Johns Hopkins surgeons performed the most complex penis transplant ever in late March on a soldier who lost his genitals during a bomb blast in Afghanistan.
Over the course of 14 hours, specialists transplanted a penis, a scrotum and a part of the abdominal wall from a deceased donor onto the wounded soldier, Johns Hopkins announced Monday. The handful of similar transplants previously performed at hospitals in Massachusetts, South Africa and China involved only a penis.
The Hopkins doctors said the surgery appears so far to have gone smoothly and are optimistic the patient, who wishes to remain anonymous, will gain full function.
"It is our hope that such a life-changing transplant will allow him to regain urinary and sexual function and lead a normal life," said Dr. Richard Redett, a professor of plastic and reconstructive surgery at the Johns Hopkins University School of Medicine.
Doctors should know later this week, when the patient is expected to be released, whether he can urinate. It will take about six months to see if the patient can feel sensation and experience an erection. It will take that long for the nerves to grow in.
In a statement released by Johns Hopkins, the patient said he already felt normal again.
"It's a real mind-boggling injury to suffer, it is not an easy one to accept," he said. "When I first woke up, I felt finally more normal … [with] a level of confidence as well. Confidence … like finally I'm okay now."
Doctors have taken an interest in penile transplants as the nature of injuries soldiers suffer at war has changed. Some soldiers who lose lower limbs from mines and improvised explosive devices also experience loss of or damage to their genitals, injuries that the Johns Hopkins doctors said are hidden, but just as debilitating.
From 2001 to 2013, about 1,367 male service members were placed on the Department of Defense Trauma Registry with so-called genitourinary injuries, which include injuries to the genitals.
One of the first questions a soldier will ask after waking up from a severe injury is whether their genitals are intact, said Dr. Elspeth Cameron Ritchie, a retired Army psychiatrist and author of a book about intimacy and injury. Despite this, these injuries were stigmatized and, until recently, not talked about much.
"For many men, a lot of their sense of identity is also wound up in their sense of manhood," she said.
Johns Hopkins doctors formed a team more than five years ago to study and prepare for a penile transplantation, studying blood flow to the penis and practicing on cadavers.
They identified the patient in 2012 and talked then about a reconstruction of the penis, using skin from other parts of the body. While such a procedure is possible, wounded servicemen sometimes don't have enough good tissue to work with and such reconstructed genitals could not achieve an erection, said Dr. W.P. Andrew Lee, a professor and director of plastic and reconstructive surgery at Johns Hopkins medical school.
The patient, who was serving in Afghanistan when he was caught in an IED blast that also took his legs, decided to wait for a transplant, but it took time for the doctors to perfect the procedure and to find a match. The patient has a rare blood type and the matching process is more involved than inner-organ transplants. Doctors also have to account for factors such as age and skin tone in penis transplants, making the donor pool smaller.
A team of nine plastic surgeons and two urological surgeons performed the transplant. The patient still had a small part of his own penis to attach to the new organ. To ensure blood flow and sensation, surgeons also connected three arteries, four veins and two nerves during the operation.
The donor's testicles were not transplanted, so the patient won't be able to reproduce. Doctors said transplanting them raised ethical issues such as whether the donor's genetic material might go to the patient's children.
"We just felt there were too many unanswered ethical questions with that kind of transplant," said Dr. Damon Cooney, a Hopkins assistant professor of plastic and reconstructive surgery.
The patient also was given an infusion of bone marrow from the donor, which allowed doctors to reduce the number of drugs he must take to keep his body from rejecting the penis to just one pill twice a day.
The surgery is the latest breakthrough for the Hopkins reconstructive team. In 2013, the team performed a double arm transplant on Brendan Marrocco, who lost both arms, as well as his legs, in the Iraq war when the armored vehicle he was driving ran over a bomb in 2009. He was the first soldier of the Iraq and Afghanistan wars to lose all four limbs in combat and survive.
Transplanting a penis raises a host of ethical questions about costs and necessity.
Sometimes questions arise about whether such a procedure is life-saving, said Dr. Robert D. Truog, director of the Harvard Center for Bioethics.
"Medicine is about improving the quality of people's lives, not just saving lives," Truog said. "When you hear that someone is contemplating suicide and is having a hard time with life, it is hard to say it's not really important."
Johns Hopkins covered the cost of the surgery, which is expected to run around $300,000 to $400,000. The doctors donated their time and are looking for grants to cover other procedures.
As part of the transplant process, the donor's family must be told when certain body parts are donated, especially for newer transplants such as limbs, the face or penis. The family of the donor released a statement addressed to the patient through New England Donor Services saying why it agreed to such a groundbreaking procedure.
"We are all very proud that our loved one was able to help a young man that served this country," they said. "We are so thankful to say that our loved one would be proud and honored to know he provided such a special gift to you. As a family, we are very supportive of all the men and women who serve our country and grateful for the job you did for this nation. Please know that this is truly a heart-felt statement, as we have several veterans in the family. We hope you can return to better health very soon and we continue to wish you a speedy recovery."
Only a few penis implants have been performed around the world, but this is the most extensive, said Dr. Arthur Burnett, a professor in Hopkins' department of urology. China tried once and failed in the 2000s. Doctors in South Africa performed transplants in 2014 and 2017. In 2016, doctors at Massachusetts General Hospital transplanted a penis without a scrotum on a man who lost his to cancer.
Hopkins is assessing whether other people might qualify for the procedure.
An internal Hopkins review board approved 60 penis transplants in 2016, but doctors said Monday they will not necessarily do that many. Hopkins is only considering injured servicemen for the transplants, not transgender individuals or those born with defects.
Dr. Andrew Kramer, a professor of surgery at the University of Maryland School of Medicine who performs penis implants and reconstructions, said transplants, if perfected, could help more wounded soldiers and others with severe genital problems.
"I hope this works," he said.