Photos reveal donor disease and scrotum doctors transplanted onto the body of a US Navy veteran, known last year as & # 39; Ray & # 39; in a report published on Wednesday.
Ray, a Navy Corpsman, told doctors that thanks to the transplant, he feels very well again & # 39; and is able to achieve an almost normal erection and even an orgasm, according to the new report from the New England Journal of Medicine.
He was the fourth and most complex penis transplant ever to be performed after the explosion in Afghanistan had blown off most of his lower body.
To restore Ray's sexual organs, a surgical team at Johns Hopkins University had to invent new techniques to bring some of the 30-year-old veins together so that blood could flow into his new penis to keep it alive and straight. put.
But the 14-hour operation was a success, Ray & # 39; the best decision & # 39; has mentioned that he has ever taken.
More than a year after the life-changing operation, Ray's doctors told their patients about their new penis, an & # 39; improved self-image & # 39; and now attend school full time and completely independently.
A computer reconstruction of Ray & # 39; s body shows the damage that left him behind with just a 1.5 cm piece of penis tissue, no scrotum and a piece of his belly missing (pictured on the front, left and side, right)
On the day of the operation, the abdomen, penis and scrotum (photo) lay in the operating room, awaiting transplantation on Ray & # 39; s body
Ray cared for wounded soldiers during an ambush by the Taliban when he stepped on a roadside bomb in 2010.
He lost his legs, genitals and part of his abdominal wall and was forced to learn to walk on prosthetic legs after the tragic accident.
For the first time since his operation in 2018, the soldier revealed on Monday evening that his life-changing injury – which he kept secret except loved ones – had even made him think of suicide.
A team of doctors at Johns Hopkins University in Baltimore successfully grafted a new penis and scrotum from a deceased donor onto Ray & # 39; s body, making him the fourth patient in the world to receive such a transplant – and he was by far the most comprehensive ever done.
Ray spoke about his life-changing procedure in October and said he & # 39; almost & # 39; regains the full feeling in his new penis and is able to get an erection and urinate.
Eight days after the operation, Ray & # 39; s sutures began to heal and the transplanted tissue began to look pink and healthy, a sign that the vein and vein connections were working. Arrows indicate where doctors made a tissue biopsy to check if it was healthy
The John Hopkins team watched Ray cured to make sure there were no signs that the new sexual organs were being rejected. The tissue appeared healthy after two weeks
When checking in on day 340, the transplant was functional and had even grown
Ray said in an interview with MIT Technology Review: & # 39; I don't regret it. It was one of the best decisions I have ever made. & # 39;
Ray spoke for the first time about the traumatic experience of his media accident and said: & # 39; remembers everything & # 39 ;.
& # 39; I remember thinking quickly, "This is not good." And then I lay on my back, & he said.
& # 39; It was one of those injuries that really stressed you out and you think, "Why should I continue?" I think I've always kept that real hope that there is an answer. & # 39;
In 2013, Ray met Dr. Richard Redett, a plastic surgeon at Johns Hopkins Medicine in Baltimore, who decided he could be an ideal candidate for a penis transplant. His team led a schedule that aims to give 60 penis transplants.
Ray said: & # 39; This was actually something that could fix me. I could get back to normal. & # 39;
Before Ray & # 39; s there had only been four penis transplants – the first was in China in 2006, which was unsuccessful.
The US Navy corpsman, known only as Ray (depicted after his operation in 2018), cared for 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 then walked his dog.
The infantryman ran into action while doctors boarded a mapped jet from Maryland to meet the donor – a brain-dead man – before the penis was transported on ice to the hospital to start the operation with 25 surgeons at 2 o'clock.
& # 39; We were confident that we could do it, but we had never done it & # 39 ;, said Dr. Redett. & # 39; If you are not afraid of such a thing, do not think hard enough. & # 39;
Most men who need a penis get a falloplasty, a member made of tissue, blood vessels and nerves from an underarm or thigh.
& # 39; For him, it was almost like you are doing this transplant, or you are living the rest of your life with your defect, & # 39; said Dr. Redett.
But operations to create such a penis carry a higher risk of infection and the patient does not regain the natural use of their penis.
A diagram from the new case report shows the donor anatomy that has been transplanted to Ray. He received not only the scrotum and penis from the donor, but a complex network of crucial arteries and veins (labeled around the periphery), the corpus cavernosum (center), which is the key to Ray's ability to have an erection to reach, part of the urethra donor and a bundle of nerves that make Ray & # 39; s new penis feel pleasure (center)
In 2013, the veteran met a plastic surgeon, Dr. Richard Redett (left) from Johns Hopkins Medicine in Baltimore, who said he was the perfect candidate for a penis transplant
A total penis transplant, in which the body part is transferred from one person to another, is called vascularized composite allotransplantation.
Ray was able to get the transplant because he had made a urethra and a specific set of blood vessels to make the transplant work.
Surgeons had to adhere to nerves, arteries, veins and blood vessels finer than human hair from the transplant penis to Ray.
The donor scrotum was also transferred – but their testicles were removed for ethical reasons to avoid the risk of the patient receiving his babies.
To ensure its success, Ray & # 39; s procedure should be more extensive than all previous transplants performed.
Not only did Ray's surgical team, led by Dr. Redett, harvesting the donor and reaffirming Ray's body, but the blast had taken a piece of Ray's abdominal tissue and part of his thigh and scrotum.
The complex operation also included transplanting the skin, muscles, tendons, nerves, bones and blood vessels of the donor
The testicles were not transferred to bypass the ethical dilemma that could arise if Ray also had sperm from his donor.
Doctors must ensure that all interconnected parts and tissues do not begin to die. If an area started to run, the rest would probably not succeed.
Because so few transplants have been performed, Dr. Redett told him and his team of 25 to guess how long a penis could stay on ice.
From the moment they entered the operating room where teams of surgeons took turns collecting organs, the race against time and tissue death was underway.
They should also take two major arteries and veins to re-attach to Ray's intact veins.
Dr. Redett and his team had practiced this process ad nauseum, dying off veins and arteries and coloring them again until they had adjusted the best sequence of operations, remembering the location of each vein, artery and nerve.
Almost a full day after Ray arrived in John's Hopkins, ready to receive his new penis, Dr. Redett and his team operate the veteran.
The operation lasted 14 hours – more time and more steps than had happened with the previous three transplants.
Surgeons had to attach nerves, arteries, veins and blood vessels finer than human hair from the transplant pen to Ray (photo). It also concerned an abdominal wall
Ray & # 39; s intact urethra was reassembled to his new penis, the nerves, arteries and veins connected, the abdominal tissue, the penile shaft and the scrotum reassembled and the skin replaced.
And then the team waited to see color.
& # 39; You know how to do it, but until that last blood vessel is connected and you release the clamps and blood flows through it – I mean, that's a huge sigh of relief, & # 39; said Dr. Redett.
It is not clear whether his scrotum is empty or contains prosthetic testes. He will not be able to have biological children because his own reproductive tissue has been destroyed.
However, he takes testosterone to compensate for the loss of his testicles and is being treated with another drug, Cialis, to encourage spontaneous erections.
Ray had to wait two days after surgery before seeing his transplant for the first time and described it as & # 39; swollen & # 39; and had to heal.
& # 39; In the back of your mind you know that this is a transplant and you wonder if it will be too much for you to process. Once I had completed the operation, all those worries just disappeared, & he said.
Dr. W.P. Andrew Lee, president 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 will not be able to ejaculate because he has no testicles.
In 2018, doctors performed the groundbreaking 14-hour surgical procedure at Johns Hopkins Medicine in Baltimore (part of the team pictured with a 2018 surgical dummy)
After surgery, Ray received an immunosuppressive regimen to prevent tissue rejection, which is a concern with every transplant.
Urologist Andre Van der Merwecalls, a South African surgeon who performed the world's first successful penis transplant in 2014, said that Ray & # 39; s procedure & # 39; the most complex so far & # 39; was because of the extent of his injury.
The third penis transplant – after Dr. Van der Merwecalls and the failed eight years earlier in China – 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 failed circumcision.
Although he kept his identity private and only told his parents about the loss of his private parts, Ray said he wanted to inform other veterans of their options.
The wars in Iraq and Afghanistan have caused an unprecedented number of soldiers with devastating genital wounds caused by the use of bombs by enemy combatants on the ground.
According to a report released in 2017, 1,367 male US service members suffered one or more urinary tract injuries between October 2001 and August 2013.
When exploded from below, high-tech protective equipment can protect soldiers' torsos and vital organs – but their genitals are vulnerable and are directly in the path of the explosion.
The resulting amount of groin injuries is & # 39; to a level never reported in the history of the war & # 39 ;, wrote military urologists.
The majority of the injuries were related to the external sexual organs, including the scrotum, the testes, the penis and the urethra, which can influence various skills, including having sex, conceiving children and urinating normally.
Nearly 94 percent of patients were 35 years or younger during their peak years of sexual development and reproductive potential, according to the US Department of Defense's TOUGH report (Trauma Outcomes and Urogenital Health).
TOUGH say among infantrymen with genital urinary wounds from Iraq and Afghanistan, 502 were so seriously injured that a penis transplant might be their only option.
DOCTORS DISCLOSE WHAT PENIS CONTAINS TRANSPLANT SURGERY
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 would entail.
How does the team identify a suitable donor?
Dr. Redett said the organ will come from a deceased person, but added that the person's family must give consent before the proceedings can continue.
He said: & # 39; Many people may think that organ donation means uncontested permission from all organs.
& # 39; That is not the case with the face, hand or penis. & # 39;
He added that once found, the donor tissue is evaluated for various factors, including blood type, age – within five to 10 years – and skin color.
How do you identify which patients need a penis transplant?
Dr. Cooney said, as with other transplants, that the patient must be in good physical and mental form,
She said that psychiatric evaluations can take up to a year before a patient is approved for surgery.
& # 39; There is a significant loss with the first injury that the patient must overcome emotionally.
& # 39; If the patient has a significant other when he starts working with our team, we also work to inform that person about what to expect.
& # 39; We cannot guarantee the outcome or degree of urinary function, erection, and the ability to have sexual intercourse or have children. & # 39;
How long do you expect before the don villages fully function?
Dr. Redett said the first priority is to ensure that the transplanted tissue has sufficient blood supply to prevent immediate rejection.
He said that should be clear within a few days to weeks.
& # 39; The next priority will be to get the function back, & # 39; he said.
& # 39; Nerves grow at a speed of one millimeter per day, about one centimeter per month.
& # 39; We expect that reaching a position, including urinary and sexual function, can take between six and twelve months.
& # 39; If the patient's testicles are still present, he can even father children. & # 39;
What precautions are being taken to prevent the risk of rejection?
Dr. Cooney said the patient will receive immunosuppressants after the procedure.
Ten to 14 days later he receives a bone marrow fusion from the donor.
& # 39; By doing that, we have been able to reduce the number of anti-rejection drugs that the patient has to take for the rest of his life to one pill twice a day, & # 39; she explained.
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