Using long-handled forceps, Jezior passes the dangling tissue to Molly. They look like a couple sharing a Chinese entrée. Molly drapes the graft over one gloved thumb and, with her other hand, snips away bits of fat and tissue to make it thinner. It takes time for new blood vessels to grow in and service a graft. For the first couple of days, the cells of the graft are nourished by a broth of serum. If the graft is too thick, only the cells on the surface will thrive, and those on the interior will die. For this reason, larger skin grafts, like the ones on the back of White’s remaining leg, are run through a mesher. The holes of the mesh create more surface area for the business interactions of cellular life: nutrients in, waste out.
If replacing part of the urethra doesn’t resolve the problem, another option would be perineal urethrostomy. Here the surgeon would excise the damaged portion and thread the shortened urethra through an opening in the perineum—the no-man’s-land between scrotum and rectum. “Then they have to sit to urinate, like ladies do,” says Molly.
How big of a deal is that? Jezior makes the point that someone whose reproductive organs have been damaged by an IED has typically also lost one or more limbs. Having to sit down to urinate probably doesn’t rank high on the worry list.
Molly tilts her head to face me. “It’s huge.” Depending, to some extent, on culture. Some years back, she attended a session on perineal urethrostomy at an international urology conference. The Italian surgeons were aghast. “You can’t tell an Italian man he’s going to have to pee sitting down.”
Molly was one of two female urologists at the meeting. She notices the disparity, but it doesn’t faze her. On the upside, she never waits for a toilet during session breaks. “I’ve been the only one in the women’s room at some of these urology conventions.”
“Same here,” deadpans Jezior.
The piece of cheek is ready to begin its new career. A nurse pulls a sterile drape from White’s hips and begins rubbing his skin with the antiseptic wand. Such is the vigor of the youthful male that even under general anesthesia, even when it’s a ChloraPrep sponge bestowing the caress, the penis responds. It is a less robust response than normal, perhaps, because Jezior has prescribed something to temporarily blunt erections. Surgical incisions are sewn up while the organ is flaccid; erections stretch the incision. They hurt. However, erections bring more blood into the penis, which speeds healing, and they also help prevent scarring. The latter is important because scarring—especially in erectile tissue—can make erections crooked and uncomfortable. For this reason, sexual activity is sometimes encouraged postoperatively as a kind of physical therapy for the penis. Walter Reed nurse manager Christine DesLauriers, whom we’ll shortly meet, convinced the intensive care unit staff to establish a daily “intimate hour,” during which no medical staff would visit the patient’s room, just spouses and partners.
Jezior opens the organ to access the urethra. As he works, he rests the heel of one hand on White’s scrotum, using it like a tiny beanbag chair. Molly’s style is more formal; she holds her instruments like a knife and fork, wrists raised. The rectangular graft is stitched in place but left flat. Urine is temporarily diverted through an opening made in the skin below the graft. In a follow-up operation, once a new blood supply grows in and it’s clear the graft has taken, Jezior will go back in and hook up the waterworks. He’ll roll the graft into a tube and connect it to the original urethra, and that, one hopes, will be that.
When it’s over, Jezior snaps off his gloves and walks directly to a phone on a desk in the corner of the operating room and punches an extension. White’s mother is waiting in his hospital room. “He’s awake, and everything went well.”
FOR THE third time today, I’ve lost Dr. Jezior. I’ll bend down to slip on some surgical shoe covers or step away to use a drinking fountain, and when I turn back he’s gone: pulled away by a nurse, an administrator, a patient’s wife. He never says no, although he has every reason to. Chronically over-busy, he moves through the halls at a slight forward cant, as if arriving a second sooner might give him a jump on the enduring backlog of things that need doing. The stack of reading material in his office bathroom, all of it urological, threatens to collapse the sink.
Like a lost child in a mall, I know to stay put and eventually he’ll come for me. I browse some information on “Boxes and Storage,” one of the many themed bulletin boards that line the corridors of Walter Reed. “Mature Indian wheat moth larvae pupating in corrugated cardboard,” says a photo caption. It’s the most unsettling image I’ve seen all day, but not for long. Jezior and I are headed to his office so he can show me photographs of some of his patients in Iraq. Not to unsettle me, but to give me a broader sense of what bullets and bombs, and then surgeons, can do.
Jezior narrates with simple anatomical vocabulary, but I can’t always parse what I’m seeing in a way that matches the words. I can’t even see person in some of these images. I see butcher shop. Bandages protect the psyche, too; some of these soldiers never saw what I’m seeing. Jezior had a patient who didn’t see the injuries to his penis for three weeks. He clicks ahead to a slide from this man’s arrival at the hospital, a close-up of the weapon-target interaction, as they say in ballistics circles. How do you prepare a patient like this for the unveiling? “We used to try to sound optimistic,” Jezior says. “But when this guy finally saw it, he was like, ‘Oh, my God.’ It was another devastation, a second loss.” Now they’re blunter. “I’ll say, ‘It’s a severe injury. You’ll have to see it.’” If there’s going to be a surprise, let it be a positive one.
What can be done for these men? A lot. The art of phalloplasty—crafting a working penis from other parts of a patient’s body—has come a long way (thanks in no small part to the transgender community). To build a penis, Jezior begins with an arm. A rectangular flap of skin on the underside of the forearm is planed into two thinner layers. The inner one is rolled to form a urethra; the outer becomes the shaft. This tube within a tube is left in place, nourished by the arm’s blood supply. When what remains of the original organ heals, the new model is detached from the arm and reattached farther south.
Erectile tissue is the challenge. While spongiform erectile tissue exists in other parts of the male anatomy—along the urethra and in the sinus cavity (congestion being an erection of the nasal turbinates)—there isn’t much of it, and no one has tried to transplant it. And while there are eye banks and sperm banks and brain banks, no one is banking noses. So in place of the corpora cavernosa—the two parallel cylinders of erectile tissue—surgeons install a pair of inflatable silicone implants. (To get erect, the patient—or his friend—squeezes a little silicone bulb implanted in the scrotum that pumps saline from a receptacle in the bladder.) Hook up the tubes and let the nerves regrow, and in time orgasm and ejaculation are back on track.