A young military veteran who lost his genitals and both of his legs when a bomb exploded in Afghanistan received a transplanted penis and scrotum last month in the first procedure of its kind. The 14-hour surgery, performed at Johns Hopkins Hospital in Baltimore, Maryland, was the first total penis and scrotum transplant in the world. The man, who wishes to remain anonymous, is expected to be released from the hospital this week.
There have been two successful penis transplants before: In 2015, South African doctors performed a transplant on a man who'd had his penis amputated after a botched circumcision and, in 2016, a man who lost much of his penis to cancer received a transplant at Massachusetts General Hospital; it was the first time the surgery was done in the US.
But this procedure is much more complex, with surgeons transplanting the penis, scrotum, and part of the abdominal wall as well as the necessary arteries, veins, and nerves from a deceased organ donor, whose family gave consent. (The donor's testes were not transplanted for ethical reasons; this way the recipient can't father the biological children of the donor.)
"All of the transplants that have been done so far have basically been the shaft of the penis," says Damon Cooney, clinical co-director of the genitourinary transplant program at Johns Hopkins. "In this blast injury, the entire penis, the blood vessels inside the shaft were destroyed, as well as some tissue on the abdomen and the scrotum. The complexity came from the fact that this tissue had to come with the transplant but the blood supply would not be supplied by the blood vessels in the penis itself. We had to do some vascular studies, some research anatomy studies, to figure out which blood vessels to take with us." Yes, to take with them; the donor was in another state.
Cooney and two other surgeons from Johns Hopkins flew on a private jet to remove the tissue needed from the donor, then flew back. A team of nine plastic surgeons including Cooney and two urological surgeons removed a portion of the recipient's abdominal wall and started attaching the donor tissue to the recipient. First, they connected the urethra, the tube that carries urine from the bladder out of the body, and the corpus cavernosum, the spongy erectile tissue of the penis. Then they connected arteries, veins, and nerves of the penis by stitching them together under a microscope. Next came connecting the blood vessels of the abdominal skin and finally the edges of the tissue were stitched into place like a puzzle piece.
Here's an animation of exactly what they did:
The man also received an infusion of stem cells from the donor after the surgery to help prevent rejection—the body's natural instinct to attack a transplant—and reduce the amount of anti-rejection drugs he'll need to take. The technique has been successfully used in hand transplants.
It's the first penis transplant performed on a veteran injured in an explosion. According to data from the Department of Defense Trauma Registry, 1,367 servicemen sustained injuries to their genitals or urinary tract in Iraq or Afghanistan from 2001 to 2013. A third suffered injuries to the penis and 94 percent of the men injured were 35 or younger. These invisible wounds can affect men's ability to urinate normally, have sex, and father children, and experts say the genitourinary injuries are associated with a higher risk of suicide.
The recipient, who wishes to remain anonymous, told the New York Times that when he was recovering from the explosion, other wounded soldiers said they were grateful they hadn't lost their genitals. "They would say things like, ‘If I lost mine I’d just kill myself,’” he said. “And I’m sitting there. They didn’t know, and I know they didn’t mean any offense, but it kind of hits you in the gut.” He considered suicide and misused OxyContin prescribed for pain. He learned to walk on prosthetic legs, started seeing a therapist, and earned his college degree but was afraid to date.
“That injury, I felt like it banished me from a relationship,” he said. “Like, that’s it, you’re done, you’re by yourself for the rest of your life. I struggled with even viewing myself as a man for a long time.”
Doctors hope the man will be able to urinate standing up in a few months; they believe sexual function is also possible in time. Nerves grow from the recipient into the transplanted tissue at a rate of about one inch per month. “We’re hopeful we can restore sexual function in terms of spontaneous erection and orgasm,” W.P. Andrew Lee, the chairman of plastic and reconstructive surgery at Johns Hopkins, told the New York Times. (The South African man who received the world's first penis transplant did later impregnate his girlfriend, so erection and orgasm are indeed possible.)
Doctors at Johns Hopkins have been preparing to operate on vets for several years by conducting research and practice surgery on cadavers to map out the blood supply to the organ, according to the New York Times. The team has approval to perform 60 transplants on men injured in combat and then the hospital will decide if the procedure should become a standard treatment.
Gerald Brandacher, scientific director of the hospital's reconstructive transplant program, says there are several patients undergoing the screening process for a transplant and it's even more involved than the process for, say, a kidney. "It’s not only the blood type, as well as certain immunological parameters that we are matching, but you have to match for age to a certain extent, you have to match for skin tone," he says.
To be eligible for a transplant, a person also needs to have certain blood vessels and the urine-carrying urethra intact, and doctors have to be sure they have a support system and that they'll commit to taking anti-rejection drugs, then the team has to find a matching donor. This recipient waited on the transplant list for more than a year. "In this particular case, the recipient had a blood type that is rare, that also limited the donor pool somewhat," Brandacher says. The team is also limited by geography: "There is a finite time the tissue tolerates being outside the body without the blood supply…we have a travel radius where we know the flying time is acceptable," he says.
Lee estimates the surgery would cost between $300,000 and $400,000, which the school will pay for, but he hopes grants from the Pentagon will help fund future procedures. The Department of Defense has also funded some of the research.
It's expensive, but Brandacher says "this is currently the best restorative option available for patients with devastating tissue defects that don’t have any way of conventional reconstruction." The team uses the term "reconstructive transplantation" to differentiate this kind of procedure from transplants involving internal organs. It serves a different purpose, too. "Reconstructive transplantation tries to improve the quality of life and not necessarily save life," Cooney says. "So the risk-benefit ratio is different, but we agree strongly that it doesn’t mean it shouldn’t be done. It just has to be done for the right reasons and the right patients. But when it’s appropriate it can dramatically improve the quality of a patient’s life, and that’s what reconstruction is all about."
One thing the patient told the Times stood out to Cooney in particular. "The patient told the reporter that he felt whole again. This is a patient that has other significant injuries, including bilateral amputation [of his legs]. That just shows you how important the restoration of the penis and the groin tissue was for his body image."
"The message we want to get out is that for patients that have these kind of injuries there are options," Cooney says. "Not everyone needs a treatment this extreme; there are more conventional surgeries that use the patient’s own tissue to reconstruct smaller defects.
"These are injuries that are frequently not talked about; not talked about in the media, not talked about with other members of the patient’s family, sometimes there’s not even a lot of talk about them in the medical community."
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