To the Editor:

Male genital tissue loss can have devastating effects on sexual and reproductive function as well as on the psychosocial well-being of the injured patient. Conventional reconstructive efforts are often insufficient to restore full function of the phallus. Only four successful penile transplantations have been reported to date.1,2 We performed transplantation of the penis, scrotum, and lower abdominal wall from a young, closely age-matched donor to an injured veteran who had sustained traumatic penile loss caused by an improvised explosive device.

Figure 1. Figure 1. Transplantation of a Penis, Scrotum, and Lower Abdominal Wall. Panel A shows a preoperative computed tomographic reconstruction of the extent of the injury in the transplant recipient. A small penile stump is visible, with loss of the lower abdominal wall, the entirety of penile shaft, and the scrotum and testes. Panel B shows the graft after explantation from the donor. The graft included the right and left external pudendal artery, a segment of the femoral artery, and the saphenous veins on both sides. Dorsal arteries can be seen on the deep, proximal portion of the penile graft. Panel C shows the graft before the procedure along with clinical images from postoperative day 8, day 15, and day 340. The graft has been incorporated without evidence of rejection. Biopsy sites (arrows) are visible on the skin of the abdomen and groin.

The patient’s initial injury also included above-knee amputation of both legs, substantial tissue loss in the lower abdominal wall, and bilateral traumatic orchiectomy and loss of the scrotum. After initial healing, the patient had a 1.5-cm-long remnant of penile tissue with a urethra at the end of the amputated shaft. Scrotal tissue was absent, as were the testes (Figure 1). Preoperative imaging revealed normal bilateral inferior epigastric, iliac, and femoral arteries (Figs. S1 and S2 in the Supplementary Appendix, available with the full text of this letter at NEJM.org), but the dorsal penile and cavernosal arteries were insufficient to support transplantation. Thus, a surgical technique was developed for this patient in which the deep inferior epigastric arteries were used to revascularize the dorsal penile arteries and the graft, with the external pudendal arteries used to supplement blood supply to the tissues of the proximal shaft, groin, abdomen, and scrotum.3

The transplantation was initiated with a primary urethroplasty and corporal anastomosis. The donor dorsal arteries and veins were then anastomosed to the recipient’s deep inferior epigastric arteries and veins, and both recipient dorsal nerves were coapted to those of the graft (Figure 1). The left donor external pudendal artery was taken with a segment of femoral artery and revascularized by an end-to-side anastomosis to the recipient femoral artery with demonstrated full perfusion of the graft. The patient received alemtuzumab and glucocorticoid induction therapy, tacrolimus maintenance monotherapy, and a donor bone-marrow infusion (descriptions of the operative details and full immunologic course and treatment are provided in the Supplementary Appendix).

It has now been more than 1 year since the patient received the penile transplant. He has near-normal erections and the ability to achieve orgasm, as well as substantial improvements in pleasure scores on patient-reported outcome measures. He has normal sensation to the shaft and tip of the transplanted penis and can localize touch sensation. Neurosensory testing with the Pressure-Specified Sensory Device (AxoGen) reveals that the glans has recovered to near-normal sensibility for the one-point moving touch and has recovered to lower (better) thresholds than for the one-point static touch. Sensation in the penile shaft has recovered to higher thresholds than that in the glans. The patient urinates while standing, without straining, frequency, or urgency, with the urine discharged in a strong stream.

The patient has returned to school full time and continues to live independently using leg prostheses. He reports an improved self-image and “feeling whole” again and states that he is very satisfied with the transplant and the implications it carries for his future.

Richard J. Redett, III, M.D.

Joanna W. Etra, M.D.

Gerald Brandacher, M.D.

Arthur L. Burnett, M.D., M.B.A.

Sami H. Tuffaha, M.D.

Justin M. Sacks, M.D., M.B.A.

Jaimie T. Shores, M.D.

Trinity J. Bivalacqua, M.D.

Johns Hopkins School of Medicine, Baltimore, MD

[email protected]

Steven Bonawitz, M.D.

Cooper University Health Care, Camden, NJ

Carisa M. Cooney, M.P.H.

Devin Coon, M.D., M.S.E.

Aliaksei Pustavoitau, M.D.

Nicole A. Rizkalla, M.D.

Johns Hopkins School of Medicine, Baltimore, MD

Annette M. Jackson, Ph.D.

Duke University School of Medicine, Durham, NC

Vidhi Javia, B.S.

Samuel A.J. Fidder, M.D.

Janice Davis-Sproul, M.A.S.

Daniel C. Brennan, M.D.

Inbal B. Sander, M.D.

Shmuel Shoham, M.D.

Nikolai A. Sopko, M.D., Ph.D.

W.P. Andrew Lee, M.D.

Damon S. Cooney, M.D., Ph.D.

Johns Hopkins School of Medicine, Baltimore, MD

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.