Missing limbs have become a well-known symbol of recent wars, but the genital damage is a hidden wound — and, to many, a far worse one — cloaked in shame, stigma and embarrassment.
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 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.
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“These genitourinary injuries are not things we hear about or read about very often,” said Dr. W.P. 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 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 program 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 Skiles, the polytrauma social-work supervisor at the Veterans Affairs Palo Alto Health Care System.
Some doctors have criticized 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 Johns Hopkins, 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.
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 Johns Hopkins 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.
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.
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.
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.
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.
He estimated the cost at $200,000 to $400,000 per operation.
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 would 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 would be left in place to drain urine. Sexual function would 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 would depend in part on the extent of the recipient’s injuries and how far the nerves need to go.