need to define to which extent they will be introduced into teaching and learning AI. An enriched metaverse learning environment would blend both physical and virtual worlds. This is to provide the best learning opportunities for students and young professionals in a collaborative setting wherein learning will become decentralized. In the years to come, we should be aware if we are applying critical thinking or paying too much attention to algorithms that make the clinical decisions for us. AI is going to direct us to a world where we will receive information that our profiles predict we deserve to receive, and that is a world that is dangerously self-absorbed and limiting. In my opinion, these are the paradigms that changed urology in the last 50 years and will continue to change it in the near future. Friday 10 March, 15:30 - 15:45 7th International Congress on the history of urology Yellow Area, Amber 7
pathway inhibitors, new classes of molecules such as antisense oligodeoxynucleotides and small interfering RNA (siRNA) are being developed The search for gene mutations that cause some patients to respond better to certain drugs is another field of development along with targeted drugs aimed at proteins produced by specific gene mutations in cancer cells. Benefitting from lessons learned in two decades of clinical trials, functional urology has progressed with a more precise use of pharmacology in controlling prevalent disorders such as lower urinary tract symptoms, urinary incontinence and erectile dysfunction. Evidence-based medicine is increasingly used and patient-reported outcomes are now considered more important than physician reported outcomes. Teaching and practice for the new generation New generations will probably benefit from AI instructors using virtual reality to create immersive learning experiences in an augmented reality scenario, and make productive curriculum materials more individualised for professionals. Educators will
system, and the technical shift from open to laparoscopic robotic radical prostatectomy became a reality worldwide. Early studies indicated that robotic prostatectomy had promising outcomes in short-term oncological control, potency and continence. However, the results of experienced surgeons with radical prostatectomy, following any approach, set high standards in oncologic and functional outcomes. Robotic surgery has helped generalize excellent results in other challenging techniques such as partial nephrectomy and radical cystectomy. To determine the true place of robotics in the surgical podium, validated questionnaires, and analogue assessment scales are essential to determine true functional results and need to be combined with careful long-term oncologic outcomes. Reconstructive urology remains the most classical and one of the most precise surgical fields continually being developed. It is also unique as it serves to restore both structure and function to the GU tract. Multidisciplinary experience, refined surgical technique, use of grafts, flaps, tissue
engineering and scaffolds, meshes and prosthesis make it one of the most interesting fields of current urology for academic surgeons worldwide. Targeted therapy with tailored prediction Until the late 1990s, cancer treatment drugs - with the exception of hormone treatments - worked by killing cells that were in the process of replicating their DNA and cell division. As such, chemotherapy had a greater effect on cancer cells but also killed normal cells. Targeted therapies developed in the 21st century work by influencing the processes that control growth, division, and spread of cancer cells, as well as, the signals that cause cancer cells to die naturally. Targeted therapies work by inhibiting growth signal (hormone-like substances that instruct cells when to grow and divide), inhibiting angiogenesis, and inducing apoptosis (the natural process through which cells with DNA are too damaged to repair and forced to die). As more is learned about the molecular biology of cancer, researchers continue to accumulate targets that will benefit the development of new drugs. Very recently cancer immunotherapy has revolutionized the field of oncology by prolonging survival. Along with monoclonal antibodies and small signalling
Management of floppy glans after penile prosthesis surgery From diagnosis to treatment strategy
the glans of the penis does not stay in the same axis with penile shaft, but droops ventrally, dorsally, or laterally. Two main factors that may be responsible for lack of glans stability are incorrect position of the implant tips and the anatomy of the glans. Real glans hypermobility means the glans droops despite the implant’s cylinders being correctly sited in the tips of the cavernosal bodies (Fig. 1). This may be related to structural anomaly of the corporoglans ligament or tips of the cavernosal bodies being disproportionally narrow in comparison to the glans. Men with erectile dysfunction are described to have thinner corporoglans ligaments in comparison to men with good erectile function. Impairment of corporoglans ligament structure and function can be also related to previous implant surgeries or it’s complications e.g. erosion. FGS results from improper glans support. Etiologically it may be caused by wrong size of the cylinders (too short/long) or malposition of the cylinders (cylinders localized off-centre, distal tunical erosion, proximal perforation, cross-over). It is more common in patients with fibrotic cavernosal bodies e.g. in Peyronie’s disease, post priapism, or re-do surgeries. In these cases dilatation of cavernosal bodies may be difficult and is associated with increased risk of incomplete dilatation, crossover and tunical perforation. Supersonic transporter deformity (SST), named after the silhouette of a Concorde aircraft, is a classic example of FGS presenting as ventral droop caused by undersized cylinders (Fig. 2). Reverse SST deformity is a variant of FGS syndrome, where oversized cylinders press against the ventral tip of the cavernosal bodies and push the glans dorsally causing droop. In most cases, lateral droop should be treated surgically as it is usually a sign of serious complications such as distal perforation, proximal perforation, or cylinders crossover. Diagnosis The first step in diagnostic process is a physical examination with a fully inflated implant. The direction of the droop indicates possible cause of the abnormality. Imaging modalities such as magnetic resonance (MRI) or penile ultrasound (USS) with the inflated device can be helpful. An experienced uro-radiologist is invaluable.
Dr. Marta Skrodzka St. George’s University Hospital, London (GB)
Figure 1. 1a) Real glans hypermobility – ventral glans droop despite correct position of the implant. 1b) MRI image – adequate length of the cylinders seating at the tips of cavernosal bodies.
Figure 2. 2a) Floppy glans syndrome – SST deformity caused by undersized cylinders. 2b) MRI image of disproportionally short cylinders demonstrating a gap between cylinders and cavernosal tips.
drmartaskrodzka@ gmail.com
Prof. David Ralph University College Hospital & St Peter’s Andrology Centre, London (GB)
For real glans hypermobility: The glanspexy is typically used in real glans hypermobility. Several approaches have been described, all based on one principle of glans realignment on the penile shaft. Glans is surgically fixed on the side opposite to the tilt e.g. dorsal anchoring for ventral deflection. (Figure 3) In selected cases, sutures in multiple quadrants can be necessary. Usually (hemi) circumferential incision is used to expose the plane between the glans and the corporal tips. Sutures to fix the glans are inserted with ultimate attention to protect the neurovascular bundle, the urethra and implant cylinders. Penoplasty is an alternative technique for patients preferring less invasive surgery and accepting circumcision. Its principle is based on a Nesbit technique and involves removal of an ellipse of penile skin and dartos from an aspect opposite to the glans deflection to stabilize the glans. The technique does not require exposure of the corpora and minimises operative risks. It can be applied in dorsal and ventral deflections, but it is particularly effective in dorsal and reverse SST deformities. Both techniques have a high success rate. Summary In case of glans engorgement or stability issues, the accuracy of the position and size of the implant should always be assessed before the final diagnosis. Imaging might be helpful, especially with support of an experienced uro-radiologist Conservative therapy can always be attempted before a revision surgery as long as it is safe for the penile structures and the function of the implant. The surgical treatment should be tailored to a clinical scenario. Figure 4. Glanspexy procedure. 4a) Exposure of plane between cavernosal tips and glans. 4b) Careful placement of the sutures. 4c) The final effect.
Figure 3 . Floppy glans syndrome with lateral droop. 3a) Distal perforation; 3b) Proximal perforation; 3c) Cross-over.
david.ralph@nhs.net
proximally during attempted penetrative intercourse or use of a condom to overcome glans hypermobility by stabilising the glans on the tips of the inflated cylinders. If satisfactory for the patient, medical management can help avoid extra surgery and additional complications. B. Surgical correction Surgical intervention should be offered when the device malposition endangers the function of the implant, integrity of tunica albuginea, or creates risk of a urethral injury. It should always be considered in patients whose cylinders are misplaced or not properly sized. For FGS: Revision surgery and correction of the position or size of the cylinders usually resolves the problem. In case of undersized cylinders, revision and supplementation with rear tip extenders or exchange of cylinders into appropriate size is advised. It is very important to incise the old pseudocapsule and re-dilate corporal tips to secure adequate position of distal cylinders. An oversized implant increases risk of erosion. During revision surgery it should be replaced with the correct size cylinders. Usually additional manoeuvres are not necessary and the old pseudo-capsule can be used as long as cylinder tips are not positioned off-centre. In case of cylinder tips being placed too superficially (off-centre), the same strategy is used as in undersized cylinders. It includes incision of the old pseudocapsule and re-dilatation of corporal tips to provide central cavernosal space for cylinders. The same rules apply to cross-over or cylinder perforation. In extreme cases additional strengthening to tunical integrity may be necessary. In cases of minimal cylinder over/undersizing, glanspexy can be offered (details are described in section below). This is a less invasive option which minimizes the risk of infection in comparison with implant revision.
Penile implant insertion by large volume surgeons is associated with low risk of complications and the patients’ satisfaction rates, which exceed 95% in most published series. Although penile prosthesis implantation provides excellent axial rigidity of the shaft, patients need to be aware that the erection with penile implant may differ in certain aspects compared to natural erection. In particular, patients may notice a lack of engorgement, hypermobility, or floppiness of the glans penis. The classification of glans disorders is presented in Table 1. Characteristics Soft glans syndrome Compromised glans engorgement in patients with erectile dysfunction Real glans hypermobility Diagnosis Instability of the glans after penile implant insertion despite good position and size of the cylinders Floppy glans syndrome Instability of the glans after penile prosthesis insertion due to: - P oor position of the cylinders (cross-over, tunical perforation, other) - Implant undersized or oversized Table 1. Classification of glans disorders following penile prosthesis insertion Glans issues may cause patient dissatisfaction due to difficulties during penetrative sex, painful intercourse, and a poor cosmetic result. These may prevent the patient from using an otherwise fully functional implant. Soft glans is defined as lack of appropriate engorgement of the glans spongiosum. Patients may complain about cold glans, compromised sensitivity, and penile length as it may be perceived as shorter. This may cause partner complaints and dissatisfaction. Glans deflection is not observed, but soft glans may contribute to a floppy glans phenomenon. Floppy glans syndrome (FGS) and real glans hypermobility have similar clinical presentation. They are observed when the cylinders are fully inflated and
Treatment A. Conservative management
Conservative management includes PDE-5 (5-Phosphodiestherase type 5) inhibitors,
intraurethral alprostadil, and vacuum erectile device. It aims to support glans engorgement. Non-surgical treatment may be helpful in cases of soft glans, real glans hypermobility, and floppy glans syndrome, as long as there is no risk of damage to tunica albuginea and urethra or of an implant’s function impairment. It may increase satisfaction from penile prosthesis and in some cases, improve sensation of the patients who complain of cold glans. In mild cases, some authors advise pulling the foreskin
Saturday 11 March 11:31 - 11:41 ESAU Meeting: Disorders in reproductive and sexual health Pink Area, Coral 6
European Urology Today
February/March 2023
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