Within a year, maybe in just a few months, a young soldier with a horrific injury from a bomb blast in Afghanistan will have an operation that has never been performed in the United States: a penis transplant.
The organ will come from a deceased donor, and the surgeons, from Johns Hopkins University School of Medicine in Baltimore, say they expect it to start working in a matter of months, developing urinary function, sensation and, eventually, the ability to have sex.
From 2001 to 2013, 1,367 men in military service sustained wounds to the genitals in Iraq or Afghanistan, according to the US department of defense trauma registry. Nearly all were under 35-years-old and were hurt by homemade bombs, commonly called improvised explosive devices, or IEDs, sometimes losing all or part of their penises or testicles, what doctors call genitourinary injuries.
Missing limbs have become a well known symbol of these wars, but the genital damage is a hidden wound – and, to many, a far worse one – cloaked in shame, stigma and embarrassment.
"These genitourinary injuries are not things we hear about or read about very often," said Dr WP Andrew Lee, chairman of plastic and reconstructive surgery at Johns Hopkins.
“I think one would agree it is as devastating as anything that our wounded warriors suffer, for a young man to come home in his early 20s with the pelvic area completely destroyed.”
Only two other penis transplants have been reported in medical journals: a failed one in China in 2006 and a successful one in South Africa last year. The surgery is considered experimental, and Johns Hopkins has given the doctors permission to perform 60 transplants. The university will monitor the results and decide whether to make the operation a standard treatment.
The risks, like those of any major transplant operation, include bleeding, infection and the possibility that the medicine needed to prevent transplant rejection will increase the odds of cancer. Lee cautioned that patients should be realistic and not “think they can regain it all.” But doctors can give the recipients a range of what to expect. “Some hope to father children,” Lee said. “I think that is a realistic goal.”
Just the penis will be transplanted, not the testes, where sperm are produced. So if a transplant recipient does become a father, the child will be his own genetically, not the offspring of the donor. Men who have lost testicles completely may still be able to have penis transplants but will not be able to have their own biological children.
In the 2006 case in China, the recipient asked that the transplant be removed a few weeks after the operation, because of “apparent psychological rejection,” Johns Hopkins doctors said, adding that in photographs the transplant had patches of dead and peeling skin, possibly from inadequate blood flow.
But the South African recipient, a young man whose penis had been amputated because of a botched circumcision, recently became a father, said Dr Gerald Brandacher, scientific director of the reconstructive transplantation programme at Johns Hopkins.
Doctors who treat young men wounded in combat say that no matter how bad their other injuries are, the first thing the men ask about when they wake up from surgery is whether their genitals are intact.
"Our young male patients would rather lose both legs and an arm than have a urogenital injury," said Scott E Skiles, the polytrauma social work supervisor at the Veterans Affairs Palo Alto Health Care System.
Army Sgt Aaron Causey, who lost both legs, one testicle and part of the other from an IED in Afghanistan in 2011, said the testicular damage was the most troubling of his injuries. "I don't care who you are – military, civilian, anything – you have an injury like this, it's more than just a physical injury," Causey said. Some doctors have criticised the idea of penis transplants, saying they are not needed to save the patient's life. But Dr Richard Redett, director of pediatric plastic and reconstructive surgery at Johns Hopkins, said: "If you meet these people, you see how important it is."
"To be missing the penis and parts of the scrotum is devastating," Redett said. "That part of the body is so strongly associated with your sense of self and identity as a male. These guys have given everything they have." Jeffrey Kahn, a bioethicist at the hospital, said that at a conference convened last year by the Bob Woodruff Foundation, which aids injured veterans, wives said that genitourinary injuries had eroded their husbands' sense of manhood and identity. Most telling, Kahn said, was that the men themselves attended the conference but did not speak about their wounds.
Although surgeons can create a penis from tissue taken from other parts of a patient’s own body – an operation being done more and more on transgender men – erections are not possible without an implant, and the implants too often shift position, cause infection or come out, Redett said.
For that reason, he said, the team thinks transplants are the best solution when the penis cannot be repaired or reconstructed. If the transplant fails, he said, it will be removed, leaving the recipient no worse off than before the surgery.
But can men – and their partners – get used to the idea that their most intimate part came from another man’s body? The best analogy is hand transplants, Brandacher said, because hands are personal and distinctive. It’s a transplant that the recipient can see, unlike a kidney or liver.
“I can tell you from all the patients – and I’ve been involved since 1998 – every single one, after surgery, look at the graft, try to move it and they immediately call it ‘my hand,’?” Brandacher said. “They immediately incorporate it as part of their body. I would assume, extrapolating, that this is going to be the same for this kind of transplant.”
Kahn said it was essential that the families of organ donors be asked specifically for permission to use the penis, just as special permission was required for face and hand transplants. It is not assumed that people willing to donate kidneys or livers will also consent to having their loved one’s genitals removed. The surgeons want a relatively young donor to increase the odds that the transplanted organ will function sexually.
For now, the operation is being offered only to men injured in combat, Lee said. It is not available to transgender people, though that may change in the future. “Once this becomes public and there’s some sense that this is successful and a good therapy, there will be all sorts of questions about whether you will do it for gender reassignment,” Kahn said. “What do you say to the donor? A 23-year-old wounded in the line of duty has a very different sound than somebody who is seeking gender reassignment.”
For a transplant to be possible, certain nerves and blood vessels have to be intact in the recipient, as does the urethra, the tube that carries urine out of the body. The screening process, as for any organ transplant, also involves making sure that the candidate is psychologically ready, understands the risks and benefits, can stick to the regimen of anti-rejection medicine and has a family support network.
A few initial candidates are being evaluated. “We have one that we’re moving forward with, and we’re very far in the process,” Redett said, adding that he expected the patient to be put on the transplant waiting list soon. “That means you are really only waiting for a donor.”
A spokeswoman for Johns Hopkins said the candidates and their families had declined to be interviewed. The university will pay for the first transplant, Lee said, adding that he had asked the Defense Department for money to cover more operations. The surgeons are donating their time, he said. Comparing the surgery to hand transplants performed at Johns Hopkins, he estimated the cost at $200,000 to $400,000 per operation. He said the department of veterans affairs would pay for the drug that the men will need to prevent transplant rejection.
The project has been years in the making, doctors said, with extensive research and practice surgery on cadavers. Some of the work involved injecting brightly colored food dyes into the cadavers to map out the circulatory system in the penis. Lee said the research had found previously unknown aspects of its blood supply, which will be critical to the transplant’s success.
The operation should take about 12 hours, Lee said. The surgeons will connect two to six nerves, and six or seven veins and arteries, stitching them together under a microscope. For the first few weeks after the surgery, a catheter will be left in place to drain urine.
Sexual function will take longer to develop, probably a few months, Lee said. He said nerves would grow from the recipient into the transplant at a rate of about 1 inch per month, so the timing will depend in part on the extent of the recipient’s injuries and how far the nerves need to go.
After the transplant, the men will begin taking anti-rejection medication and will need it for the rest of their lives. Such drugs work by suppressing the immune system and can increase the odds of infections and cancer. To minimise the risks, the medical team has found a way to use just one drug, rather than the three usually needed for other transplants. At the time of the penis transplant, they will treat the recipient with a medication that reduces immune system cells. About two weeks later, he will receive an infusion of stem cells from the donor. The infusion dials back the tendency of the recipient’s immune system to attack the transplant, and just one anti-rejection drug, tacrolimus, is then enough to keep it in check.
Doctors have used this technique successfully in patients who have had hand transplants.
Ultimately, the goal is to restore function, not just form or appearance, Brandacher emphasised. That is what the recipients want most.
“They say, ‘I want to feel whole again’,” Brandacher said. “It’s very hard to imagine what it means if you don’t feel whole. There are very subtle things that we take for granted that this transplant is able to give back.”
New York Times
