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The Long Road to Penile Allotransplantation in South Africa

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The Long Road to Penile Allotransplantation in South Africa 5 Editorial Commentary Page 1 of 5 The long road to penile allotransplantation in South Africa Guglielmo Mantica1,2, André Van der Merwe2 1Department of Urology, Policlinico San Martino Hospital, University of Genova, Genova, Italy; 2Department of Urology, Tygerberg Hospital and Stellenbosch University, Cape Town, South Africa Correspondence to: Guglielmo Mantica. Department of Urology, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy. Email: [email protected]. Received: 20 September 2020; Accepted: 17 March 2021. doi: 10.21037/amj-20-163 View this article at: http://dx.doi.org/10.21037/amj-20-163 In the collective imagination, transplantation is the The aim of this paper is to provide a global vision on epitome of surgery, including the concepts of sacrifice, penile transplantation, including possible indications gift and life. Since 1950, the year in which Joseph Murray and future prospects, as well as ethical and donor performed the first successful kidney transplant in the procurement issues. history of medicine in Boston. The evolution of medical sciences and technology has led to the interplay of millions Is there a need for penile transplantation? of lives of recipients, donors and surgeons (1-4). Urologists have always been widely involved in Penile loss and injury can have various causes. In South transplantation, especially kidney transplantation, Africa in particular, a significant number of healthy young which currently represents one of most explanted and men are rendered aphallic each year due to complications transplanted organs in the world (5). resulting from ritual circumcisions which are widely While the kidneys, heart, liver, lungs and corneas are practiced. In fact, ritual circumcisions are a deeply rooted historically the most explanted and transplanted organs, in practice in South African culture, especially among the recent years we have witnessed a race pushing the limits Xhosa-speaking people of the Eastern Cape (7,9,10). of ethics and technology with the proposal and execution Circumcision is an integral part of a larger initiation of new types of transplants, such as hand, face, penis and ritual, which is generally an eagerly awaited event even head transplants (1-5). in a young person’s life, symbolizing his transition In the wake of these developments, the first penile to manhood and failure to do so results in social transplant attempt was carried out in Beijing in 2006, stigmatization (9,10). During the ritual process, the which failed due to an early psychological rejection in circumcisionist removes the foreskin with an assegai the early post-operative days (6). However, the Chinese (traditional spear). A hemostatic bandage of a strip of team demonstrated the technical feasibility of the surgery, buckskin or cloth and herb leaves are wrapped tightly opening the doors to what in 2014 was the first successful around the penis. The initiates are then confined to a hut operation of its kind by the Department of Urology of for the next eight days, during which the consumption of Tygerberg Hospital and Stellenbosch University (7). certain foods and drink is limited (7,9,10). To date, out of five attempts made worldwide, four Current ritual circumcision practices in South Africa interventions have been successful: two carried out at have raised serious health problems. The complications of the aforementioned South African center (in 2014 and the procedure can lead to severe penile mutilation which 2017) and two others (one of the surgeries included often results in amputations of various degrees for about a simultaneous scrotal transplantation) carried out 250 young people a year. Moreover, among the young respectively at the Massachusetts General Hospital in people who are hospitalized in the days following the Boston and John Hopkins University Hospital in Baltimore procedure, due to complications of the same, there is a in 2016 and 2018 (8). mortality of almost 9% (7,9,10). © AME Medical Journal. All rights reserved. AME Med J 2021 | http://dx.doi.org/10.21037/amj-20-163 Page 2 of 5 AME Medical Journal, 2021 In fact, given the secrecy and confidentiality of the tribes Ethical issues about these practices, the true incidence of post-procedural The possible social value of penis transplantation in South complications is difficult to establish. In fact, a “complaint” Africa is justified by the relatively large number of young of complications can often be seen as an act of weakness or adults undergoing partial or total penectomies following even be punished (9). ritual circumcisions and traumatic injuries (7,9). The Ritual circumcision is typically performed in a non- ethical issues surrounding penile transplantation are clinical setting by a traditional surgeon with little, if any, complex and are in part similar to those involving face clinical training. In addition to the surgical risks, if the transplantation, especially regarding self-acceptance of hemostatic bandage is applied too tightly, it may happen body image (9,13-24). that the penile skin or the entire organ undergo necrosis. Although it is not strictly speaking a "life-saving" Also, initiates are discouraged from drinking fluids in intervention, it can bring about a significant improvement the days following circumcision, in an attempt to reduce in quality of life, especially for some of these patients who urine output to prevent acute urinary retention. As a result, dehydration initiates predisposition to thrombosis are still very young. Therefore, penile loss can not only of the blood vessels in the penis, increasing the risk of lead to possible complications from the point of view of penile necrosis. Poor sterility and hygiene contribute to voiding, but also a complete renunciation of sexuality and the exacerbation of the problem. In fact, about a hundred paternity (7,9). deaths a year are due to septicemia (9,10). Often, such patients fall into a profound depressive However, ritual circumcisions are not the only cause crisis, exacerbated by the unacceptable further stigma and of penile amputation. South Africa is one of the countries marginalization to which they are subjected by their own with the highest incidence of penile cancers, also due family and relational entourage. This depression results in a to the high prevalence of HIV and sexually transmitted high suicide rate for these individuals. diseases. Currently, this incidence is estimated to be As part of the project aimed at developing penile in the order of 6 patients per 100,000 inhabitants, allograft surgery, the correct identification of candidates is which translates into more than 3000 diagnoses per first of all important in order to minimize the risk-benefit year of penile carcinomas requiring surgical therapy. ratio (7,13-24). Furthermore, diagnostic delays of the penile tumors In addition to the physical risks of long-term themselves, requiring subsequent radical surgery adds to immunosuppression after transplantation, these patients the morbidity (7). face potential risks of ostracism and psychological harm. Conventional reconstructive techniques, with the use In fact, the environment surrounding the possible of grafts and flaps, lead to functionally and aesthetically candidate is also fundamental. The post-operative period imperfect results of replacing the normal penile organ. In should be managed with extreme sensitivity and respect for addition, they are burdened with frequent complications, privacy, in order to prevent stigma or discrimination (9). which include flap atrophy or necrosis, urethral stricture, Another important consideration is adherence to and extrusion of the prostheses (11,12). immunosuppressive treatment and proper compliance The use of a bundle cutaneous flap of the radial forearm, with follow-up. The age category between 18 and which is currently the most used in common practice, can 25 years is the one that presents the greatest risk for non- also compromise functional capacity in patients who depend adherence to immunosuppression in kidney transplant on manual labor to earn a living. The use of prostheses recipients (9). associated with free-flap reconstructive techniques are Furthermore, the psychological effect of penis burdened by high costs, often not sustainable by the patient, transplantation cannot be underestimated and could induce as well as by a high rate of complications such as the psychosis or non-acceptance of the organ, which happened, extrusion of the prosthesis itself. for example, in the case of the first patient operated on in For these reasons, penile transplantation could China in 2006 (6). In this case, in the early postoperative represent a valid answer to the problem as well as an period, the patients developed a psychological rejection of effective option to the reconstructive surgical treatments the transplanted penis and therefore asked the surgeons to currently available (11,12). remove the organ. © AME Medical Journal. All rights reserved. AME Med J 2021 | http://dx.doi.org/10.21037/amj-20-163 AME Medical Journal, 2021 Page 3 of 5 For all these reasons Penile transplantation should be placing on the waiting list. The participant selected to performed only in patients with severe damage to the penis, receive the transplant was informed about the potential in appropriate institutions under the protocols approved by risks and benefits of the procedure. institutional review boards. Appropriate selection criteria The patients excluded from the waiting list after should be established,
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