*Purpose: In 2018 we performed a total penis, scrotum, and lower abdominal wall transplant on a man who had sustained a loss of his bilateral lower extremities, a portion of his lower abdominal wall, both of his testes, scrotum, perineum, and the entire penis following a blast injury while serving in the Armed Forces. Here we present an 18-month update of the patient’s progress.

*Methods: Having secured IRB approval for a protocol on penile transplantation (NA_00089306), we screened and subsequently transplanted a genotypic male with the scrotum, lower abdominal wall, and entire penis from an age-matched, brain-dead, heart-beating donor. The recipient was treated with an immunomodulatory regimen consisting of monoclonal antibody induction, calcineurin inhibitor (tacrolimus) monotherapy maintenance, and a donor bone marrow cell infusion. Infectious disease (ID) prophylaxis was managed by transplant ID and administered for 12 months post-transplant.

*Results: The recipient had a large scrotal hematoma requiring washout five hours after completion of the transplant. At three weeks, no anastomotic leaks were detected on urethrogram. He initially had urinary retention with removal of the Foley catheter in week three; the catheter was successfully removed in postoperative week 5. Subsequently, the recipient has been able to urinate standing with normal continence and flow; there are no concerns for strictures, fistulas, or other urethral complications. Protocol skin biopsies were performed at weeks 1, 2, 3, 4, 6, 12, and 24 (+/- 7 days) and months 9 and 12 (+/-30 days). Protocol biopsies have shown predominantly no evidence of acute cell-mediated rejection, and few have shown sparse perivascular lymphocytic infiltrate compatible with grade 1 rejection according to the Banff grading system for skin-containing VCA. The patient has experienced four episodes of slight erythema and rash to the graft, all of which were treated promptly with topical clobetasol +/- topical tacrolimus with quick and full resolution without requiring increases in systemic tacrolimus or addition of steroid bolus therapy. A biopsy at the time of the third episode showed a moderate perivascular and perineural inflammatory infiltrate within the reticular dermis with admixed eosinophils, compatible with grade II rejection. The recipient reports improved pain pre-to-12-months post-transplantation, near-normal erections and sensation, and the ability to achieve orgasm.

*Conclusions: Penile transplantation has the ability to restore near-normal function in select patients. Additional longitudinal data are needed to assess graft function and patient satisfaction.

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