The Doctors Who Did the First US Penis Transplant Explain How It All Works

A "quantum leap" from "taking soft tissue from the arm or leg and wrapping it in a tube to make it look genitalia-like."
May 16, 2016, 10:08pm
Image: Shutterstock

On Mother's Day, a team of scientists at Massachusetts General Hospital successfully performed the first-ever penis transplant in the United States.

Plastic surgeons Curtis Cetrulo and Dicken Ko performed the 15-hour operation on Thomas Manning, a 64-year-old who lost the vast majority of his penis in order to cure him of his cancer.

There have been two other penis transplants—one in China in 2006 that failed, and a successful one in South Africa in 2014.

Though penis transplants have thus far been rare, urotrauma is not. Cartel and Ko say that there are many young men—many of them military veterans—languishing in silence without their penises because of injuries sustained in Iraq or Afghanistan.

And so Cetrulo, Ko, and Manning have decided to be very public about the surgery in hopes that the procedure becomes more common. As you might expect, there's a lot that goes into transplanting a penis. It's a technically difficult surgery that Cetrulo says is a "quantum leap" beyond current options for those who have a penis amputation, which often involve "taking soft tissue from the arm or leg and wrapping it in a tube and basically placing a catheter through the center to make it look genitalia-like."

Cetrulo and Ko say that first and foremost, they want Manning's penis to look like a normal penis. Secondarily, they want him to be able to pee standing up—now, "he just sprays," Ko told me. Finally, they want him to be able to regain normal sexual function. He'll be working with a sexual medicine therapist over the coming months on that last goal.

"Connecting the urethra is not that difficult. We know how to do it from the reconstruction of urethras, which are injured in a lot of other circumstances"

I spoke to the doctors to learn how the donor penis was chosen, Manning's state of mind, and how, exactly, one transplants a penis.

MOTHERBOARD: How does a penis transplant work? What made you want to do this in the first place?
Cetrulo: We see this as a continuum of other transplants such as hand transplantation and face transplantation.

These are all called "vascularized composite allographs," which are organs made up of skin and more than one type of tissue. With a kidney, it's all kidney. But with a hand it's tendons, nerves, blood vessels, which are vascularized. Allographed just means it's from a different person.

It sort of follows logically that the intricacy of the genital urinary system lends itself to a transplant that is more similar to these sorts of vascularized composite transplants. It's technically more difficult than a hand transplant because, vascularly, it's more technically challenging.

So what is the order of operations then? What makes it more difficult than a hand?
Ko: The urethra is the largest structure in reconstruction, that's what needs to be secured first. It's kind of forms a large scaffolding for the rest of the surgery. All the other things are wiring—you're creating a network that makes the penis allograph work.

There are many different veins and arteries in the penis. Image: baus.org.uk

Connecting the urethra is not that difficult—we know how to do it from the reconstruction of urethras, which are injured in a lot of other circumstances. It's not the newest technology there. The urethra is put together and forms an anchor. We have a catheter in the bladder, and then it's a much more delicate procedure to proceed and connect all the vascular tissue and the nerves.

He said, "Anything to just help me out would be a wonderful opportunity. The key is to have the opportunity to become whole again so I can look myself in the mirror"

It sounds as though this was successful, at least so far. He will be able to have full function eventually, right?
Ko: There are three goals established in this order: Number one is appearance. We want him to have full genitalia that looks as normal and natural as possible. Two is genital urinary function, so he can void normally while standing up. The third benchmark is whether these patients can develop full sexual function. That will take a lot of time before we know.

What is the rehab process like?
Cetrulo: He'll engage with a urological team to make sure he gets urinary function when the catheter comes out. Then we have a sexual medicine expert, she'll be a very important part of his care going forward as he tries to reestablish sexual function. We'll spend a lot of time on that because this is one of the biggest goals of our transplant. He'll require support psychologically.

Will his sexual partners be able to tell that he's had a transplant?
Cetrulo: We're hopeful that it'll be pretty inconspicuous. He'll have scars in the region but it'll look like what it is, which is full genitalia.

"The suicide rate in this population is somewhere between 15 and 50 percent"

How does the donation process work? Where do you find a penis donor?
Cetrulo: The donors are selected by organ procurement organization called the New England Organ Bank. They had a separate protocol they used to approach families to find a potential donor [for the penis]. They call the hospital when one is identified.

It's just like when other organ transplant teams are alerted. We worked with them to obtain the tissue we need, with the caveat that we certainly don't get in the way of life saving organs for others.

Did you have to find a penis that was roughly the same size as the one he had?
Cetrulo: Yeah, there's things we can do with the anatomy to tailor the tissue to match the recipient donor. There's a little leeway there, but we needed a match with room for a minor discrepancy.

And do you have to worry about things like blood type? How do you know if he'll reject it or not?
Ko: It's a blood-type identical donor-recipient organ. So we tested our recipient for anti donor antibodies, of which there were none. So he can take most donors without a high risk of hyper acute rejection.

"If he stands up to pee, he just sprays"

You mentioned in the New York Times article that you're being so public about this because you want this to become more common—what did it take in this case to get it done? Is it fair to call this a proof of concept?
Cetrulo: We're hoping it'll become more routine. It takes a while to get through the ethics approval board and things like this. We're not dragging our feet—we think we can do it but there's a lot of hurdles that need to be overcome, which is why we started with our own patients here. We hope we'll do it successfully so we can begin reconstructing wounded warriors.

It's more than a proof of concept. We call it an index case in that it's our first one, but we're hyper prepared and hyper vigilant and we expect it to go well. We hope the first one goes as well as our next 100.

From reading that article, the patient seems like an amazing person. What can you tell me about his attitude through all this?
Ko: He's an amazing man. Four years ago when he lost a large portion of his penis, it was hard for him. Before the cancer, the man was totally functional, but he lost his ability to urinate properly. If he stands up to pee, he just sprays.

He lost sexual function, he became much much more withdrawn. When the opportunity for this came out, he said, "Anything to just help me out would be a wonderful opportunity. The key is to have the opportunity to become whole again so I can look myself in the mirror." It's something society has had a changing attitude on—a holistic type of medicine. We're treating the form and we're treating function. Part of that is his mental health. It's a tribute to the man behind the disease.

Cetrulo: The inspiration for this was a colleague's experience at Walter Reed [Army Medical Center].

Young kids coming back from Iraq and Afghanistan in the urologic trauma ward with devastating injuries one after another. He's a grizzled and experienced surgeon who had seen bad urologic injuries, but he wasn't prepared for this. He said we have to do this for these patients. It was a patient-driven project and continues to be. It's inspiring to talk to these patients who were suffering from these injuries in silence, they were so uncomfortable they couldn't even talk about it with buddies and friends and spouses. The suicide rate in this population is somewhere between 15 and 50 percent. As you can imagine an 18 to 20 year old kid coming back without any genital urinary function is prone to being quite hopeless.

Before transplantation, were there any other options? Like prosthetics, or what?
Cetrulo: The reconstructive option we used to use was to take soft tissue from the arm or leg and wrap it in a tube and basically place a catheter through the center and make it look genitalia-like.

It accomplishes in a rudimentary fashion the first two goals we talked about. Sometimes you can pee standing up, other times you cannot. But it doesn't function like a sophisticated anatomic tissue. This is a quantum leap as far as we're concerned.