which is perfused by the external pudendal arteries bilaterally. The second
territory includes the glans and corpus spongiosum, which are supplied by the dorsal arteries. Finally,
the corpora cavernosa are perfused by the cavernous arteries. The dorsal and cavernous arteries both
originate from the internal pudendal artery. However, depending on the level of the penis transplantation,
[29]
each may require its own vascular anastomosis . Venous outflow similarly depends upon the extent of
graft required. In a mid-shaft transplantation, this could be limited to as little as the deep and superficial
dorsal veins, whereas, in the most extensive penis, scrotum, and abdominal wall transplantation performed
[7]
to date, the dorsal veins were anastomosed in addition to the bilateral saphenous veins . Similar to
replantation, the donor dorsal penile nerves can be coapted with the recipient dorsal penile nerves, and the
donor urethra anastomosed with the recipient urethra in a spatulated fashion. The tunica albuginea, Buck’s
fascia, and dartos fascia are also connected in addition to the skin between donor and recipient tissues.

Postoperative care
Postoperatively, transplant recipients must have access to the appropriate monitoring to minimize both
medical and psychological risks. Psychological counselling should begin during the pre‐transplant work-
up and be continued afterward to ensure that the patient integrates the graft with their sense of identity.
Certain sexually transmitted infections may be particularly devastating to the graft within the context of
systemic immunosuppression, and safe sex counselling is essential to the patient’s long-term safety. Given
the intimate nature of penile transplants, sexual partners should also be involved in care if the recipient so
wishes. Relationship counselling provides an opportunity to ensure that the recipient has a stable support
network to assist with the necessary emotional adjustments and can also be an essential component of
these patients’ care.