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Photo: Thomas Manning post transplant/Courtesy Mass General Hospital

The complex quality-of-life procedure is, in some sense, life-saving: It allows patients to feel like themselves again.

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It would be the fifth procedure of its kind ever, only four of which were successful, and just the second attempt in the United States. It would be the first to transplant so much tissue; not just the external penis, but the scrotum and part of the lower abdominal wall as well, extra flesh and muscle, more veins and arteries and nerves to join, more of the body to require blood flow, more of another to potentially be rejected.

The patient had lost his legs and suffered a severe groin injury to an improvised explosive device while serving in Afghanistan. A penis transplant was the only option available if he desired to live life as he had, as a standing-up-to-pee, standing-up-to-have-sex, quality of life-restored male.

Marshaling the bravery that served him well in country, the patient agreed to become the fifth penis transplant recipient in the world.

More men have walked on the moon.

The first successful penis transplant was achieved by surgeons from South Africa. A Stellenbosch University team led by Dr. André van der Merwe, head of the university’s urology department, performed the procedure at Cape Town’s Tygerberg hospital in 2014. In 2017, the South Africans would complete the third successful transplant as well, with the second—and first American—at Massachusetts General sandwiched in between, in 2016. Both patients in South Africa had lost their penises to complications from traditional circumcision, a rite of passage for the Xhosa ethnic group wherein the circumcision is performed in adolescence out in the bush as part of a larger ceremony to mark a boy’s transition to manhood.

“I think that South Africa is unique for the penis transplant because the pressure from the community was there to improve the reconstruction of the penis because of that high volume of patients without a penis after traditional circumcision,” Dr. Alexander Zuhlke, head of Stellenbosch’s plastic reconstructive surgery clinical team and a member of the surgical team for both South African transplants, said via Skype. Infection and a loss of blood due to tourniquet can cause these patients’ penises to be amputated, leaving short stumps—often less than a centimeter. To this the South African team transplanted a shaft, in effect plugging the external part of the penis in to the patient’s body. Massachusetts General performed a very similar procedure for Thomas Manning, who required a penectomy for his penile cancer.

Penis transplant surgery—as with any other transplant—is no minor thing. The complications are varied and many, ranging from the physiological to the psychological and societal. As with any transplant, there is the risk of rejection and the life-long potential danger of living with a suppressed immune system.

Only five successful penis transplants have been completed. More men have walked on the moon.

For some patients, non-transplant options include phalloplasty, the creation of a working penis using the patient’s own body, which has become quite sophisticated in part because of increased demand from transgender patients. Silicon implants inflate to provide an erection, and  urination can be achieved through perineal urethrostomy, the re-routing of what is left of the urethra through the perineum, between the rectum and scrotum. Those patients must pee sitting down, no small thing to a man trying to become how he was again.

“It is not a life-saving transplant; it’s really a life-enhancing transplant,” said Dr. Rick Redett, clinical director of the genitourinary transplant program and a reconstructive and plastic surgeon at Johns Hopkins, who worked on the transplant team. “So you have to be very cautious and very serious about the risks of immunosuppression.”

Helping life-enhancing transplants on the ethical ledger are new procedures that minimize the need for suppression and risk of rejection. At Johns Hopkins, they took bone from around the spinal cord of the donor, ground it up and extracted bone marrow, which was infused in the patient a few weeks after the transplant.

“The bone marrow infusion tricks the body into being a little more tolerant of the transplant,” Redett said.

Plug and play: A diagram of all the tissues that need to be connected. Stellenbosch University

As the penis is so culturally infused with notions of virility, power and masculinity, the wound and subsequent surgery has a high level of psychological and emotional complications. Indeed, it was psychological concerns which led to the failure of the world’s first attempted penis transplant, in China in 2008.

“Because of a severe psychological problem of the recipient and his wife, the transplanted penis regretfully had to be cut off,” Dr. Weilie Hu, surgeon at Guangzhou General Hospital, told The Guardian. The psychological impact of a dead person’s organ in such an intimate place may have been too much to overcome. Patients since that ill-fated attempt have since been screened not only for their physical viability, but also their mental and emotional state.

 “I didn’t look at it for a few days—maybe three days. I didn’t have the courage to look at myself.”

The loss of the penis throws so much into question, said Dr. Frederick S. Berlin, director of the sexual behavior consultation unit and associate professor of psychiatry and behavioral sciences at Johns Hopkins. Will the patient ever be able to stand to urinate again? Have penetrative sex and be accepted by a partner?

“It was a real kick in the chops,” Massachusetts General recipient Thomas Manning told Boston Magazine’s Blair Miller of his penectomy. “I actually thought I was going to die. Then I thought I was going to have tubes forever hanging off of me. I wondered how I was going to go to the bathroom. The doctor told me not to jump to conclusions. When I woke up from the surgery, my penis was gone and they had put in a catheter. I didn’t look at it for a few days—maybe three days. I didn’t have the courage to look at myself.”

“There’s a sense of loss, a sense of grieving; that they’re not whole in terms of themselves and their body image,” Berlin said by phone. The penis transplant is, then, in some sense life-saving; the quality of life improvement if it is successful can help the patient feel like themselves again. “This isn’t some trivial thing that people ought to dismiss,” Berlin said.

With the aid of social workers like Johns Hopkins’ Jason Wheatley, patients can help plan out their care and be sure they have built the support network they will need up to, and after, the surgery. Work will be missed; homes could be in jeopardy, and transportation to various medical checkups arranged.

“A lot of it is a practical thing,” Wheatley said by phone. “How are we going to get the right medications, get back and forth to appointments, and make sure that this surgery is a successful venture.”

The stress does not end with the surgery; in fact, it has only just begun.

“It was tough. It was black and blue—and I mean black and blue,” Manning told Boston. “I was all cut up—I had stitches everywhere. I took one look at it three days after the surgery, and I was in shock. It knocked me down and I couldn’t believe it. I looked at it a couple of times and then I didn’t want to look at it anymore. I wanted it to heal and do what it’s supposed to do. If I were to keep looking at it and dwelling on it, it would’ve gotten to me and I didn’t want it to. So I gave it time, and when it was ready, it would be ready. I didn’t look again until a week later.”

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The Stellenbosch University transplant team. Stellenbosch University

The process of transplanting one penis begins with a lot of penises. The surgeries are prepped years in advance, with cadavers used for understanding and practice. Surgeons need to be prepared for what should happen on the table, as well as what could happen; this would be crucial in one South African case. The various teams, representing among them the few individuals with firsthand experience and knowledge in the world, also consult with each other and reference each other’s groundwork.

All four transplants shared a similar path, the vagaries coming down to the amount and types of tissues, cultural values of the patients, and operation idiosyncrasies.

Once the teams felt ready to perform the operation, a donor had to be found. Willing donors in South Africa were particularly difficult to locate, according to Zuhlke; families needed to be asked specifically for the organ, even as others were being procured. For the donor in the 2014 surgery, the family requested that their loved one be restored for burial, a request fulfilled by taking abdominal skin to reconstruct a penis.

After being procured, the donor penis and its structures are prepared under loupe, basically a magnifying glass, and microscope. The organ is flushed with a preservation solution, through the arteries, veins, and corpora cavernosa, the spongy erectile tissue, Zuhlke said. Then the penis is transported to the surgical site, where the patient has been prepared—in the Hopkins case, the remains of the penis being cut away, an all-or-nothing moment if ever there was one.

In a penis transplant multiple tissues are transplanted as a functioning group, unlike a solid organ transplant of, say, a heart or liver. Difficult and intricate in execution, the surgeries are relatively simple in concept. The donor tissue is essentially hooked in to the recipient’s body; blood vessels, nerves and larger structures—like the urethra or erectile tissue—are attached together, using sutures, some finer than hair, or couplers.

“It’s certainly the most complicated transplant I’ve done,” Redett said of the procedure at Johns Hopkins, which included part of the abdominal wall and scrotum, the most extensive penis transplant so far.

Working under a microscope, the surgeons wield exceptionally fine instruments to perform the operation, which can take anywhere from 11 to 14 hours. The skill is highly specialized, relatively rare and difficult to perform.

“Totally in the zone, with a focus as sharp as a scalpel,” Redett said of his mindset in the OR. “Fatigue and aches and pain can set in after hours, but can be abated by focusing one’s concentration on the task on hand, especially with a surgery of this magnitude.”

“I love it,” Zuhlke said, with the sangfroid de rigeur for surgeons.

Dr. Curtis Cetrulo of the Massachusetts General team credits physical conditioning—specifically his training in Brazilian jiu-jitsu—with helping him in the OR. His team had an unexpected challenge on the table when they discovered the recipient’s arteries were too atrophied to use. Invoking a backup plan developed during their preparation, the Mass General team performed a vein graft, taking a vein from the foot and a vessel from the eye to create a new artery to connect to the femoral artery.

“You have to think in a strategic manner with physical stress and emotional stress and solve a problem,” Cetrulo said by phone, whether sparring or in surgery. In that way, Brazilian jiu-jitsu makes a fine, if unexpected, analogue for his work.

“Once you open up the clamps and you see that these tissues are perfused, it’s each time a very rewarding phenomenon to see,” Zuhlke said. “That the blood comes flowing through the tissue again and it comes alive again.”

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The South African patients are recovering, or have recovered, ahead of schedule. With no frame of reference for the first-ever penis transplant, the team had projected sexual function returning in six months. It did so in five weeks. That penis transplant patient then got his girlfriend pregnant, although she lost the baby. Thomas Manning from Mass General is taking longer to recover, possibly due in part to his older age compared to the others, which affects sexual function in men whose bodies have gone through far less.

Seeing patients’ quality of life improve dramatically, making them men in their own eyes again, makes the years of prep work, the anxiety, the mental, emotional and physical toll of having someone risk their life on your table worth it for the surgeons.

“I think about that all the time, what he went through making that decision,” Redett said. “You know, you have to take some risks for innovative medical procedures like this, but you have to do it with caution.”

Watching patients move forward with their lives “feels great,” Redett said. “I saw [the Johns Hopkins patient] last week, and he’s very happy. He’s moving his life forward, and that’s what makes you the happiest.”

“The way our patient thinks about it is he’s setting an example by opening the door for wounded warriors to have this operation,” Cetrulo said of Manning. “He thinks outside of himself; it’s not even really all about him.”

In addition to helping wounded veterans and those who have lost their penises from traditional circumcision, Zuhlke hopes that soon penis transplants will be performed on transgender patients.

Manning has been the sole recipient to go public with his surgery, a decision that may help others understand the procedure and if it’s right for them. “I have a choice. I can be up front or I can hide,” Manning told Boston. “If I lie about it, then it turns into another lie after another lie. I’m just not in the mood to cover up something that I just don’t have to. If other people can’t deal with it, they can’t deal with it. I mean, it’s always going to be there, so what am I going to do?”