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Human Penile Allotransplantation

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ClinicalTrials.gov Identifier: NCT02395497
Recruitment Status : Recruiting
First Posted : March 23, 2015
Last Update Posted : March 1, 2019
Sponsor:
Information provided by (Responsible Party):
Johns Hopkins University

Brief Summary:

Injuries to the external genitalia are of great concern to the military with emphasis being placed on the surgical reconstruction and psychological health of these Wounded Warriors. However, despite significant surgical advances in microvascular surgery and autologous free tissue transfer, conventional reconstructions cannot truly replace the complicated structures and functions of the penis including the urethra, erogenous sensation, and erectile corporal bodies. Conventional reconstruction poses several challenges: patients may not have sufficient donor tissue (i.e., the forearm or thigh) due to other injuries or previous surgery; multiple operations are often needed to restore the neophallus; the final reconstruction only approximates the penis' native form; recreating the urethra is challenging and the new urethra is prone to stricture and fistula formation; the erectile function necessary for sexual intercourse is often lacking; and insufficient protective sensation can lead to penile implant extrusion, infection, and subsequent explantation or loss of the reconstruction.

For these reasons, the investigators propose the current clinical trial to determine functional outcomes and quality of life (QOL) for Wounded Warriors and civilians who choose to undergo penile allotransplantation. The investigators will combine extensive experience performing total penile reconstruction in a large population affected by congenital, traumatic, and therapeutically extirpated Genitourinary (GU) deformities and expertise in reconstructive transplantation using an immunomodulatory protocol to implement this study. The investigators anticipate that penile transplantation can potentially replace "like with like," restoring the appearance, anatomy, and function of the recipient in a manner far superior to autologous reconstruction. This project will establish the ability to perform penile allotransplantation using an immunomodulatory protocol and will compare outcomes with conventional phalloplasty patient results.

Study Design: This is a non-randomized subject self-controlled clinical trial to implement a cell-based immunomodulatory protocol for penile allotransplantation. An intermediate deliverable is achieving allograft survival and functional return with reduced dosing/frequency of maintenance immunosuppression on steroid-free monotherapy (tacrolimus) immunosuppression. The long-term deliverable and goal is to demonstrate equivalent or superior outcomes when compared to satisfaction and QOL in conventional phalloplasty patients 12-60 months post-transplant.


Condition or disease Intervention/treatment Phase
Amputation Wounds and Injuries Amputation, Traumatic Urologic Surgical Procedures, Male Amputation, Traumatic/Surgery Penis/Transplantation Penis/Surgery Penis/Injuries Procedure: Penile Transplant Biological: Monoclonal Antibody (Humanized Anti-CD52) Drug: Tacrolimus Phase 2 Phase 3

Detailed Description:
Specific Aims: 1) To assess the feasibility and function of penile allotransplantation in Wounded Warriors and civilians who have lost their penis due to battle or traumatic injury, using an immunomodulatory protocol to reduce immunosuppression; 2) To assess pre-to-post changes in QOL in patients who undergo penile allotransplantation.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 60 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Human Penile Allotransplantation
Actual Study Start Date : June 2014
Estimated Primary Completion Date : June 2024
Estimated Study Completion Date : June 2024

Arm Intervention/treatment
Experimental: Treatment: Transplantation
Penile transplantation with an immunomodulatory protocol consisting of monoclonal antibody induction therapy of humanized anti CD52 followed by donor bone marrow infusion and tacrolimus monotherapy.
Procedure: Penile Transplant
Biological: Monoclonal Antibody (Humanized Anti-CD52)
Drug: Tacrolimus



Primary Outcome Measures :
  1. Allograft Survival [ Time Frame: Transplantation through end of study period (up to 5 years) ]
    use an immunomodulatory protocol to reduce immunosuppression. Post-operative allograft survival will be assessed by various clinical measures including: physical assessments, imaging assessments (ultrasound, CT angiography, magnetic resonance (MR) Neurography and MRI) immune monitoring (screen patient sera for donor specific antibodies), hematologic and metabolic tests, viral tests, chimerism tests, and skin biopsies


Secondary Outcome Measures :
  1. Quality of Life (QOL) as assessed by Brief Symptom Inventory [ Time Frame: Transplantation through end of study period ( 5 years) ]
    Brief Symptom Inventory questionnaire evaluates psychological distress and psychiatric disorders. It consists of 53-item self-report inventory in which participants rate the extent to which they have been bothered. 5-point rating scale, 0 indicating not at all bothered to 4 extremely bothered.

  2. QOL as assessed by Affect Balance Scale (ABS) [ Time Frame: Transplantation through end of study period (up to 5 years) ]
    ABS is a 10-item questionnaire that assess positive and negative affect as indicators of life satisfaction and/or well-being. Score range from 0-4. 0 indicating the feeling never affected to 4, where the feeling is affected always.

  3. QOL as assessed by NEO Five-Factor Inventory Scale (NEO-FFI) [ Time Frame: Transplantation through end of study period (up to 5 years) ]
    NEO-FFI is used to examine personality traits. Questions consists of 60 items. Items are scored from Strongly disagree to Strongly agreed

  4. QOL as assessed by the International Index of Erectile Function (IIEF) [ Time Frame: Transplantation through end of study period (up to 5 years) ]
    A score of 0-5 is awarded to each of the 15 questions that examine the 4 main domains of male sexual function: erectile function, orgasmic function, sexual desire and intercourse satisfaction.

  5. Psychosexual Measures assessed by Self-Esteem and Relationship (SEAR) questionnaire [ Time Frame: Transplantation through end of study period ( 5 years) ]
    14 item questionnaire where responses are scored from 1-5. Response of 1 indicating almost never/never to 5 indicating almost always/always

  6. T0 asses Erection Hardness Score (EHS) [ Time Frame: Transplantation through end of study period ( 5 years) ]
    EHS rates the hardness of erection on a scale of one to four, with four being the maximal score.

  7. Modified Sexual Life Quality Questionnaire-Quality of Life (mSLQQ- QoL) [ Time Frame: Transplantation through end of study period ( 5 years) ]
    Used to validate as a tool for evaluating sexual QoL. mSLQQ is measured from score of 0 to 8. 0 indicates a low score compare to 8, indicating high. A score of 4 indicates, nothing has been changed.

  8. Psychological Measures by Satisfaction with Life Scale (SWLS) [ Time Frame: Transplantation through end of study period ( 5 years) ]
    SWLS is a measure of life satisfaction. Uses scale to rate from 1-7, Where 1 indicates Strongly disagree to 7 indicating strongly agree.

  9. Brief Pain Inventory (Short Form) ) (BPISF) [ Time Frame: Transplantation through end of study period ( 5 years) ]
    BPISF assesses the severity of pain and its impact on functioning. It is scored from 0 to 10, 0 indicating no pain, does not interfere to 10 indicating pain as bad as you can imagine, completely interferes.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years to 69 Years   (Adult, Older Adult)
Sexes Eligible for Study:   Male
Gender Based Eligibility:   Yes
Accepts Healthy Volunteers:   No
Criteria

Donor Inclusion Criteria:

  • Males aged 16 - 65 years.
  • Brain dead meeting the criteria for Determination of Death.
  • Family consent for penile graft donation.
  • Stable donor (i.e., does not require excessive vasopressors to maintain blood pressure).
  • Same blood type as recipient.
  • Negative lymphocytotoxic crossmatch.
  • Accurately matched for skin tone

Recipient Inclusion Criteria:

  • Males of any race, color or ethnicity; aged 18-69 years.
  • Recent (≥6 months) or remote (i.e., several decades) penile injury resulting in the loss of ≥75% of the phallus.
  • Must have completed a clinic appointment with one of the study surgeons to discuss all penile reconstructive options.
  • Completes the protocol informed consent form(s).
  • No co-existing medical condition which, in the opinion of the study team, could affect the immunomodulatory protocol, surgical procedure, or functional results (If the condition is amenable to treatment, the study team must agree that said condition should not significantly enhance the surgical risks of penile transplantation.).
  • No co-existing psycho-social problems (i.e., alcoholism, drug abuse).
  • Negative for malignancy for past 5 years.
  • Negative for HIV at transplant.
  • Negative crossmatch with donor.
  • Consents to sample (i.e., skin biopsy) collection and storage and bone marrow infusion as part of the treatment regimen.
  • USA citizen or equivalent.
  • Patient agrees to comply with the protocol and states a dedication to the immunomodulatory treatment regimen.

Recipient and Donor Exclusion Criteria:

  • Untreated sepsis.
  • HIV (active or seropositive).
  • Active tuberculosis.
  • Active Hepatitis B infection.
  • Hepatitis C.
  • Viral encephalitis.
  • Toxoplasmosis.
  • Malignancy (within past 5 years).
  • Current/recent (within 3 months of donation/screening consent) IV drug abuse.
  • Paralysis of ischemic or traumatic origin.
  • Inherited peripheral neuropathy.
  • Infectious, post infectious, or inflammatory (axonal or demyelinating) neuropathy.
  • Toxic neuropathy (i.e. heavy metal poisoning, drug toxicity, industrial agent exposure).
  • Mixed connective tissue disease.
  • Severe deforming rheumatoid or osteoarthritis in the limb.

Donor Only Exclusion Criteria:

  • Evidence of active herpes simplex virus-2 (HSV-2) infection.
  • Tattoos: non-professional tattoo within the last 6 months, or personally identifiable tattoo (i.e., donor name) on potential transplant.

Recipient Only Exclusion Criteria:

  • Conditions that, in the opinion of the study team, may impact the immunomodulatory protocol potentially exposing the recipient to an unacceptable risk under immunosuppressive treatment.
  • Sensitized recipients with high levels (50%) of panel-reactive human leukocyte antigen (HLA) antibodies.
  • Conditions that may impact the success of the surgical procedure or increase the risk of postoperative complications including inherited coagulopathies like Hemophilia, Von-Willebrand's disease, Protein C and S deficiency, Thrombocythemias, Thalassemias, Sickle Cell disease, etc.
  • Conditions that may impact functional outcomes including Lipopolysaccharidosis and amyloidosis (may impact nerve regeneration).
  • Patients considered psychologically/psychiatrically unsuitable.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02395497


Contacts
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Contact: Jane Littleton, CRNP, MSN 410-955-6875 jlittl38@jhmi.edu

Locations
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United States, Maryland
Johns Hopkins University School of Medicine Recruiting
Baltimore, Maryland, United States, 21287
Contact: Carisa Cooney, MPH,CCRP    443-287-4629    ccooney3@jhmi.edu   
Contact: VIdhi Javia, BS    443-287-7848    vjavia1@jhmi.edu   
Sub-Investigator: W. P. Andrew Lee, MD         
Principal Investigator: Richard Redett, MD         
Sub-Investigator: Damon Cooney, MD,PHD         
Sub-Investigator: Gerald Brandacher, MD         
Sub-Investigator: Arthur Burnett, MD         
Sponsors and Collaborators
Johns Hopkins University
Investigators
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Principal Investigator: W.P. Andrew Lee, MD Johns Hopkins University

Publications:
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Responsible Party: Johns Hopkins University
ClinicalTrials.gov Identifier: NCT02395497     History of Changes
Other Study ID Numbers: NA_00089306
First Posted: March 23, 2015    Key Record Dates
Last Update Posted: March 1, 2019
Last Verified: February 2019

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Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Johns Hopkins University:
Penile Transplant
Vascularized Composite Allotransplantation (VCA)
Composite Tissue Allotransplantation (CTA)
Penis
Amputation
Immunosuppression
Composite Tissue
Male
Humans
Allotransplantation

Additional relevant MeSH terms:
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Wounds and Injuries
Amputation, Traumatic
Antibodies
Immunoglobulins
Tacrolimus
Antibodies, Monoclonal
Antineoplastic Agents, Immunological
Immunologic Factors
Physiological Effects of Drugs
Immunosuppressive Agents
Calcineurin Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents