Photos reveal the donor penis and scrotum doctors transplanted onto the body of a US Navy veteran, known as ‘Ray’ last year in a case report published Wednesday.
Ray, a Navy Corpsman, told doctors that, thanks to the transplant he ‘feels whole again’ and is able to achieve a nearly normal erection and even orgasm, according to the new New England Journal of Medicine report.
His was the fourth and most complex penis transplant every performed, after explosion in Afghanistan blew off most of his lower body.
In order to restore Ray’s sex organs, a surgical team at Johns Hopkins University had to invent new techniques to route some of the 30-something-year-old’s arteries together so that blood could flow into his new penis keeping it alive, and erect.
But the 14-hour surgery was a success, that Ray has called ‘the best decision’ he’s ever made.
More than a year out from the life-changing operation, Ray’s doctors relayed that their patient has sensation in his new penis, an ‘improved self-image’ and is now in school full time and fully independent.
A computer reconstruction of Ray’s body shows the damage that left him with just a 1.5cm piece of penis tissue, no scrotum and a chunk of his abdomen missing (Pictured from the front, on the left, and side, on the right)
On the day of the surgery, the donor abdomen, penis and scrotum (pictured) lay in the operating room, awaiting transplantation onto Ray’s body
Ray was tending to wounded soldiers during an ambush by the Taliban when he stepped on a roadside bomb in 2010.
He lost both his legs, genitals, and part of his abdominal wall and was forced to learn how to walk on prosthetic legs after the tragic accident.
Speaking for the first time since his 2018 surgery, the soldier revealed Monday night that his life-changing injury – which he kept a secret except from loved ones – had even made him contemplate suicide.
A team of doctors at Johns Hopkins University in Baltimore successfully grafted a new penis and scrotum from a deceased donor onto Ray’s body, making him the fourth patient in the world to receive such a transplant – and his was by far the most extensive ever done.
Speaking in October about his life-changing procedure, Ray said he’s ‘close’ to regaining full sensation in his new penis and is able to get an erection and urinate standing up.
Eight days after surgery, Ray’s sutures were starting to heal, and the transplanted tissue had started to look pink and healthy, a sign that the artery and vein connections were working. Arrows point out where doctors biopsied the tissue to make sure it was healthy
The John’s Hopkins team carefully watched as Ray healed to make sure that there were no signs the new sex organs were being rejected. Two weeks out, the tissue appeared healthy
By check-in on day 340, the transplant was functional and had even grown hair
Ray said in an interview with MIT Technology Review: ‘I don’t regret it. It was one of the best decisions I ever made.’
Speaking about the traumatic experience of his accident to the media for the first time, Ray said he ‘remembers everything’.
‘I remember thinking a quick thought: “This isn’t good.” And then I was on my back,’ he said.
‘It was one of those injuries that really stresses you out and you think, “Why would I keep going?” I guess I always just kept this real hope that there’s an answer out there.’
In 2013, Ray met Dr Richard Redett, a plastic surgeon at Johns Hopkins Medicine in Baltimore who decided he may be an ideal candidate for a penile transplant. His team lead a scheme that aims to give penis transplants to 60 soldiers.
Ray said: ‘This was actually something that could fix me. I could go back to being normal again.’
There had only been four penis transplants before Ray’s – the first was in China in 2006, which was unsuccessful.
The US Navy corpsman, known only as Ray (pictured after his operation in 2018), was tending to wounded soldiers during an ambush by the Taliban when he stepped on a roadside bomb in 2010
Ray received the life-changing news in March 2018 that a donor was available in another state. He was walking his dog at the time.
The infantryman raced into action while medics boarded a charted jet from Maryland to meet the donor – a brain-dead man – before transporting the penis on ice to the hospital to begin the 25-surgeon operation at 2am.
‘We felt very confident we could do it, but we had never done it,’ said Dr Redett. ‘If you’re not anxious for something like that, you’re not thinking hard enough.’
Most men needing a penis are given a phalloplasty, a member made of tissue, blood vessels and nerves taken from a forearm or thigh.
‘For him, it was almost either you do this transplant, or you live the rest of your life with your defect,’ said Dr Redett.
But operations to create such a penis carry a higher infection risk and the patient doesn’t regain natural use of their penis.
A diagram from the new case report details the donor anatomy that was transplanted to Ray. He not only received the scrotum and penis of the donor, but a complex network of for crucial arteries and veins (labeled around the periphery), the corpus cavernosum (center), which is key to Ray’s ability to achieve an erection, part of the donor’s urethra and a bundle of nerves that let Ray’s new penis feel pleasure (center)
In 2013, the veteran met with a plastic surgeon, Dr Richard Redett (left) of Johns Hopkins Medicine in Baltimore, who said he was the perfect candidate for a penile transplant
A total penis transplant, where the body part is transferred from one individual to another, is called vascularized composite allotransplantation.
Ray was able to have the transplant because he had a urethra and a specific set of blood vessels created for the transplant to work.
Surgeons had to stitch nerves, arteries, veins and blood vessels finer than human hairs from the transplant penis to Ray.
The donor’s scrotum was also transferred – but their testicles were removed for ethical reasons to avoid the risk of the patient having his babies.
To ensure its success, Ray’s procedure would have to be more extensive than any of the previous transplants performed.
Not only did Ray’s surgical team, led by Dr Redett, need to harvest the donor penis and reattach it to Ray’s body, but the blast had taken a chunk of Ray’s abdominal tissue and part of his thigh as well as his scrotum.
The complex surgery also involved transplanting the donor’s skin, muscles, tendons, nerves, bone and blood vessels
The testes were not transferred, to sidestep the ethical quandary that could arise if Ray also had his donor’s sperm.
Doctors would need to keep each interconnected parts and tissues from beginning to die. If one area started to go, it was likely the rest would fail to.
Because so few transplants have been performed, Dr Redett said that he and his team of 25 had to guess how long a penis could last on ice.
From the moment they entered the operating room where teams of surgeons were taking turns harvesting organs, the race against time and tissue death was on.
They would also have to take two major arteries and veins to reattach to Ray’s intact penile veins.
Dr Redett and his team had practiced this process ad nauseum, dying and re-dying veins and arteries until they’d fine-tuned the best order of operations, memorized the location of every vein, artery and nerve.
Nearly a full day after Ray had arrived at John’s Hopkins, ready to receive his new penis, Dr Redett and his team began operating on the veteran.
The operation took 14 hours – more time and more steps than had been involved in the previous three transplants.
Surgeons had to stitch nerves, arteries, veins and blood vessels finer than human hairs from the transplant penis to Ray (pictured). It also involved some abdominal wall
Ray’s intact urethra was reattached to his new penis, the nerves, arteries and veins connected, the abdominal tissue, penis shaft and scrotum reassembled, and skin was replaced.
And then the team waited to see color.
‘You know how to do it, but until that last blood vessel is hooked up and you release the clamps and blood flows through it – I mean, that’s a huge sigh of relief,’ said Dr Redett.
It is not clear if his scrotum is empty or contains prosthetic testes. He won’t be able to have biological children because his own reproductive tissue was destroyed.
However, he takes testosterone to compensate for the loss of his testes and is being treated with another drug, Cialis, to encourage spontaneous erections.
Ray had to wait two days after surgery before he saw his transplant for this first time, describing it as ‘swollen’ and needing to heal.
‘In the back of your mind, you know this is a transplant, and you wonder if it’s going to be too much for you to handle. Once I went through with the surgery, all of those concerns just went away,’ he said.
Dr W.P. Andrew Lee, the chairman of plastic and reconstructive surgery at Johns Hopkins, told The New York Times they are hopeful Ray will be able to achieve orgasms – but he won’t be able to ejaculate because he doesn’t have testes.
In 2018, medics performed the groundbreaking 14-hour surgical procedure performed at Johns Hopkins Medicine in Baltimore (part of the team pictured with a a surgical dummy 2018)
After the surgery, Ray was put on a regimen of immunosuppressive drugs to prevent tissue rejection, which is a concern with any transplant surgery.
Urologist Andre Van der Merwecalls, a South African surgeon who performed the first successful penis transplant in the world in 2014, said Ray’s procedure was ‘the most complex to date’ because of the scope of his injury.
The third penis transplant – after Dr Van der Merwecalls and the unsuccessful one in China eight years earlier – was in Massachusetts in 2016, a 64-year-old man who lost his penis to cancer. And the fourth was in Cape Town for a 41-year-old victim of a circumcision gone wrong.
Despite keeping his identity private, and only telling his parents about the loss of his private parts, Ray said he wanted to let other veterans know about their options.
The wars in Iraq and Afghanistan have left unprecedented numbers of soldiers with devastating genital injuries due to enemy combatants’ use of bombs on the ground.
According to a report released in 2017, 1,367 male US service members sustained one or more genitourinary (GU) injuries between October 2001 and August 2013.
When they explode from below, high-tech protective gear might protect soldiers’ torsos and vital organs – but their genitals are vulnerable and directly in the blast’s pathway.
The resulting slew of groin injuries are ‘to a level never before reported in the history of war,’ military urologists wrote.
The majority of injuries involved the external genitalia including the scrotum, testes, penis and urethra, which can impair several abilities including having sex, fathering children and urinating normally.
Almost 94 per cent of the sufferers were 35 or younger ‘during their peak years of sexual development and reproductive potential,’ according to the US Department of Defense’s TOUGH (Trauma Outcomes and Urogenital Health) report.
TOUGH say among infantrymen with genital urinary injuries from Iraq and Afghanistan, 502 were injured so severely that a penis transplant might be their only option.
DOCTORS REVEAL WHAT PENIS TRANSPLANT SURGERY ENTAILS
In 2016, Dr Richard Redett, director of pediatric plastic and reconstructive surgery at Johns Hopkins Hospital, and Dr Carissa Cooney, the department’s clinical research manager, explained what the penis transplant operation would entail.
How will the team identify a suitable donor?
Dr Redett said the organ will come from a deceased person, but added the person’s family will have to consent before the procedure can go ahead.
He said: ‘Many people might think that organ donation means unquestioned consent of all organs.
‘That’s not the case with the face, hand or penis.’
He added that once found, the donor tissue is evaluated on a variety of factors, including blood type, age – within five to 10 years – and skin tone.
How do you identify which patients need a penis transplant?
Dr Cooney said as with other transplant operations, the patient has to be in good physical and mental shape,
She said psychiatric evaluations can take up to a year before a patient will be approved to have the operation.
‘There’s a significant loss with the initial injury that the patient has to overcome emotionally.
‘If the patient has a significant other when he begins working with our team, we also work to educate that person on what to expect.
‘We can’t guarantee the outcome or the extent of urinary function, erection, and ability to have sexual intercourse or have children.’
How long do you anticipate before the donor penis will be fully functioning?
Dr Redett said the first priority is to ensure the transplanted tissue has adequate blood supply, to prevent immediate rejection.
He said that should be apparent within a few days to weeks.
‘The next priority will be to regain function,’ he said.
‘Nerves grow at a rate of one millimeter per day, about one inch per month.
‘We anticipate that achieving function, including urinary and sexual function, could take between six to 12 months.
‘If the patient’s testes are still present, he may even be able to father children.’
What precautions are taken to try and prevent the risk of rejection?
Dr Cooney said the patient will be given immunosuppressive drugs following the procedure.
Ten to 14 days later he will receive a bone marrow infusion from the donor.
‘By doing that, we have been able to reduce the number of anti-rejection medications the patient will have to take for the rest of his life, down to one pill twice a day,’ she explained.