Mary Roach - Grunt

“This is a soldier who was hit with an RPG in Afghanistan. Lost his testes and scrotum and penis. There’s the flap being raised on his arm.” Redett swipes through photos like a proud parent. “We made a scrotum using a tissue expander in his perineum. Here it is with the artificial testes. He has total sensation now.” After nine months to a year, a patient’s penile nerves regrow in the tissue formerly known as arm, supplying normal penile sensations and triggering orgasm very much as they used to.

So why would a man opt for a transplant? Especially since transplants still—even with the marrow infusion—require some degree of immunosuppression. And not only does immunosuppression diminish the body’s defenses, opening the door to infections and cancers, but the drugs it requires have hefty side effects. Why not stick with phalloplasty?

“Here’s the problem.” Redett steps over to a whiteboard on the wall and draws a penis. For a moment, it looks like fifth graders had the run of the place. The problem is extrusion: implants poking through the tip of the penis, typically during intercourse. Penile implants were designed for men with erectile dysfunction (severe cases that Cialis won’t help). In these men, the inflatable rods are inserted into tough fibrous sheaths that line the erectile chambers (two of which run the length of the shaft like the barrels of a gun). Phalloplasty patients have no sheaths, just skin—which is easier to poke through. Think of holding a restaurant drinking straw in your fist and pulling down the wrapper until the straw pushes out the top. It’s that kind of situation. The extrusion rate has been reported to be as high as 40 percent (though sheathing the implants with Dacron or cadaveric tissue sleeves has helped somewhat). Also, as mentioned in the previous chapter, urethras made from forearm skin sometimes prune up and deteriorate in a moist environment.

Besides, a man might like to have a natural, no-pumping-needed erection. (To get hard, a man with implants has to squeeze a bulb inside the scrotum that pumps saline.) A man might also, when he’s finished with that erection, wish to have a less bulky, more retractable organ. Uninflated penile implants are less rigid but no shorter. “Right?”

Cooney glances over his loupes. “In general, Mary? Men don’t complain about it being too big.”

AS YOU read this, Redett’s team may have undertaken their first transplant. When I last checked in, in February 2016, a wounded veteran had been selected and was awaiting a suitable donor. In addition to the matching criteria used with internal organs, a penis must also, Redett said in an email, be a good match visually: “Skin color and… age.” And size, I wrote back? This he shrewdly ignored.

Their first won’t be the world’s first. That took place in China in 2006, at the hospital of the Guangzhou Military Command. In the case study, the surgeons describe the recipient not as a soldier but as the victim of an unspecified “unfortunate traumatic accident.” Additional trauma ensued: The new penis “regretfully had to be cut off” after two weeks. The man’s body didn’t reject it, but his wife did. No details were supplied other than to say that there was a “severe psychological problem… beyond our and the patient’s imagination.” Swelling was mentioned, and some necrotic tissue.

Necrosis happens when tissue is deprived of oxygen—in this case, because someone’s transplant surgeon didn’t hook up the necessary arteries. The skin turns black and leathery and eventually falls off.

“ Necrotic means dead,” explains Cooney. “Surgeons don’t like to say dead .”

Even without necrosis, a transplanted appendage has a taint of death. It’s not dead, but it is a bit resurrected. You can imagine how a patient might be uncomfortable with it. With internal organs like kidneys or lungs, the psychological consequences are generally mild: out of sight, out of mind. “But it is not so easy to use and see… a dead person’s hands, nor is it easy to look in a mirror and see a dead person’s face,” wrote Jean-Michel Dubernard, the surgeon who successfully transplanted the first hand—which was later removed, the patient believing it to be evil. (The hand was swollen and inflamed, though not from evil. The recipient had stopped taking his immunosuppresants.)

Cooney’s experience has been otherwise. “People really thought that with the hand and face transplants, conversion”—the psychological assimilation of another person’s body part—“was going to be an issue.” It has not been. “I realized that that is the whole person’s hubris: You and I have two hands, so having another hand would feel unnatural. But having a missing hand is more unnatural.” Cooney’s experience with all six of the hand transplant patients his team has worked on is that the instant they wake up, even though they can’t yet feel or even see their new hand, it feels like their own. This has been true even in cases where the hand was from a person of a different gender or with a slightly different skin color.

Receiving a stranger’s face has also proved less disturbing than people had imagined, because the alternative is no face at all. “Patients say, ‘I don’t care whose face I get,’” says Cooney. “Having a face is being human. Not having a face is being some movie monster.”

And penises? “I’ve been trying to think,” says Cooney, straightening a row of surgical instruments laid out on the big guy’s belly. “What’s different about the penis? It’s not part of one’s identity in the way a face or even hands are. But there’s something about it. It’s more personal, in a way, because no one sees it.”

And in this case, everyone will want to. The media spotlight will be intense and especially uncomfortable. “When you’ve got somebody sitting there in a wheelchair with bilateral arm transplants, it’s easy to look at him and say, ‘Wow, that is really something,’” says Redett, from his work station at the other gurney. “But when you’ve got a guy sitting there in a hospital gown, saying, ‘Yup, everything went well…,’ you know what everyone’s thinking: Does it work? Can we see it? ”

Cooney makes a deep cut, the big man’s penis springing open, kielbasa-like, under the blade. When pressed, he will allow that this is, as a male, an uncomfortable act. And then change the topic.

“So this is the spongy tissue of the corpus cavernosum.” He indicates one of the twin erectile chambers. He squeezes the stump, and blood appears like water from a sponge.

Because blood is the substance of erection, hooking up the right arteries is doubly important: not only to avoid necrosis, but to facilitate sexual function. The Chinese surgeons didn’t reattach the cavernosal arteries, which run down the center of each erectile chamber and supply much of the blood for erections. One reason, perhaps, for the wifely discontent.

Meanwhile, one gurney over, an artery in the skin on the lean cadaver’s abdomen is being hooked up to a tube running down from an IV bag. The fluid in the bag is dyed indigo, and when it begins to flow, a patch of skin will blush blue, revealing the precise territory fed by the artery. In this way, Redett and his colleagues are able to pinpoint which vessels are critical for the transplant. There will be no necrosis when the Americans move their first penis.

The IV isn’t a drip but a rapid infusion, a setup used in emergency rooms to replenish blood volume quickly. “The first time we tried this, it was a disaster,” says Sami Tuffaha, who has been researching penile vasculature as part of his residency. “Dye all over the place.” Irritated janitor. Ruined loafers. He sticks out a foot. “They’re my cadaver shoes now.”