• circumcision
• ethics
• surgery
• transplantation

I refer to the paper by Moodley and Rennie published towards the end of 2017.1 This article was in response to a successful penile allotransplantation performed by a multidisciplinary team lead by me.2 Moodley and Rennie correctly state that there was personal communication with me in 2015 regarding the first successful penile transplantation. Personal communication is prone to different interpretation and recollection, and I would like to present what I believe to be more accurate, that is, information about the costs of this intervention.

First, the cost that Moodley and Rennie report requires some context. The price of 243 000 ZAR is the cost our hospital had estimated it would cost for a private patient receiving a penile transplant at a government hospital, including the fees charged for the specialists’ services. The real extra cost of this treatment to government is much less; unfortunately, this was not calculated. Cost is the principal basis of Moodley and Rennie’s arguments. No one on the team received or charged any money. We received our usual salaries which are no extra cost. Theatre costs and ward costs are ongoing and given expenses in an academic hospital, and the money spent regardless of penile transplantation.

In fact, the actual cost of penile transplantation may be compared with renal transplantation. While induction immunosuppression was expensive, it is not more so than some of the high-risk kidney transplants we also perform in this unit. With penile transplantation, one does not need to have potential penile transplant recipients receiving expensive haemodialysis or peritoneal dialysis. Moreover, there is creation of vascular access and peritoneal access for dialysis as is nearly routinely needed for our renal replacement programme. This is a cost not incurred at penile transplantation.

While Moodley and Rennie correctly state that around 250 men lose at least part of the penis per year in South Africa, they do not explain that due to cultural taboos; these men are not allowed to seek Western medical help; therefore, very few will ever enter the waiting lists. At the time of surgery, we had 12 cases on our waiting list. Currently, only three potential cases attend routine workup visits with the rest of them uncontactable, possibly dead by suicide.

During in-depth interviews, I found that the bewildered and depressed aphallic young men have a particular similar pattern of considering suicide in a strangely uniform way, as the most dignified act to escape their situation. During these interviews, I found that affluent Xhosa people often have ways to protect their young against the brutal complications of ritual circumcision. The men we are helping and giving hope are the poorest of the poor, not allowed to talk about their loss or seek medical help, seen as too weak and failed their culture.

Second, the hope we create for this group of men is judged by Moodley and Rennie to be ‘false hope’ as they are unlikely to be helped. Indeed, not everyone who lost their penis will be accepted into the programme, and due to donor scarcity, perhaps not everyone will be transplanted once accepted into the programme. However, as the number was small on our waiting list because of the cultural reasons named above, those seeking help have a more than fair chance to receive penile transplantation. By analogy: while an individual playing the National Lottery has virtually no chance of winning the jackpot, their hope is not false because there is a still small chance they might win. Prospects for a young aphallic man to get a penile transplant once on our waiting list is much bigger than winning the lottery given that the penile transplant programme may continue. In fact, critics of penile transplantation have succeeded to make our local government withdraw any funding such as theatre time, consumables or immunosuppression stating that we need to fund this privately. To obtain financing for someone for an estimated 40 years of immunosuppression is impossible. This effectively closed our programme. In a setting where we also, for example, perform breast reconstruction after mastectomy and bariatric surgery on a routine basis, it is strange that the small numbers of penile transplants anticipated to be performed have to be singled out to save money forwards the fiscal deficit in South Africa.

Third, while penile transplantation should be seen as the gold standard for penile replacement therapy, it cannot be seen as the standard of care. Reconstruction surgery will still help most men with penile injuries. Penile transplantation will only be available for the ones who fully qualify to be admitted to our penile transplantation programme and receive a suitable donor penis.

Fourth, Moodley and Rennie object that high-end and expensive technology is used to perform surgery on indigent third-world patients to the benefit of the first world. But in fact, those of us working for this government service created this option for our poor patients. We only used standard academic hospital equipment and no new purchases were made. The operating microscope we used was not new. We used fine suture material to connect different structures; again, this is standard theatre stock and can hardly be called high tech in an academic hospital. The surgical time of 9 hours will be reduced with more experience.

Moodley and Rennie object that all government efforts related to a penile loss at ritual circumcision should be toward prevention. They claim that to save cost, in the case of treating men who lost their penis from ritual circumcision, the government has no duty to cure at all, but only to prevent, even when the cost is reasonably small and similar or less than that of a renal transplant. However, they do not consider the implications of this objection to other forms of life-enhancing surgeries, such as the laparoscopic bariatric surgery programme or breast reconstruction after mastectomy, routinely performed at this institution. These would be more costly than one or two penile transplantations per year. The argument that is posed by Moodley and Rennie seems to suggest that the costs of penile transplantation should be allocated to a fund that will effectively reduce the penile amputations in ritual circumcisions in South Africa. It is not clear why they argue that the few penile transplantations performed per year and an effective prevention programme cannot coexist.

As is the case with facial transplantation, much emotion is attached to the transplantation of a penis to a previously aphallic man. This can be a very positive or very negative emotion. Agich and Siemionow comment that public had a ‘yuk’ reaction to the potential facial transplant to be performed in the United Kingdom; indeed this backlash was so severe that the Royal College of Surgeons stopped their facial transplant programme temporarily just before the first case could be done.3 In penile transplantation, a similar response might exist. The fact that the transplant relates to genitalia might enhance such ‘yuk’ responses.