On April 21, an anonymous 40-year-old South African man was inducted into one of the most exclusive clubs in the world: the Society of Penis Transplant Recipients. Okay, so it’s not actually a club, but if it existed, this guy — whose name remains private for ethical reasons — would be its newest member. After 17 years without a penis, he is now the proud owner of a (hopefully) fully functioning organ — and only the third penis transplant recipient of all time.

Which is pretty strange, considering that many forms of organ and tissue transplantation have become relatively commonplace in recent decades.

His operation is actually the second successful penis transplant performed at Tygerberg Academic Hospital in South Africa, which performed its first (also the world’s first) at the end of 2014. Part of the reason the nine-and-a-half-hour surgery, led by Dr. André van der Merwe, is so rare is because doing this sort of transplant is, well, really hard.

Whereas most transplants involve a single organ, the dick transplantation procedure is much more complex. A penis transplant is known as a “composite tissue transplant” because it involves multiple different types of tissues from a donor being attached to the recipient’s corresponding tissues, which can sometimes be arranged a bit differently. For the transplanted penis to be fully functional, the nerves, blood vessels, and urethra in the donor penis must be carefully dissected and aligned with those of the recipient. A “fully functional” penis is one that can achieve erection and experience intercourse, requiring proper blood flow and nerve connections. Guaranteeing that, however, is easier said than done.

penis transplant
A penis transplant involves connecting many different types of sensitive tissues,

For a penis to become erect, the two corpus cavernosa must also be attached properly so they can fill with blood. These structures, each of which has an artery running through it, contain the spongy tissue that becomes engorged with blood when a penis gets stiff.

It’s difficult to preserve all these tiny, fragile structures during transplantation, especially because transplant recipients often lose their penis to some kind of trauma, like a combat injury or an accident. In fact, the Johns Hopkins University team that plans to perform future penis transplants has developed its program with wounded soldiers in mind. The world’s second penis transplant, performed by a team at Mass General in 2016, successfully gave a functional penis to a man who had lost his due to cancer.

The South African patient, however, lost his penis during a type of coming-of-age circumcision that is not uncommon in South Africa. According to a press release associated with the most recent case, experts estimate that around 250 partial or total penile amputations occur in South Africa each year. As such, penis transplant capabilities will fill the need created by these complication-prone circumcisions (though the cost, however, remains unknown). The team of doctors from Tygerberg Academic Hospital and Stellenbosch University that performed this surgery hope that the lessons they learn during the procedures will continue to make it safer and cheaper to provide transplants for more people.

Like much of modern medicine, organ transplantation is a relatively young science. The first successful organ transplant only took place in 1954, when a kidney was transplanted from one man (who was still alive) into his identical twin. And even though heart, lung, kidney, eye, and liver transplants have since become relatively commonplace, there’s still something taboo about a penis — which might make sourcing organs for transplantation difficult. While many people have opted to become organ and tissue donors after death, it wouldn’t be surprising if some may want to opt out of giving up their penises.

With a steady source of donors, however, these doctors hope to continue restoring the sensitive body part and helping survivors of penile mutilation reclaim their dignity.

“He is certainly one of the happiest patients we have seen in our ward,” said Dr. van der Merwe in his statement.

Correction 5/24/17: In the original version of this article, it was stated that Johns Hopkins University doctors performed the second successful penis transplant, when, in fact, it was doctors at Mass General. The article has been edited to reflect that fact.

Photos via University of Stellenbosch, Wikimedia Commons/ Jason Ruck