Penile and Urethral Cancer

Veteran Receives Penis Transplant To Repair War Wound

Penile and Urethral Cancer | Johns Hopkins Medicine

The Johns Hopkins surgical team (left to right) Richard Redett, Trinity Bivalacqua, Brandacher Gerald, Arthur “Bud” Burnett and Andrew Lee.

Johns Hopkins Medicine

A team of surgeons says it has repaired the genitals of a serviceman severely injured by an explosion in Afghanistan. It's the first time a penis has been transplanted to treat a war wound.

Doctors at Johns Hopkins Hospital in Baltimore say 11 surgeons were involved in the 14-hour surgery in March.

The patient, who requested anonymity, is expected to be released from the hospital later this week, “and we are optimistic that he will regain near-normal urinary and sexual functions following full recovery,” Dr. W.P. Andrew Lee said at a news conference announcing the surgery on Monday.

The man's fertility won't be restored, however. His testicles did not survive his ordeal and a testicle transplant would raise deep ethical issues, because the genetic material in the sperm would be from the donor, not the recipient.

Surgeons in South Africa and Boston have previously reported successful penis transplants. “Our transplant is different because it's a much larger piece of tissue,” said Dr. Richard Redett, one of the Hopkins plastic surgeons.

The surgery involved reconnecting three arteries, four veins and two nerves.

Doctors expect that feeling will return to the transplanted organ in about six months, and at that point they will know more about the degree to which the man's sexual function has been restored.

Hopkins announced in 2015 that it was planning to undertake this operation for war wounded. But the Hopkins team says it took a long time to find a good match for this man, who had a rare blood type.

The medical team says the donor was an anonymous man in New England, whose family agreed to this unusual request because they believed he would have wanted to restore function to a man wounded in service of his country.

One of the challenges from this type of injury is that transplants typically require patients to take strong anti-rejection drugs for the rest of their lives. Those drugs pose a risk, which must be balanced against the benefit of surgery that is designed to improve quality of life but is not essential to health.

To address that, doctors at Hopkins have developed a method to minimize the drugs required for these patients. That involves infusing some blood cells from the donor, to prime the recipient's immune system to recognize the foreign tissue as “self.” Doctors at Hopkins say they can then treat the patient with a single anti-rejection drug rather than the usual cocktail of three.

Un previous penis transplants, this surgery included the scrotum and some tissue from the lower abdomen, in order to reconstruct a large wound. The patient was injured by an improvised explosive device. He also lost his legs below the knee as a result of the IED attack.

Doctors focused on genital transplants because they are deeply personal and especially disturbing wounds.

Iraq-war veteran Oscar Olguin found that was the case when he spent time at the Walter Reed Army Medical Center in 2004 after he was injured by a suicide car-bomb.

“We all jokingly made the statement that's the first area I checked to make sure it was OK,” he said. “Even if we'd just seen a major injury that's the organ we were all worried about.”

The tone regarding genital injuries may have been jocular, “but we were all pretty serious,” Olguin adds. It is really no joke to lose an important element of one's manhood.

Olguin, who now works for the Disabled American Veterans in Roanoke, Va., says he feels fortunate that he didn't sustain that injury, even though he lost part of his right leg. “It's much easier to get a prosthetic for the leg as opposed to that area.”

The surgery is still highly experimental. The surgeons and Johns Hopkins volunteered their services, which would otherwise have cost hundreds of thousands of dollars and wouldn't have been covered by veterans benefits or insurance, they say.

Olguin says he hopes that the surgery will eventually become routine enough that the government will pay for it as part of its commitment to injured vets.

You can contact Richard Harris at

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‘Whole Again’: A Vet Maimed by an I.E.D. Receives a Transplanted Penis

Penile and Urethral Cancer | Johns Hopkins Medicine
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BALTIMORE — In a 14-hour operation, a young military veteran whose genitals were blown off by a bomb received an extraordinary transplant: a penis, scrotum and portion of the abdominal wall, taken from a deceased organ donor.

The surgery, performed last month at Johns Hopkins Hospital, was the most complex and extensive penis transplant to date, and the first performed on a combat veteran maimed by a blast.

Two other successful penis transplants have been performed — in South Africa in 2014 and at the Massachusetts General Hospital in 2016 — but they involved only the organ itself, not the scrotum or surrounding flesh. This latest operation transplanted a single piece of tissue that measured 10 inches by 11 inches and weighed four or five pounds.

This is an evolving branch of medicine spurred in large part by the wounds of war — particularly the blast injuries from improvised explosive devices, or I.E.D.s. The medical teams in Baltimore and Boston have spent years preparing for the surgery, practicing on cadavers and refining their techniques.

The patient at Johns Hopkins is just one of many soldiers whose lives were shattered in a split second when they stepped on hidden bombs in Iraq or Afghanistan. He lost both legs above the knee, but the genital damage was even more devastating to him.

“That injury, I felt it banished me from a relationship,” he said in an interview last week. “, that’s it, you’re done, you’re by yourself for the rest of your life. I struggled with even viewing myself as a man for a long time.”

But now, four weeks after the surgery, he said, “I feel whole again.”

He asked that his name not be published, because of the stigma associated with genital injuries. Except for his immediate family and a few close friends, he has told no one about the nature of his wounds, he said.

Dr. W.P. Andrew Lee, the chairman of plastic and reconstructive surgery at Johns Hopkins, said the goal of this type of transplant is “to restore a person’s sense of identity and manhood.”

ImageThe patient chose not to be identified because of the stigma associated with genital injury.Credit…Andrew Mangum for The New York Times

For most men, that means regaining the ability to urinate while standing up and to have sex. Dr. Lee thinks transplantation can make both possible, though healing and nerve regeneration will take time. Urination is expected first, within a few months. Nerves grow from the recipient into the transplant at the rate of about an inch a month.

“We’re hopeful we can restore sexual function in terms of spontaneous erection and orgasm,” Dr. Lee said.

Although the scrotum was transplanted, the donor’s testes had been removed for ethical reasons: Keeping them might enable the recipient to father children that belonged genetically to the organ donor, something not considered acceptable by medical guidelines.

Because the recipient’s own reproductive tissue was destroyed, he will not be able to have biological children. He takes testosterone to compensate for the loss of his testes, and is being treated with another drug, Cialis, to encourage erectile function.

About 20 percent of the penile injuries were considered severe — but how many might warrant a transplant is not clear. Women in the military have also suffered genitourinary and reproductive injuries, but they are less common.

Teams at Johns Hopkins and at the Massachusetts General Hospital are both evaluating more candidates for the surgery — some hurt in the military, others affected by accidents or illness. But it can take a long time to find a matching donor — the Johns Hopkins patient waited more than a year on the transplant list — so no rush of operations is expected.

The Department of Defense has funded some of the research, but Johns Hopkins is paying for the first operation, which Dr. Lee estimated would cost from $300,000 to $400,000. The surgeons — nine plastic and reconstructive surgeons, and two urologists — worked for free.

Dr. Lee said he hoped for grants from the Pentagon to help pay for future operations, and also for insurance coverage, which is not available now for this type of transplant.

Credit…Johns Hopkins Medicine

After the explosion that injured the soldier, he remained conscious, he remembered, but knew he was sinking into shock. He passed out on the medevac helicopter. His next memory was waking up in the United States, relieved to be alive.

Soon, the gravity of the damage hit. A military doctor told him it was permanent and irreparable.

“That was crushing, but when he walked away I thought, he hasn’t been a doctor long enough, he doesn’t know what he’s talking about,” the patient said. “You got all this technology, how can you tell me this is permanent? There’s got to be something.”

He felt isolated, even in the hospital among other wounded soldiers.

“There were times you’d be hanging out and guys would be talking about getting hurt, and that’s one of the first things when they get blown up, to check down there, and they would say things , ‘If I lost mine I’d just kill myself,’” he said. “And I’m sitting there. They didn’t know, and I know they didn’t mean any offense, but it kind of hits you in the gut.”

He struggled with thoughts of suicide, he said: “When I would actually think about killing myself, I would think, ‘Am I really just gonna kill myself over a penis?’”

He learned to walk with prosthetic legs, left the hospital and lived on his own in an apartment. But he had trouble connecting with other people, and even when he no longer needed OxyContin for physical pain he kept taking it to numb his emotions.

He managed to wean himself off it. He saw a therapist. He earned a college degree and began making plans to attend medical school.

But relationships or even dating felt the question. If he got close to someone, he would have to disclose his wounds, and the thought filled him with anxiety.

“It is a lonely injury,” he said.

In 2012, he began consulting Dr. Richard J. Redett, the director of pediatric plastic and reconstructive surgery at Johns Hopkins, about a procedure to create a penis from his own tissue, possibly the skin on the inside of the forearm.

That operation makes urination possible, but requires an implant to achieve an erection. The procedure was appealing, but Dr. Redett also mentioned a future possibility that seemed much more promising: a transplant.

Hospitalized since the operation a month ago, the patient may be ready to go home in the next week or so.Credit…Andrew Mangum for The New York Times

“Basically, if you do a transplant, you’re going to have the real thing again,” the patient said.

He decided to wait.

He passed an exhaustive screening process. Certain nerves and blood vessels have to be intact, along with the urethra, the tube that carries urine the body.

Candidates also have to qualify psychologically — to be able to understand the risks and benefits and stick to their anti-rejection medicine, as well as have a family or other support network.

Families of organ donors are asked specifically for permission to use the penis, and past requests have been made for research purposes. Carisa M. Cooney, a clinical research manager in plastic and reconstructive surgery at Johns Hopkins, said that when families hear that the goal is to help wounded veterans, many consent.

In this case, the donor’s family sent the soldier a message via New England Donor Services: “We are all very proud that our loved one was able to help a young man that served this country. 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 heartfelt 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.”

The donor was from another state, and three surgeons from Johns Hopkins — Dr. Redett, Dr. Damon Cooney and Dr. Gerald Brandacher — flew there by private jet to operate on him, an exacting procedure to remove precisely the tissue that would be needed.

They had to coordinate with teams from other institutions who were collecting other organs, and at times there were 25 people in the operating room, Dr. Brandacher said.

Part of his role was to remove nine vertebrae from the donor, to provide stem cells that the Johns Hopkins team would infuse into the recipient to help prevent rejection and minimize the amount of anti-rejection medicine needed.

The patient said that before the surgery, he wondered if he would accept the new body parts, mentally and emotionally.

“What tripped me out at first is sometimes I would get a thought , ‘Am I going to be able to see it as my own?’” he said. “That thought would creep in. But once I had it done, that’s the only way I see it. It’s mine.”

Looking ahead, he sketched out his hopes.

“Definitely, to do well in school, to go to medical school and follow my career as a doctor, find my niche in the field and just excel at it. Maybe settle down and maybe eventually find someone, and get into a relationship, maybe. Just that normal stuff.”

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Doctors report success in penis transplant for injured veteran

Penile and Urethral Cancer | Johns Hopkins Medicine

It is perhaps the combat injury most feared by servicemen who have deployed to Iraq and Afghanistan: a blast that robs them of their genitals.

For one such wounded warrior, a real shot at renewed sexual health and happiness has come with a transplanted penis, scrotum and lower abdominal wall. The transplant, which also included many of the nerves, muscles and blood vessels that serve those organs, is described in Thursday’s edition of the New England Journal of Medicine.

The recipient is a young serviceman who lost his penis, scrotum, both testes and most of both legs when he stepped on a roadside bomb in Afghanistan.

Now, roughly 19 months after his penis transplant, the veteran can urinate while standing up on his prosthetic legs and enjoys what his doctors at the Johns Hopkins School of Medicine described as a “strong stream.” He also has normal sensation on both the shaft and the tip of his new penis, near-normal erections and can achieve orgasm.

For the rest of his life, the man will almost certainly take anti-rejection medication, making him more vulnerable to infections, kidney problems and certain cancers. And he cannot father biological children: ethical considerations forbade the transfer of testes, which would have generated semen bearing the DNA of his deceased donor.

Still, for a young man whose injuries were too extensive for conventional reconstructive surgery, having an external appendage that feels and works the one he had “is a big deal,” said Dr. Richard Redett, the transplant surgeon who led a team of roughly 35 medical professionals in a 14-hour operation.

In the report, Redett and his team wrote that the unnamed serviceman reports “feeling whole” again. He continues to live independently and has returned to school full time.

He is “very satisfied with the transplant and the implications it carries for his future,” the medical team concluded.

The case is the fourth-ever successful transplant of a penis from a donor to a patient who has lost his to disease or injury. But it is by far the most extensive transplant of genitalia to date. It was performed in Baltimore in March 2018 by a team that has pushed the boundaries of transplants of soft tissue such as hands and faces.

“This is a real quantum leap,” said Dr. Curtis Cetrulo, a transplant surgeon at Massachusetts General Hospital who led the group that performed the first penis transplant in the United States in 2016.

To restore this veteran’s external genitals, Cetrulo said the Hopkins team built on knowledge gained not only from the first three penis transplants, but from roughly 100 hand transplants and 140 face transplants.

Each of these procedures has yielded important insights about connecting blood vessels narrower than the diameter of a human eyelash, about how long it takes for nerves to regenerate, and about what it takes to ward off rejection of soft tissues, Cetrulo said.

Redett said his team spent close to five years laying the groundwork for the operation.

On human cadavers and in rats, they practiced the delicate work of fusing nerves, arteries and tissue that would normally shrink from the cold steel surgical instruments are made of.

They investigated which parts of this anatomical complex were most prone to rejection by the immune system (the urethra, it turns out) and how that could be detected quickly and prevented.

“We learned a lot” from Cetrulo’s work and from two penis transplants performed by a team in South Africa, Redett said.

Scanned images show the extent of the veteran’s injuries before the penis transplant.

The veteran had arrived seeking a conventional penile reconstruction. In those cases, surgeons fashion a “neophallus” from fat and skin taken from the forearm or thigh. After incorporating a pump to facilitate erection, reconstructive surgeons attach the penis to an existing urethra, blood vessels and nerves.

But Redett said the extent of this patient’s injuries made that approach impossible. Instead, he and his colleagues realized they had a physically and psychologically robust candidate for an experimental procedure that would demand meticulous compliance with a lifelong medication regimen.

The plan was put into action on a Saturday in late March of last year as another young man who shared the veteran’s blood type and skin tone lay in a hospital room in a twilight between life and death. An organ procurement team approached the young man’s bereaved family members about donating their loved one’s genitals.

“It is harder to ask a family for a face or a penis,” Redett acknowledged. But often, he said, a shared connection between donor and recipient — say, professions or hobbies or military service — will prompt a family to say yes. (The relatives of the donor wished to remain anonymous and did not discuss their decision.)

Early Monday morning, Redett’s team — including microvascular surgeons, urologists, transplantation specialists, anesthesiologists and an army of skilled helpers — went to work fusing the complex of external organs to their young patient.

The graft used in the transplant. It included the right and left external pudendal artery, a segment of the femoral artery, and the saphenous veins on both sides.

The decades-long conflicts in Iraq and Afghanistan have produced a generation of servicemen whose reproductive organs have been compromised by improvised explosive devices.

A 2017 study conducted for the Pentagon found that between October 2001 and August 2013, 1,367 servicemen experienced genitourinary wounds, more than a third of them considered “severe.” Some 423 involved the penis, 451 damaged the testes, and 760 — more than half — involved the scrotum.

These injuries need more attention to identify “novel treatments to improve sexual, urinary and/or reproductive function,” the study authors, from the U.S. Army Institute of Surgical Research and the San Antonio Military Medical Center, wrote. Sexual and urinary function are important to men, and “they have not been part of the polytrauma repertoire.”

In earlier conflicts, most of these men would not have survived the trauma inflicted on the battlefield. But body armor that protects an infantryman’s chest and midsection, as well as faster and more effective emergency medical care and evacuation practices, have meant that many such men have come home to contend with life-altering injuries.

Unchanging across conflicts, however, is the fear that such injuries provoke in combatants.

“Many soldiers we’ve evaluated for injuries have told us that when they come to, they first look to see if they’ve lost their genitals. And then, they look for their legs,” Redett said.

The impact of such injuries on the fertility of returning servicemen has spurred the Wounded Warrior Project to lobby Congress and the Department of Veterans Affairs to make funds available for fertility treatments for affected service members. Those efforts succeeded in 2017.

The organization said it “is encouraged by the results Johns Hopkins Medical Center achieved.”

IED injuries to lower extremities “are, unfortunately, quite common to wounded veterans who served in Iraq and Afghanistan,” the group said in a statement.

The cost of vets’ conventional penile reconstruction is covered by the VA.

But penis transplants remain highly experimental — and for many potential recipients, they come with risks that are hard to justify for a treatment that does not save lives.

Redett said Johns Hopkins funded the surgery and the research leading up to it and the VA will underwrite the lifelong cost of his anti-rejection medication.

After healing from his initial wounds, the patient was left with a 1.5-centimeter-long remnant of penile tissue with a urethra. His lower abdominal wall had been blown away. He had extensive scar tissue, and many of the blood vessels that would normally bring blood to the penis were either gone or unusable.

As part of the transplant, Redett said the surgeons repurposed arteries from the stomach area which normally supply blood to the abdominal muscles.

In the months after his surgery, a single episode of rejection was easily treated with topical steroids and tacrolimus, the single anti-rejection medication the patient takes.

The proliferation of nerve endings that make the penis exquisitely sensitive are generally thought to begin regenerating only after a month, and proceed outward toward the skin at a pace of one millimeter a day.

For the young serviceman, that process may have been enhanced by a happy accident: Tacrolimus, the anti-rejection drug, sends nerve regeneration into overdrive. Within a few months, the patient reported sensation in his new penis, and his continued recovery “has exceeded my expectations,” Redett said.

Cetrulo said that the renewal of sensation in transplanted soft tissue has continued to amaze physicians. Three years after getting a donor penis, his own patient continues to see progress. Hand transplant patients are reporting leaps in sensitivity as long as five years after surgery.

“We are in uncharted waters,” Cetrulo said. “You have to check your assumptions at the door.”

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Doctors Performed the First Full Penis and Scrotum Transplant

Penile and Urethral Cancer | Johns Hopkins Medicine

Physicians at Johns Hopkins University School of Medicine in Baltimore have performed the first total penis and scrotum transplant in the world, the hospital announced on Monday.

The surgery, which took place over 14 hours on March 26, was performed by a team of nine plastic surgeons and two urological surgeons. The penis and scrotum (without testicles) and partial abdominal wall came from a deceased donor.

The recipient is a military veteran who was injured by an improvised explosive device (IED) blast in Afghanistan and wishes to remain anonymous.

The hospital said he has recovered from the surgery and will be discharged from the hospital this week.

“It’s a real mind-boggling injury to suffer, it is not an easy one to accept,” the transplant recipient said in a statement released by Johns Hopkins. “When I first woke up, I felt finally more normal… [with] a level of confidence as well. Confidence… finally I’m okay now.”

The procedure is the second penis transplant to be publicly reported in the United States, but the first full transplant of this kind. In 2016, surgeons at Massachusetts General Hospital performed the first penis transplant in the U.S. on a man who had his penis amputated due to penile cancer.

Read more: The New Transplant Revolution

The Johns Hopkins team has been planning for penis transplant procedures for years, with the goal of eventually helping wounded veterans. A 2016 report found that from 2001 to 2013, 1,367 men in the United States military suffered injuries to their genitals or urinary tract in Iraq or Afghanistan.

The report also found that most of the injuries were caused by bomb blasts, and over a third were considered severe. Among the injured men, 94% were age 35 or younger.

“Many men sustained disfiguring genital injuries during their peak years of sexual development and reproductive potential,” researchers wrote in the 2016 report.

A penis transplant is a complicated procedure that includes connecting all the arteries, veins, nerves, the skin and the urethra to the recipient. Each penis removal and injury can be different depending on which parts are removed, but surgeons hope that for at least some men, sexual function can be restored.

“We are hopeful that this transplant will help restore near-normal urinary and sexual functions for this young man,” Dr. W.P. Andrew Lee, professor and director of plastic and reconstructive surgery at the Johns Hopkins University School of Medicine, said in a statement.

Other men are now undergoing screening for the procedure, Lee said in a news conference.

The Johns Hopkins team decided not to transplant the donor’s testicles because such a transplant could allow genetic material to be passed on from the donor. The hospital said there are too many unanswered ethical questions surrounding that kind of transplant.

Penis transplants are estimated to cost $50,000 to $75,000. As of now, hospitals are largely footing the bills. Since the procedures are still considered experimental, they are not covered by insurance. Johns Hopkins covered the cost of the veteran’s transplant, and the doctors there are in the process of applying for a research grant that would offer coverage for further procedures.

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Pathologic Complete Response After Chemoradiation of a Massive Primary Urethral Carcinoma

Penile and Urethral Cancer | Johns Hopkins Medicine

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