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帮助伤残军人,美推出阴茎移植术

更新时间:2015-12-10 10:10:25 来源:纽约时报中文网 作者:佚名

Penis Transplants Being Planned to Help Wounded Troops
帮助伤残军人,美推出阴茎移植术

Within a year, maybe in just a few months, a young soldier with a horrific injury from a bomb blast in Afghanistan will have an operation that has never been performed in the United States: a penis transplant.

一年之内,或许是短短几个月之内,一名派驻阿富汗,因炸弹爆炸身受重伤的年轻士兵将接受一项此前从未在美国进行过的手术:阴茎移植。

The organ will come from a deceased donor, and the surgeons, from Johns Hopkins University School of Medicine in Baltimore, say they expect it to start working in a matter of months, developing urinary function, sensation and, eventually, the ability to have sex.

这次手术将使用已故供者捐赠的器官,由约翰斯·霍普金斯大学医学院(Johns Hopkins University School of Medicine,位于巴尔的摩)的外科医生执刀。他们说,他们期望手术能在几个月内见效,患者逐步恢复排尿功能和感觉,并最终重获性能力。

From 2001 to 2013, 1,367 men in military service sustained wounds to the genitals in Iraq or Afghanistan, according to the Department of Defense Trauma Registry. Nearly all were under 35 years old and were hurt by homemade bombs, commonly called improvised explosive devices, or I.E.D.s, sometimes losing all or part of their penises or testicles — what doctors call genitourinary injuries.

根据美国国防部(Department of Defense)的创伤登记(Trauma Registry),从2001年到2013年,有1367名美国军人在伊拉克和阿富汗遭受生殖器损伤。这些人几乎都不到35岁,而且基本上都是被自制炸弹(通常称为简易爆炸装置,或I.E.D.)所伤,失去部分或全部阴茎或睾丸——医生称之为泌尿生殖系统损伤。

Missing limbs have become a well-known symbol of these wars, but the genital damage is a hidden wound — and, to many, a far worse one — cloaked in shame, stigma and embarrassment.

战争的标志之一是缺胳膊少腿,人们对这一点已经熟知,而较为隐蔽——对许多人来说,也更为严重——的生殖器损伤,往往在羞耻和尴尬中被掩藏。

“These genitourinary injuries are not things we hear about or read about very often,” said Dr. W. P. Andrew Lee, the chairman of plastic and reconstructive surgery at Johns Hopkins. “I think one would agree it is as devastating as anything that our wounded warriors suffer, for a young man to come home in his early 20s with the pelvic area completely destroyed.”

“我们并不常听说或读到关于泌尿生殖系统损伤的报道,”约翰斯·霍普金斯大学整形重建外科主席W·P·安德鲁·李(W. P. Andrew Lee)博士说。“看着我们才20岁出头的战士们带着被完全毁坏的盆腔回到家里,我相信没有人会否认他们遭受到了毁灭性的伤害。”

Only two other penis transplants have been reported in medical journals: a failed one in China in 2006 and a successful one in South Africa last year. The surgery is considered experimental, and Johns Hopkins has given the doctors permission to perform 60 transplants. The university will monitor the results and decide whether to make the operation a standard treatment. The risks, like those of any major transplant operation, include bleeding, infection and the possibility that the medicine needed to prevent transplant rejection will increase the odds of cancer.

此前,医学期刊上仅报道过两例阴茎移植手术:2006年中国的一例失败了,去年南非的一例取得了成功。在美国,这项手术被认为是实验性的,约翰斯·霍普金斯大学许可医生们进行60例移植手术。该大学将监测手术结果,并决定是否将其列入标准治疗。像所有重大移植手术一样,其风险包括出血、感染以及防止移植排斥反应的药物可能会增加患癌症的几率等。

Dr. Lee cautioned that patients should be realistic and not “think they can regain it all.” But doctors can give the recipients a range of what to expect.

李博士提醒说,患者对手术应该抱比较实际的态度,不应“以为自己可以恢复如初。”但是,医生也可以大概告知移植受者他们可以恢复到何种程度。

“Some hope to father children,” Dr. Lee said. “I think that is a realistic goal.”

“有些人希望能做父亲,”李博士说。“我认为这个目标还算现实。”

Just the penis will be transplanted, not the testes, where sperm are produced. So if a transplant recipient does become a father, the child will be his own genetically, not the offspring of the donor. Men who have lost testicles completely may still be able to have penis transplants but will not be able to have their own biological children.

此手术仅移植阴茎,不涉及产生精子的睾丸。因此,移植受者的孩子从遗传学上仍然完全是他自己,而非器官供者的后代。而连睾丸也完全丧失的男性仍可能接受阴茎移植手术,但他们无法拥有亲生孩子。

In the 2006 case in China, the recipient asked that the transplant be removed a few weeks after the operation, because of “apparent psychological rejection,” the Johns Hopkins doctors said, adding that in photographs the transplant had patches of dead and peeling skin, possibly from inadequate blood flow.

约翰斯·霍普金斯大学的医生说,2006年中国的那个病例中,移植受者在术后几周就要求移除移植物,因为他感到“明显的心理排斥”。他还补充道,从照片中可见移植物皮肤上呈现数片死亡、脱皮的斑块,可能是因血流量不足造成的。

But the South African recipient, a young man whose penis had been amputated because of a botched circumcision, recently became a father, said Dr. Gerald Brandacher, the scientific director of the reconstructive transplantation program at Johns Hopkins.

但南非的那位移植受者,一名在失败的包皮环切术中阴茎被截断的年轻男性最近还当上了爸爸,约翰斯·霍普金斯大学重建移植项目的科学主任博士杰拉尔德·布兰达切尔(Gerald Brandacher)博士说道。

Doctors who treat young men wounded in combat say that no matter how bad their other injuries are, the first thing the men ask about when they wake up from surgery is whether their genitals are intact.

为在战斗中受伤的年轻男子们治疗的医生表示,不管伤员们其他部位的伤势有多惨重,他们在术后清醒过来后问的第一件事都是他们的生殖器是否完好。

“Our young male patients would rather lose both legs and an arm than have a urogenital injury,” said Scott E. Skiles, the polytrauma social work supervisor at the Veterans Affairs Palo Alto Health Care System.

“我们的年轻男性患者宁愿失去双腿和手臂也不愿遭受泌尿生殖系统损伤,”退伍军人事务部帕罗奥图医疗系统(Veterans Affairs Palo Alto Health Care System)的多发伤社会工作主管斯科特·E·斯基尔斯(Scott E. Skiles)说。

Army Sgt. First Class Aaron Causey, who lost both legs, one testicle and part of the other from an I.E.D. in Afghanistan in 2011, said the testicular damage was the most troubling of his injuries.

陆军上士(Army Sgt. First Class)阿龙·考西(Aaron Causey)2011年在阿富汗因I.E.D.失去了双腿、一个睾丸和另一个睾丸的一部分,他说,睾丸损伤是最为困扰他的伤病。

“I don’t care who you are — military, civilian, anything — you have an injury like this, it’s more than just a physical injury,” Sergeant Causey said.

考西上士说:“不管是对于军人、平民——所有人,这样的伤都绝不仅仅是身体上的伤害。”

Some doctors have criticized the idea of penis transplants, saying they are not needed to save the patient’s life. But Dr. Richard J. Redett, director of pediatric plastic and reconstructive surgery at Johns Hopkins, said, “If you meet these people, you see how important it is.”

有些医生批评阴茎移植这个主意,说它们并非挽救患者生命所必需。但约翰斯·霍普金斯大学的整形重建外科主任理查德·J·雷代蒂(Richard J. Redett)博士说:“如果你遇到过那样的伤者,你就会发现这手术有多么的重要。”

“To be missing the penis and parts of the scrotum is devastating,” Dr. Redett said. “That part of the body is so strongly associated with your sense of self and identify as a male. These guys have given everything they have.”

“丧失阴茎和部分阴囊的打击是毁灭性的,”雷代蒂博士说。身体的这些部分与身为男性的自我意识和身份认同密切相关。这些战士们已经付出了他们所有的一切。”

Jeffrey Kahn, a bioethicist at Johns Hopkins, said that at a conference convened last year by the Bob Woodruff Foundation, which aids injured veterans, wives said that genitourinary injuries had eroded their husbands’ sense of manhood and identity. Most telling, Dr. Kahn said, was that the men themselves attended the conference but did not speak about their wounds.

约翰斯·霍普金斯大学的生物伦理学家杰弗里·卡恩(Jeffrey Kahn)说,去年,在鲍勃·伍德拉夫基金会(Bob Woodruff Foundation)召开的一次旨在帮助伤残退伍军人的会议上,妻子们发言说,泌尿生殖系统损伤削弱了她们丈夫的男子气概和他们的自我认同感。最能说明问题的是,那些男人明明自己也参加了会议,却绝口不提自己的创伤,卡恩博士补充道。

Although surgeons can create a penis from tissue taken from other parts of a patient’s own body — an operation being done more and more on transgender men — erections are not possible without an implant, and the implants too often shift position, cause infection or come out, Dr. Redett said. For that reason, he said, the Johns Hopkins team thinks transplants are the best solution when the penis cannot be repaired or reconstructed. If the transplant fails, he said, it will be removed, leaving the recipient no worse off than before the surgery.

雷代蒂博士说,虽然外科医生可以利用从患者自身其他部位采集的组织重新制造一个阴茎(这一手术在变性男子中正越来越普遍),但没有植入物的话就不可能勃起,且植入物总是移位,引起感染或脱落。出于这个原因,约翰斯·霍普金斯的团队认为,当阴茎不能修复或重建时,移植是最好的解决方案,他说,如果移植失败,还可以将移植物移除,受者总归不至于比手术前更糟。

But can men — and their partners — get used to the idea that their most intimate part came from another man’s body?

然而,男人——以及他们的伴侣——是否能适应他们最亲密的部位来自另一个人的身体这一点?

The best analogy is hand transplants, Dr. Brandacher said, because hands are personal and distinctive — a transplant that the recipient can see, unlike a kidney or liver.

布兰达切尔博士说,在这个问题上,最合适的类比是手移植,因为手部具有个人独特姓,而且与肾脏或肝脏移植不同,受者可以看到移植物。

“I can tell you from all the patients — and I’ve been involved since 1998 — every single one, after surgery, look at the graft, try to move it and they immediately call it ‘my hand,’ ” Dr. Brandacher said. “They immediately incorporate it as part of their body. I would assume, extrapolating, that this is going to be the same for this kind of transplant.”

“我可以告诉你,1998年以来我所有的患者在术后看到移植物并尝试活动它,都马上称它为‘我的手’,”布兰达切尔博士说。“他们立即认同它是自己身体的一部分。所以我推断,阴茎移植后应该也差不多。”

Dr. Kahn said it was essential that the families of organ donors be asked specifically for permission to use the penis, just as special permission was required for face and hand transplants. It is not assumed that people willing to donate kidneys or livers will also consent to having their loved one’s genitals removed. The surgeons want a relatively young donor to increase the odds that the transplanted organ will function sexually.

卡恩博士说,专门询问器官捐献者的家属可否使用阴茎至关重要,这与脸部和手移植需要征求特别许可是一个道理。不能预设愿意捐献肾脏和肝脏的人也会同意切除他们心爱的人的生殖器。外科医生们希望这次手术能有一个相对年轻的供者,这样移植器官将更可能执行性功能。

For now, the operation is being offered only to men injured in combat, Dr. Lee said. It is not available to transgender people, though that may change in the future.

李博士说,目前,该手术仅面向在战争中受伤的男性。变性者不能进行该手术,不过这一限制在未来可能会有所改变。

“Once this becomes public and there’s some sense that this is successful and a good therapy, there will be all sorts of questions about whether you will do it for gender reassignment,” Dr. Kahn said. “What do you say to the donor? A 23-year-old wounded in the line of duty has a very different sound than somebody who is seeking gender reassignment.”

“一旦手术被公开且有人认可它是成功且有益的疗法,围绕是否可以为变性人做这个手术,将会有各种各样的问题冒出来,”卡恩博士说。“你要怎么跟供者沟通?一名在前线受伤的23岁青年跟某个想要变性的人听起来差别可大了。”

For a transplant to be possible, certain nerves and blood vessels have to be intact in the recipient, as does the urethra, the tube that carries urine out of the body. The screening process, as for any organ transplant, also involves making sure that the candidate is psychologically ready, understands the risks and benefits, can stick to the regimen of anti-rejection medicine and has a family support network.

要确保移植手术可行,对受者也是有要求的,只有特定神经和血管以及尿道(将尿液排出体外的管道)完好的受者,才有可能接受移植。就像所有器官移植一样,受者筛选程序还包括确保候选人做好了心理准备,了解风险和收益,能坚持抗排斥药物治疗方案,并拥有家庭支持网络等。

A few initial candidates are being evaluated. “We have one that we’re moving forward with, and we’re very far in the process,” Dr. Redett said, adding that he expected the patient to be put on the transplant waiting list soon. “That means you are really only waiting for a donor.”

目前,几名初始候选人正在接受评估。“我们和一名候选人进展良好,但在整体的过程中还有很远的路要走,”雷代蒂博士补充道,他预计该患者很快就会被放进移植等待名单。“这意味着实际上现在已经万事具备,只等供者了。”

A spokeswoman for Johns Hopkins said the candidates and their families had declined to be interviewed.

约翰斯·霍普金斯大学的女发言人表示,候选人和他们的家人都拒绝接受采访。

The university will pay for the first transplant, Dr. Lee said, adding that he had asked the Defense Department for money to cover more operations. The surgeons are donating their time, he said. Comparing the surgery to hand transplants performed at Johns Hopkins, he estimated the cost at $200,000 to $400,000 per operation. He said the Department of Veterans Affairs would pay for the drug that the men will need to prevent transplant rejection.

约翰斯·霍普金斯大学将支付第一例移植的费用,李博士说,并补充道他已要求美国国防部拨款以进行更多手术。外科医生们无偿地献出了自己的时间,他说。参照在约翰斯·霍普金斯大学进行的手移植手术,他估计每台阴茎移植手术的费用在200000美元到400000美元之间。他还称美国退伍军人事务部(Department of Veterans Affairs)将承担该男子所需的抗移植排斥反应药物的花费。

The project has been years in the making, the doctors said, with extensive research and practice surgery on cadavers. Some of the work involved injecting brightly colored food dyes into the cadavers to map out the circulatory system in the penis. Dr. Lee said the research had found previously unknown aspects of its blood supply, which will be critical to the transplant’s success.

医生们表示,该项目已经运作数年,他们进行了广泛的研究,并在尸体上进行了手术实践。其中一些工作涉及向尸体内注射色彩鲜艳的食用染料,以显示阴茎的血液循环系统。李博士说,研究发现了此前未知的血供信息,这将成为成功移植的关键。

The operation should take about 12 hours, Dr. Lee said. The surgeons will connect two to six nerves, and six or seven veins and arteries, stitching them together under a microscope.

李博士说,手术大约需要12个小时。外科医生将在显微镜下缝合六、七根静、动脉,并连接两至六根神经。

For the first few weeks after the surgery, a catheter will be left in place to drain urine. Sexual function will take longer to develop — probably a few months, Dr. Lee said. He said nerves would grow from the recipient into the transplant at a rate of about one inch per month, so the timing will depend in part on the extent of the recipient’s injuries and how far the nerves need to go.

李博士说,术后头几周,患者将使用手术留下的导尿管来排尿。性功能则需要更长的时间来恢复——或许要几个月。他解释说,神经将会以大约每个月一英寸(约合2.54厘米)的速率从受者体内长入移植物中,所以恢复时间在一定程度上取决于受者受伤的程度以及神经需要延伸的距离。

After the transplant, the men will begin taking anti-rejection medication and will need it for the rest of their lives. Such drugs work by suppressing the immune system and can increase the odds of infections and cancer.

移植手术之后,受者将开始服用抗排斥药物——在他的余生中将一直需要这些药物。这些药物可以抑制免疫系统,因此可能会增加他感染和患癌症的几率。

To minimize the risks, the Johns Hopkins team has found a way to use just one drug, rather than the three usually needed for other transplants. At the time of the penis transplant, they will treat the recipient with a medication that reduces immune system cells. About two weeks later, he will receive an infusion of stem cells from the donor. The infusion dials back the tendency of the recipient’s immune system to attack the transplant, and just one anti-rejection drug, tacrolimus, is then enough to keep it in check. Doctors have used this technique successfully in patients who have had hand transplants.

为了尽可能地减小上述风险,约翰斯·霍普金斯大学的团队发现有一种方法可以只使用一种药物,而不是像其他移植手术那样通常需要三种。在移植阴茎时,他们会给受者使用一种可减少免疫系统细胞的药物。大约两周后,受者将接受来自供体的干细胞输注。其目的在于减低他的免疫系统的攻击移植物倾向,这样只使用一种抗排斥药物——他克莫司就足以保持一切尽在控制之中。医生们已在手移植的患者身上成功地运用了这种技术。

Ultimately, the goal is to restore function, not just form or appearance, Dr. Brandacher emphasized. That is what the recipients want most.

我们的最终目标是恢复功能,而不仅是形态或外观,布兰达切尔博士强调。这才是受者们最殷切的期望。

“They say, ‘I want to feel whole again,’ ” Dr. Brandacher said. “It’s very hard to imagine what it means if you don’t feel whole. There are very subtle things that we take for granted that this transplant is able to give back.”

“他们说:‘我想再次感到自己是个完整的人,’ ”布兰达切尔博士说。“你很难想象‘不完整’的人到底是什么感觉。我们认为此项移植手术可以将这种非常微妙的感觉带回到受者身上。”

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