Unsung Hero of First U.S. Penile Transplant: Radiology

This month, medical news has been filled with fanfare about the first successful penis transplantation in the United States. According to all reports, the surgery was a success, but little attention has been paid to why the procedure went so well.

Working collaboratively, it took a multidisciplinary team of a dozen surgeons and approximately 30 additional members to attach a penis from a deceased donor to a 64-year-old man who had his penis removed due to penile cancer. But, crucial to this win , buried under the spectacle– and driving the capability to correctly attach the organ and provide full functionality – was radiology. Having clear glimpses into the body was critical for the surgical team.

“Radiology was integral because they created a road map for us with the diagnostic arterial angiography, CT angiography, and MRI,” said co-lead surgeon Dicken Ko, MD, director of the Massachusetts General Hospital (MGH) Urology Regional Program and associate professor of surgery at Harvard Medical School. “We could actually define how much tissue was left behind and what the possibilities were for reconstruction.”

The Importance of Imaging
Ultimately, said Garry Choy, MD, the MGH diagnostic radiologist recruited to provide services to the transplant team, radiology allowed the surgeons to maximize the patient’s vascular capabilities while connecting the nerves that will support tactile sensation. He and his colleague, Raymond Liu, MD, an assistant radiologist in MGH’s Division of Interventional Radiology, designed the imaging protocol to optimize the results for both nerves and blood vessels.

To reach this goal, the radiologists provided imaging services both preoperatively while surgeons were practicing their technique on cadaver tissues, as well as during the procedure with the transplant recipient. First, to get the best images, they conducted MRI studies for the soft tissues and added CT angiography to catch any other anomalies that might have been present. These studies show surgeons how deeply they should anticipate dissection of the patient’s tissues, Choy said.

In many ways, Ko said, having diagnostic images available was very similar to the high-altitude guidance available through Google Maps. It was a sophisticated preliminary guide, but the surgeons didn’t get exact pictures until they embarked on the procedure in the operating room.

At that time, Liu said, interventional radiology imaging played an important role in determining the patient’s potential vascularity.

“It was an important area of concern for the surgeons because having good blood flow is vital for the transplant’s viability,” he said. “We took images to showcase what the vasculature would look like for the recipient patient.”

Liu imaged both the dorsal penile artery and the bulbouretral artery. He also used a CT angiogram to help gather the best real-time data possible. The hope, he said, was to give the surgeons an in-the-moment look at how they could best reconnect the vessels that serve those arteries.

Other Benefits of Imaging
As with any transplant, Ko said, patients with penile injuries will present with different characteristics. Not only do these differences make each case unique, they also make it critical to know how much healthy and damaged tissue each patient has and how much will need to be removed from the donor to compensate for the injuries. 

In addition to helping surgeons identify the arteries and veins that could be easily connected, high-resolution imaging also facilitates pinpointing the areas that might be dependent on parallel veins for a jump graft, he said.

Without imaging, Choy said, the level of precision surgeons needed to train for the transplant on cadaver tissue wouldn’t have been possible. The team spent three years analyzing and fine-tuning the penis transplant procedure. They operated on five or six deceased donors to perfect their skills. The level of detailed imaging provided helped maximize this preoperative planning.

Diagnostic imaging also came in handy in identifying the largest blood supply sources, as well, Choy said. MRI and CT images offer information about bilaterality and the anatomy of the pelvic structures.

“Usually, a patient has one side of their pelvis that is dominant – it has a larger caliber artery, so it gets more blood,” he said. “That’s important for a surgeon to know when he or she is going to try to connect dominant blood supplies to a donor organ. Having that knowledge is helpful as you got into surgery.”

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Currently, there are two types of patients most likely to benefit from penis transplants and the radiology services that make these procedures most effective – men with penile cancer and servicemen who are wounded in combat.

According to the American Cancer Society, roughly 2,030 men are diagnosed with new cases of penile cancer annually, and 340 men are expected to die from it this year. A few hundred men must have part of all of their penises removed yearly due to cancer. This first U.S. transplant has proven the procedure can be effective and successful in these cases.

It could be equally as impactful for veterans who sustain pelvic wounds during combat service. Penile injuries can increase their risks for cancer and kidney damage, as well as relegate them to taking medication for many years.

Based on U.S. Department of Defense Trauma Registry data, between 2001 and 2013, 1,367 servicemen sustained genitourinary injuries during their tours of duty in Iraq or Afghanistan. In most cases, the soldiers were under age 35, and many lost part of or all of their penises from homemade bombs or improvised explosive devices.

Among these men, those who still carry shrapnel in their pelvis would be most helped by diagnostic radiology services, Choy said. Although MRIs wouldn’t reveal accurate results, a CT scan could help surgeons pinpoint how deeply into the pelvic cavity the metal is buried.

“Surgeons have to know how deep they have to go to find nerves and vessels that they can connect,” he said. “Diagnostic imaging shows you how deeply you have to dissect in order to find usable tissues. It helps surgeons visualize exactly what they want and need to do to help the patient.”

Interventional radiology procedures will also be helpful for wounded servicemen, he said, because they are X-ray based and provide clear images.

Why Radiology Is Rarely Mentioned
Despite playing an integral role in the success of the first penis transplant in the United States, mentions of radiology didn’t figure prominently in any major news story. That’s not uncommon Choy and Liu said. But, it’s also not a problem.

“It’s not unexpected that radiology isn’t readily recognized,” Choy said. “Radiology has always been in a consultant role – we’re doctors to the doctors. The surgeons are at the front lines. We played an important role, but we don’t need to be in the spotlight.”

Overall, Liu said, being part of an interdisciplinary team was enough to demonstrate to partners within the health care system that radiology has the capability of being a value-added player that can bring benefits, improved communication, and strategic skill to any clinical care situation.

And, the country’s first penis transplant case was an excellent opportunity to showcase that ability, Choy said.

“With imaging, we were able to prepare for the outcome with this patient,” he said. “That’s a good thing because it increases our overall odds of success.”