It’s one of the most common and devastating wounds of modern warfare. It also happens to be the one injury that neither active-duty troops nor veterans want to talk about.
Damage to or loss of a soldier’s genitals is something every man in a combat zone thinks about. And with good reason.
According to the Department of Defense Trauma Registry, at least 1,367 men in the United States military suffered genital-urinary injuries in Iraq or Afghanistan from 2001 to 2013.
Some of these men lost all or part of their penis.
The injury is a staple of a post-9/11 combat era whose weapon of choice for the enemy is the roadside bomb, also known as an improvised explosive device (IED).
Even the most battle-tested warriors are reluctant to speak publicly about these wounds, which for many men are as difficult emotionally as they are physically.
But a recent groundbreaking medical procedure could be the catalyst for a new national dialogue about these injuries.
And it could be transformative for thousands of wounded veterans.
A new life for one veteran
On March 26, Dr. W.P. Andrew Lee, director of plastic and reconstructive surgery at Johns Hopkins University School of Medicine in Maryland, and his transplant team successfully performed the world’s first complete penis and scrotum transplant.
The patient had suffered severe injuries to his lower pelvis, lower abdominal wall, and lower extremities in an IED blast while serving in Afghanistan.
Like many soldiers who’ve preceded him in combat, the veteran lost his penis and scrotum in the blast.
But they were replaced during the 14-hour surgery, which generated headlines nationwide and worldwide.
“It’s not something you read a lot about in the newspaper, but it is a very significant problem among veterans,” Lee told Healthline. “Men care about an injury to this part of the anatomy. It can be devastating.”
The veteran, who’s chosen to remain anonymous, is recovering well and expected to regain both urinary and sexual function.
Lee and others describe the patient as a strong person, an optimist who has a good support system and a ton of gratitude.
“It’s a real mind-boggling injury to suffer. It is not an easy one to accept,” said the veteran, whose quote was provided to Healthline by the hospital.
“When I first woke up [from the surgery], I felt finally more normal, [with] a level of confidence as well. Confidence. Like finally I’m OK now,” he said.
The transplant surgery is being hailed by veterans groups as a game-changer.
"It’s a critically important and terribly under-reported issue,” Paul Rieckhoff, an Iraq War veteran and founder of Iraq and Afghanistan Veterans of America, told Healthline.
“The promising news of this procedure will provide hope for countless vets and their families,” Rieckhoff said.
Technology finally catching up?
The idea of transplanting a complete penis and scrotum from a deceased donor to a live man seemed unheard of just a short time ago.
Two years ago, surgeons at Massachusetts General Hospital reportedly performed a more limited transplant on a penile cancer patient.
The recipient in that case, Thomas Manning, reportedly continues to do well, but his sexual function hasn’t fully recovered.
A man in China received a penis transplant in 2005, but he reportedly asked them to remove the new organ two weeks later because he and his wife were having psychological problems.
In 2014, a 21-year-old man in South Africa whose penis had been amputated following complications from circumcision in his late teens received a transplant.
The Associated Press reported in 2016 that the man in South Africa is healthy, has normal sexual function and was able to conceive, although the baby was stillborn. His recovery was difficult, however, with blood clots and infections, his doctor said.
The procedure at Johns Hopkins involved more tissue than had previously been transplanted.
The surgery included the scrotum as well as a substantial amount of lower abdominal tissue needed to reconstruct what was a large wound.
Lee and his team, who began their work at the University of Pittsburgh then moved to Johns Hopkins in 2010, brought a long track record of success with them into the operating room.
They’ve conducted 13 arm and hand transplants, including the first double hand transplant in the United States in 2009, the first above-elbow transplant in 2010, and the first double arm transplant of a wounded warrior in 2012.
Not all these transplants involved veterans, but in the process of his work, Lee met with current and former members of the military, who explained to him the profound need for genital replacement and transplants.
In 2014, Lee and his team sponsored a symposium titled “Intimacy After Injury” with journalist Bob Woodruff’s nonprofit foundation.
That’s when Lee realized just how important and widespread this issue is.
“We talked at the symposium about genital-urinary injuries and had powerful speakers, including spouses, family members, and caregivers who have this injury. It impressed all of us, the scope and significance of it,” Lee recalled.
“A lot of times in field hospitals, when injured servicemen first wake up, the first question they ask is, ‘How is my junk?’” Lee said.
The wonders of modern medicine
In preparation for this type of complicated surgery, the Hopkins team honed their skills in a cadaver lab, doing dissections and plastic and urologic surgeries.
“It required a different approach to isolate the entire penis, scrotum and lower portions of the abdominal wall, the arteries, etc.,” Lee said.
The surgery, which took 14 hours, was complex and intricate. Nine plastic surgeons and two urological surgeons were involved.
The patient didn’t receive testicles from his donor to avoid the potential ethical issues if he later had children.
Including testicles in these transplants is still considered controversial because the testicles contain sperm from the deceased donor, who in this case was also not publicly identified.
The procedure required a large skin graft covering part of the sergeant’s abdomen, penis, and scrotum.
It also involved connecting three arteries, four veins, and two nerves to provide blood flow and sensation to the donated tissue.
The patient’s internal organs were not severely damaged by the combat explosion, Lee explained.
Dr. Rick Redett, clinical director of the Johns Hopkins genitourinary transplant program and another surgeon on the case, said in a statement that in order to perform the transplant, “We procured the necessary tissue from the donor to restore normal anatomy in the recipient.”
The significance for America’s veterans
Lee and other transplant experts interviewed by Healthline believe these transplants will eventually change the lives of wounded warriors just as hand and arm transplants are doing now.
But just when and how wounded veterans will have access to such a complicated and expensive procedure remains in question.
Dr. L. Scott Levin, chairman of orthopedic surgery and a professor of plastic surgery at Penn Medicine, told USA Today that when it becomes more routine, penile transplantation is likely to cost about $800,000, the same as a liver transplant.
The Johns Hopkins team volunteered its time and has received grants to support this work.
The team needs to receive continued funding to perform such complex procedures in the future, Lee said.
Transplants are not covered by insurance companies yet.
“We have been fortunate that the Department of Defense has given us research grants to do the hand and arm transplants, but these expire this year,” Lee said. “We are grateful for their support. Without funding, we cannot continue to do this work.”
Despite Johns Hopkins’ successful procedure, these surgeries are still widely viewed as experimental.
It’s also uncertain if veterans have access to this type of procedure at the Department of Veterans Affairs (VA), which provides healthcare to more than 9 million veterans.
Currently, transplants and transplant referrals at the VA are problematic, several sources told Healthline, and these types of transplants are likely to be expensive.
Brewster Rawls, a lawyer who represents veterans and military families in malpractice cases nationwide, told Healthline that the VA has a “terrible record” on transplants in general and especially on referrals for transplants outside the VA.
“Hence, my concern is that getting such a procedure is not likely to be easy for the veterans who need it,” he said.
“I’ve had a number of cases in which the VA just dragged its feet on transplants of almost any sort, and the veteran sometimes died in the process. I have also had more than one doctor tell me that the VA is, in fact, notorious for doing so. If they have to refer outside the system it is even worse.”
But others are more optimistic.
Dr. Jill Buckley, a urologic trauma reconstruction surgeon at UC San Diego Health who performs tissue transplants and repairs injured genitals, also volunteers at the VA in San Diego.
She believes this transplant procedure will eventually be covered by the VA.
“If the VA continues to be committed to treating war casualties, if they continue to provide veterans with their healthcare, I would expect they would want to make the veteran as whole as possible and cover this procedure,” she said.
“This procedure will transform people’s lives,” she added.
David Shulkin, the medical doctor and former hospital administrator who was fired from his position as Secretary of the VA recently by President Trump, said the transplant at Johns Hopkins is an “important advance for veterans and all Americans.”
Shulkin said that fixing the broken transplant system at VA was a top priority for him during his tenure at the agency.
“This was one of the reasons we pushed hard at VA to expand coverage for infertility services for service-connected issues,” he explained. “We did this on January 19, 2017, as one of our key initiatives at VHA (Veterans Health Administration).”
Shulkin said the push will allow the VA to offer procedures like this, “Once they become proven and safe. The Hopkins work is a big step toward this.”
Shulkin added, “This work reinforces why VA must continue to work closely with academic and community partners. Advances will happen both within VA and from others. Veterans must have access to the best care anywhere.”
Curt Cashour, press secretary for the VA, told Healthline that the department performs plastic and reconstructive surgery “for procedures deemed medically necessary.”
Specifically, he added, “Medically necessary care is provided to enrolled veterans as determined by appropriate healthcare professionals to promote, preserve, or restore the health of the individual and the care and treatment is deemed to be consistent with generally accepted standards of medical practice.”
Cashour said the transplant procedure at Johns Hopkins represents the first of its kind and should be considered a research protocol under investigation.
“VA does not currently have a research protocol for this type of transplant procedure,” he said.
Given the fact that this medical breakthrough could profoundly improve the lives of tens of thousands of American veterans, Healthline asked Cashour if the agency had any communication with Johns Hopkins or others who are studying these procedures.
Healthline also asked Cashour whether this procedure, once it is proven to be safe and effective, will be covered for veterans who are enrolled at the VA.
In response, Cashour said the VA is “always striving to provide veterans with the most effective treatments when a sufficient evidence base for safety and effectiveness of treatment has been developed, and we are monitoring this new development.”
Next steps for Dr. Lee’s team
Lee hopes these procedures become widely available to veterans and non-veterans who need it.
With the proper funding, he said his team is eager to provide this to more patients.
“Our team is ready, but the first thing we need to do is raise public awareness that this is feasible. It takes time for people to learn what’s not widely known, which is that people can undergo transplants and regain normal body parts,” he said.
Lee said it’s also important to make medical providers aware that this is now a real possibility.
And finally, he said, “The right candidates for this procedure need to be identified. Not everyone with penile loss is a candidate for transplant. We have a rigorous screening process to make sure they are medically appropriate and also ready from a psychological standpoint.”
These patients, Lee said, need to understand the risks and benefits of transplants.
“They need to be motivated to take lifelong immune-suppressants that prevent rejection. This is a lifelong commitment, the same as a kidney or heart,” he said.
The donor family
Lee and others interviewed for this story emphasized that just as it is for heart, kidney and other transplants, the donor and the donor’s family are an integral part of this story.
In a statement, the family of the donor said:
“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.”