16:41, 22.Aug 2018
In the past five years, doctors in America and South Africa have performed four full penile transplants. The first and only surgeries of their kind, they entail exactly what you’d think: removing the penis from a deceased donor and attaching it to someone without a penis. (The two South African men who have undergone this procedure, in 2014 and 2017 in Cape Town, lost their penises to botched ritual circumcisions. The first American man to undergo the procedure, in Boston in 2016, had his penis surgically removed to address a rare case of penile cancer. The second American patient, whose surgery took place in Baltimore in 2018, lost his penis, testicles, and a bite of his abdomen to an improvised explosive device in Afghanistan.)
Ample coverage of these surgeries at the time they took place offered readers plenty of details about what a penile transplant involves—all the nerves and arteries to be reattached, the techniques used, and the years of research and hours of operating time they took to come to fruition. Yet no coverage to date has answered what for many observers may be some of the most burning questions about penile transplants: What is the post-surgery recovery process, the sensation of having a new penis after years without one, and the process of integrating a new penis that came from someone else’s body into yourself like?
The lack of public info to date on patients’ post-transplant experiences is largely logical. Recovery takes time, so it can be years until there is something meaningful to say on the topic. Three of the four patients who have undergone the procedure have requested that their doctors and the media reserve their anonymity for entirely understandable reasons. (Only the 2016 Boston-area patient, Thomas Manning, who was 64 at the time of his surgery, allowed his name and picture into the press in hopes of destigmatizing genital injuries and accidents. Doctors can only say so much about their patients’ post-op conditions in most cases to nosy reporters.
But recently, we got to speak to some of the doctors who performed America’s first two penile transplant procedures. They were able to tell us quite a bit, in general, about their expectations for their patients’ post-transplant experiences going into the surgeries. They were also able to share a number of details about their patients’ actual experiences of recovery, sensation and function, and psychological integration after receiving a new donor penis.
How successful are penis transplants?
Although it may seem odd, the doctors all told us that they actually expected, going into these procedures, that their patients would probably regain penile functions and sensations, including sexual sensations, better and faster than many patients having their own penises reattached.
Doctors have actually been reattaching penises for decades. Although the John Wayne and Lorena Bobbit case thrust the procedure into the US spotlight in 1993, it seemingly first garnered major academic attention in the 1970s when Thai doctors performed at least 18 reattachments during a spree of penis dismemberments committed by local women against their abusive or cheating husbands.
Early 1970s procedures often failed, but by the 1990s, surgeons were already getting pretty good at them; the male Bobbit notoriously made a few pornos after his surgery to show off his still functional dick. Fairly consistently, says Richard Redett of the team at Johns Hopkins University that performed the 2018 transplant surgery, “we know that these men get return of decent sensation and the ability to get an erection, although not a very firm erection.”
What's it like to have a penis transplant?
Usually, people lose their penises in fairly traumatic ways, so there is stretching and tearing damage on both ends of the organ, says Curtis Cetrulo of the Massachusetts General Hospital team that performed the 2016 transplant procedure. “You have to shorten things” to compensate for damage, he explains, “and you can’t really tell the extent of the injury sometimes,” so that rejiggering of tissue can be a little rough. It can lead to, say, tension on reattached nerves. “A transplant is a much more controlled situation,” Redett says.
In many cases, a man who lost most of his penis will likely have messy or confusing damage on his end, unless it was surgically removed, as in Manning’s case. But doctors can remove a donor’s penis in a clean and known manner—and remove some extra nerve from the donor for tension-avoiding safety and good measure. Not only that, but they can minimize the time the penis is severed before being attached to a new body.
Some who bring in their own penises for reattachment might have been holding onto their severed shafts for upwards of half a day (in the worst cases), after which reattachment is still viable but the organ may have suffered some additional damage. And in a lucky coincidence, Redett adds, one of the immunosuppressant drugs transplant patients take to keep their body from rejecting new organs seems to promote and improve nerve regeneration, and thus penile sensation.
This isn’t to say that transplant procedures are uncomplicated. Even with quickened or improved nerve regeneration, doctors never expect patients who have lost and regained a penis to recover full sensation in the organ, much less the same sensation they had before losing their members. There is also always a risk when attaching a free-floating penis to a body that inflammation of the blood vessels during the healing process could lead to long-term erectile dysfunction to some degree.
Still, the American transplant teams said they had high hopes for their patients, expecting that they would be able to gain the ability to urinate within a few weeks and regain sensation throughout the penis, including sexual sensation (even if reduced) in the glans, within about six months to a year.
What are the psychological side effects of having a penis transplant?
On the psychological front, too, they did not expect many difficulties. Even early hand and face transplant patients (procedures that doctors have been doing for about 20 years and 15 years now, respectively) didn’t, for the most part, have much trouble learning to see those new, visible organs as their own despite the fact that they came from donors, notes Cetrulo. “It was a surprising outcome with those patients,” he adds. “This face is their new face. This hand is their new hand. There hasn’t been as much of a psychological barrier as most people would have predicted.”
And in the intervening years, medical psychologists and social workers have developed all manner of screening methods and pre- and post-op protocols to help people prepare for and work through the integration of a new visible organ. “We have psychiatrists, psychologists, and social workers on our team who specialize in these issues,” says Redett.
(According to some reports, the first ever attempted, but failed, penile transplant, conducted in China in the mid-2000s, went south due to psychological complications. However, the details of this procedure and the patient’s experience are shoddy. Cetrulo thinks it’s possible, based on pictures from the case, that “it could have been a technical failure or a rejection—we don’t know.”)
How have previous penis transplants turned out?
At least two transplant patients have exceeded even the rosy expectations doctors had for them. The first ever transplant patient in South Africa, for instance, reportedly regained his ability to get hard and get off within about four months of his surgery and got a partner pregnant within seven. Redett’s patient regained sensation at least a few weeks before his doctors expected him to and seems on track to start having erections again soon. His patient’s transplant was the most extensive ever, involving a full penis and a chunk of abdominal tissue, so—given that the more tissue replaced, the longer it typically takes for nerves to grow back through all that new tissue—that is quite amazing. “You don’t know if these are going to be entirely normal erections,” he cautions, “but a young, healthy person has the best chance of anyone of getting erections after a transplant.”
Manning’s recovery was not as quick and easy as these patients’. Sure, three weeks after his surgery he could pee normally again. (With just a stump, explains Cetrulo, “every time he would sit down to go to the bathroom, it would spray all over his clothes, all over the toilet, and he’d smell like urine the whole day no matter what he tried to do. He couldn’t stand up to use a urinal.”) But as an older man, he was almost bound, his doctors say, to have slightly slower nerve regeneration; it took him around 18 months to get physical sensation back in the tip of his penis. He is also only able to achieve partial erections, but Cetrulo says they still have many options left for improving that functional issue. Manning had to have heart surgery after his transplant, he explains, and suffered some complications related to treatment for a kidney stone, which precluded moving forward with erectile dysfunction therapies that they’re only just digging into now.
“But it’s more realistic, I think, in a 64-year-old to be patient and use adjuncts like Viagra and Cialis, or even down the road to consider an implant or something like that,” says Cetrulo. “Many people in this country have a sensate penis and have to have mechanical help to get an erection.” Ultimately, Redett believes, having performed the operation and watched and listened to his patient post-op, “the results of a transplant are far better than conventional reconstruction when you’re talking about sensation, the ability to void, and the ability to get an erection withoug having to get an implant.”
(Conventional reconstruction usually involves bringing out whatever urethra a man has left after losing his penis, and taking, as needed, skin, nerves, and blood vessels from other areas of the body—typically an arm or thigh—then shaping them into a phallus. Although a common procedure for many who have lost their penis and cannot recover it, it does not work for everyone, especially people with extensive blast or burn injuries. It is also “just rudimentary compared to the actual tissue,” says Cetrulo, and the urethral element of the reconstruction process all too often results in scars, fistulas, and other flaws that lead to problematic urination post-op.)
On the psychological front, both American patients appear to have avoided any complications; actually, they have apparently reaped ample mental benefits thanks to their new organs. Most men lacking a penis, explains Cetrulo, feel distraught. Seeing that you have a penis again after years without one, adds Dicken Ko, another doctor involved with Manning’s surgery, “is a big deal.”
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“That’s definitely what he was thrilled about initially,” says Ko of Manning, “because, all of a sudden, he’s whole again.” Cetrulo notes that, from all Manning has said, he’s fairly certain that he quickly started to see his new penis as an integrated part of him. Redett says his patient seems to have had a similarly profound and positive experience integrating his new penis into his sense of self. “I can see a difference in his demeanor,” he says, “just his joy.”
It's worth pointing out, though, that the second South African patient, a 40-year-old black man, received a transplant from a white donor, whereas other patients’ donors have matched their skin tone. His doctors are reportedly exploring medical tattooing to change his penile complexion to match the rest of his body. It is unclear whether this tonal mismatch has caused complications in the integration process, but it is not hard to see how it could be potentially quite jarring.
What's the future look like for penis transplant patients?
These are just the early days of these patients’ post-surgical experiences. They could still develop more sensation and functionality; Cetrulo points out that in, say, hand transplants, it can take up to six years after an operation for nerves to finish regenerating. But they could also suffer setbacks or losses. Ko points out that, while most transplanted organs last for a good long time, “the question now becomes, how long will the transplant last.” As long as it lasts, though, the patients will have to take a cocktail of immunosuppressant drugs to keep their immune systems from attacking their new penises.
They’ll need to take less and less over time, but over the course of 10 to 20 years their side effects or long-term effects can take all manner of health tolls. This is actually one of the reasons penile transplant surgeries are so rare: Although well over a thousand young veterans have suffered genital injuries in America’s ongoing wars, a good chunk of them losing their penises, the risks of a lifetime on immunosuppressants are so serious that many doctors are hesitant to consider doing a transplant on a man with decades to live. Wake Forest Baptist Health has been approved to do a penile transplant, notes Ryan Terlecki, a urologist there, but doesn’t want to do one on a cancer patient because of immunosuppression concerns.
The penile transplant teams at both Johns Hopkins and Massachusetts General are hard at work on efforts to reduce the amount of immunosuppressants their patients would need to take post-surgery. Cetrulo thinks his team’s methods are almost “ready for prime time.” If they can move the dial on immunosuppressant risks, he says, “the risk-benefit profile would plummet and we could potentially do kids [born with penile defects], young trauma patients, lots of different patients."
(A team at Wake Forest, with which Terlecki is involved, is working on lab engineering replacements for parts of the penis using cells from a patients own body. This would basically allow for transplants without any complications related to one’s immune system rejecting the new, yet still you, organ element. However, he explains that they’re still far away from being able to engineer a whole penis, which is much more complex than generating just, say, a urethra.)
It is hard to say, given how few penile transplants have been performed to date, just how typical the four extant patients’ experiences will end up being. Every post-surgical experience, they explain, will be different based on the patient’s age, general health, and the nature of his injury, as well (most likely but less clearly) on the health and background of the penis donor. If future patients have more initial episodes of rejection, Redett points out, that will definitely affect their future erectile function, and could affect other aspects of functioning and sensation as well. Specific surgical techniques could have major effects on post-op sensation and functionality, too.
It will take many procedures to start to get a sense of exactly what variables lead, in most cases, to which experiences—and what the average post-transplant experience is overall. Building up all those data points will take lots of time, as penile transplants are still experimental, costly, and time consuming. The United Network for Organ Sharing’s records do not show any requests for new penile donors, so it’s not likely we’ll see a third American transplant in the near future.
Even with all those caveats in mind, though, the experiences of the first two American penile transplant patients post-op seem extremely heartening. Their experiences should be a ray of hope for the thousands of men worldwide each year who lose their penises in accidents or attacks, or to botched circumcisions or disease.