Last May, a 64-year-old cancer survivor got a procedure to get his life back. Thomas Manning, a resident of Massachusetts, had had much of his penis surgically removed after doctors diagnosed him with penile cancer. So he was particularly excited to receive the first-ever penis transplant from a deceased donor in the United States. "I want to go back to being who I was," Manning told the New York Times shortly after the procedure.
The team of 30 doctors and support staff that treated Manning hope that he will be the first of many patients to receive a penis transplant. The procedure isn't strictly necessary for patients to survive, but it can have a huge psychological and physical impact on men who lost some or all of their genitalia in traumatic incidents—or in battle, in the case of veterans. Now, a year after the first procedure, Manning's doctors have a better sense of the specific needs of penis transplant patients and how such procedures will go in the future. A member of the team presented their findings at the American Transplantation Conference, held in May in Chicago, and recently published an article in the journal Annals of Surgery.
The success of procedures like Manning's has shown surgeons that they can do complex transplants such as those of faces, arms, and hands—called Vascularized Composite Allotransplantation (VCA), which involves transplanting multiple complex structures such as delicate nerves and blood vessels, skin, muscles, and sometimes bones so that they work in conjunction with the donor's existing tissues. Now their concerns are shifting from the abstract (can we do this?) to the concrete and logistical (how do we do this?). "Right now some of the debates are not whether or not we can do these, but what are the technical issues, who are the appropriate patients, and how to pay [for the procedures]," says Dicken Ko, an associate professor of surgery/urology at Harvard Medical School and one of the lead surgeons on the team that has been treating Manning.
Ko and his collaborator Curtis Cetrulo Jr. are working on how to prepare a patient's immune system so that there is less risk for rejection without the need for constant immunosuppressive drugs, as are currently needed for anyone who receives a transplant today: A technique called immune tolerance induction would use stem cells to effectively re-educate the recipient's immune system to recognize the transplanted organ as its own (instead of as a foreign body that needs to be attacked, which leads to rejection) allowing these procedures to be performed on young, healthy wounded warriors and children without the need for dangerous immunosuppressive drugs, Ko says.
Another challenge is accepting the right patients to receive the transplant. Lots of people have contacted Ko and Cetrulo's team both before and after Manning's procedure in the hope of receiving a transplant, but it's not necessarily the right intervention for everyone—some are better suited for reconstructive surgery (which involves rebuilding parts of the body with tissue taken from elsewhere in the person's own body), or maybe need medical, surgical, and social support instead of a transplant. "They have to have devastating losses, to be compliant, to understand the procedure they're going to undergo, to be healthy enough to understand the pros and cons [of that procedure]," Ko says. Because each injury is unique and can have different physical and psychological effects, a multidisciplinary team evaluates each patient for eligibility.
As far as what constellation of traits makes a patient an ideal recipient, doctors are still figuring that out. According to a 2010 paper, recipients of penile transplants have to consider if the benefits (being able to pee while standing, for example, or a return of sexual function) outweigh the risks (the possibility of infection or rejection, being one of the first to receive the experimental procedure, a long recovery process, more physical pain after physical trauma or injury that made the patient a candidate for the procedure in the first place). Other experts have detailed the emotional impact of a penile transplant, which can touch on body image issues like wanting to feel whole or masculine.
A possible complicating factor: media overexposure. Ko estimates that more than 50 media outlets worldwide ran stories about last year's procedure. That's driven more potential candidates to get in touch with the team. Ko thinks much of that coverage has been "extraordinarily appropriate and professional," especially since the topic is so delicate—the surgical team, and Manning himself, was prepared for it, and they're certainly ready for the coverage for future procedures—but he wants to be sure it's helping the surgeons work towards their goals of helping patients. "We have to be careful about the public's perception about transplanting a sexual organ… I think people worry about sensationalism about doing what we did," Ko says, adding that people have found giving and replacing a penis from one person to another to be "rather interesting… [it] has raised eyebrows for sure. We want to make scientific progress, move things forward in a measured but appropriate manner." (A side note, since this news raised questions about whether opting to be an organ donor automatically made you a prospective penis donor: The surgical team has a special conversation with the families of prospective penis donors to make sure they're okay with it.)
As for Manning, the journal article notes that the patient has improved self-esteem, is able to urinate standing up, and has some erectile function. Ko is not allowed to comment further on his status.
Of course, there's only so much one procedure can teach surgeons, especially when the procedure itself is so complex and the nature of the injuries can be so varied. "Every male who has a devastating injury, whether it's a car accident, burns, trauma, or cancer like our patient, everyone has a different defect," Ko says. "Having done one [transplant] doesn't mean the next one is easier or simpler because we've done one. It's a learning process."
Manning likely won't be the last American to receive a penis transplant. Ko and his collaborators have been assessing potential candidates as they have come forward, but they have no timeline to conduct another transplant yet. "We are waiting for the appropriate circumstances to move forward," he says. They are also looking at Manning's long-term data to determine what they can do better next time. "This field has so much momentum and so many brilliant collaborators we want to keep it going and keep helping patients."
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