For years, the main challenge associated with sex reassignment surgery (SRS) has been the ability to provide patients with genitalia that is not only fully functional but also aesthetically acceptable. Miroslav Djordjevic, MD, PhD, an internationally renowned surgeon and a leading authority on surgery for transgender individuals, believes he has the answer.

His idea is matching two patients undergoing transgender surgery—one male-to-female, the other female-to-male—and transferring the genitalia between these live donors in a one-stage procedure instead of discarding them as is done now.

“This will result in a huge improvement over what we currently offer patients,” says Dr. Djordjevic, who joined Mount Sinai Health System in June 2019 as a Professor of Urology at the Icahn School of Medicine at Mount Sinai and a urogenital reconstructive surgeon at the Mount Sinai Center for Transgender Medicine and Surgery. “We are striving to find a way to use all genital organs that are planned for removal in transition surgery to improve the lives of others who request this surgery and enable them to lead a normal life.”

Dr. Djordjevic says he is ready to proceed with transplantation now that he has developed the necessary special surgical techniques.

His confidence in this new approach is the result of nearly three decades of expertise and innovation in SRS and urogenital reconstructive surgery, which includes 600 male-to-female vaginoplasties, 900 female-to-male metoidioplasties, 300 female-to-male phalloplasties, and the co-development of a penile disassembly technique for epispadias repair. He also performed his first uterus transplant in 2017 and the second-ever testicular transplant in December 2019 at the Belgrade Center for Genital Reconstructive Surgery. Dr. Djordjevic is also a Professor of Urology and Surgery at the School of Medicine at the University of Belgrade in Serbia.

“Through the procedures I have done, I have demonstrated to the world that it is possible to successfully perform uterine and penile transplantation,” says Dr. Djordjevic, who joined Mount Sinai from the Belgrade Center for Genital Reconstructive Surgery in Serbia, where he was one of the few urologists in the world whose scope of expertise encompassed treatment of all anomalies of the genital system regardless of sex or age.

Dr. Djordjevic joined Mount Sinai to develop his procedures, which would include finding the right pairing of donor and candidate and leading surgeons in performing concurrent transplant surgeries.

Although there have been five successful penile transplantations performed since the introduction of the procedure in 2006, Dr. Djordjevic notes that these cases involved trauma or removal of the penis due to oncological reasons. In all cases, patients had retained the corpora cavernosa and some degree of tissue, which facilitated transplantation.

His approach is novel in that it will not only involve transplantation of the entire penis with the corpora cavernosa and their crura but also determining the best position for fixation. He also expects to transplant a penis from a male to a female body.

“This is a far more complex procedure,” he explains. “I am continuing to refine my technique through cadaveric and micrometric study, and I plan to publish papers that detail the approach so that other surgeons can offer it to their patients.” For example, he plans to publish a cadaveric study in 2021 on penile transplantation.

If his technique proves successful, Dr. Djordjevic believes it will offer considerable advantages over existing modalities for creating male genitals, such as metoidioplasty or a full phalloplasty involving musculocutaneous latissimus dorsi (MLD). For one, penile transplantation with the corpora cavernosa would result in improved sexual function and sensation, and it would reduce the 50 percent risk of complications among patients who have undergone creation of the urethra from oral mucosa or surrounding material.

“Current surgical treatments do not enable us to provide a urethra with surrounding spongiosa as is present in normal penile anatomy,” Dr. Djordjevic says. “A penile transplant would enable the usage of existing urethra and corpora cavernosa, which promises an almost ideal solution for patients looking for male genitalia because there is a good channel for voiding and good erectile tissue for normal sexual function.”

Dr. Djordjevic says advances in therapeutics could address the risks involved in transplantation of reproductive organs, specifically the effects of postoperative immunosuppressant therapy among patients. But he has also developed strategies for mitigating risk in the meantime.

For example, he notes that the first successful organ transplantation was made possible by the fact that the patients involved were monozygotic twins. The testicular transplant he performed also involved monozygotic twins, and no immunosuppressive therapy was required.

“What I will be looking for is a possible genetic match between two candidates that would minimize the need to administer immunosuppressants, or a candidate who has undergone transplant surgery and is doing well on immunosuppressant therapy because the risk of rejection will be much lower,” he says.

To facilitate identification of candidates who match these criteria, Dr. Djordjevic envisions a worldwide network or registry of patients seeking SRS. In the meantime, he continues to develop his technique, optimistic that transplantation of genitalia will eventually become standard of care in the same way that hand and face transplants are becoming routine.

“Ultimately, I would like to see us reach the point where a patient is able to conceive and deliver a baby after transplantation of a uterus and ovaries, or has a functioning, anatomically acceptable penis with normal erection and voiding,” he says. “By pioneering these procedures, we are one step closer to enabling people to live the lives they want to live.”