Plenary Session 2-1

Ho-Yee TiongSingapore Moderator Living kidney donation with AI - Augmented or ArtificialAt the National University Hospital, we have utilized AI to try improving our pre-operative and peri-operative management of our patients for donor nephrectomy. This presentation shares the benefit of the learning experience of using AI through a standardized procedure like donor nephrectomy.

Tatsuo KawaiUnited States Speaker Overview and Recent Advancement of Renal Xenotransplantation(TBC)

Damien BoltonAustralia Moderator

Brian K. LeeUnited States Speaker Genetic Testing in the Evaluation of Recipient Candidates and Living Kidney DonorWith the advent of more affordable next generation sequencing with ever faster turnaround times, precision medicine has taken on a more prominent role in clinical practice. This has meant that when determining the most appropriate course of action when evaluating potential kidney transplant recipients, genetic ascertainment of the underlying cause of their ESKD/CKD has become an increasingly indispensable tool. At the same time, related living kidney donors, especially those who are young, and who may not have any manifestations of renal symptoms can now be genetically tested to reassure transplant professionals and donors and their families that they are unlikely to harbor a hereditary condition that could jeopardize their future renal function. And yet the interpretation of genetic testing results is not part of the regular nephrology/transplant curriculum, and many centers do not have readily accessible medical geneticists or genetic counselors at their disposal, making the appropriate triaging of recipient and donor candidates alike somewhat of a black box. Through this session, we hope to elucidate the tough decisions and triumphs that comes with recognizing both the powers and the limitations of using genetic tests in transplant recipient and donor evaluations. Non-Invasive Immune MonitoringThe success of kidney transplantation is dependent on the close monitoring of kidney function and the net immune status of the host recipient. Traditional biomarkers such as serum creatinine are unreliable at best, often lagging behind histologic evidence of anti-graft activity when protocol biopsies are performed which could jeopardize opportunities for clinicians to intervene timely. Surveillance renal allograft biopsies have been employed in an attempt to match clinical outcomes with histologic findings, but this invasive procedure could lead to bleeding complications and is time- and labor intensive. Better immune monitoring has recently become more widely adopted in transplant practice, and its introduction could allow closer follow-up of the recipient and shed light on the state of immune milieu.

Cheng-Kuang YangTaiwan Moderator Robotic Radical Prostatectomy: Trying to Fit the Right Surgery to the Right PatientDefinitive treatment for localized prostate cancer included radical prostatectomy and radiation. Successful criteria of radical prostatectomy have to meet oncology control, not persistent PSA after surgery without salvage therapy. MRI imaging stage and PSA density are predictors for short‐term BCR after prostatectomy. NCCN‐defined high‐risk patients with a high initial PSA 28 density, imaging stage (T3aN0M0 and T3bN0M0), and 29 pathologic stage (any N1) had a higher risk of BCR when 30 compared with other patients with undetectable PSA, while 31 those with pathologic stage (T3bN0M0 or any N1) displayed 32 a higher risk of postoperatively detectable PSA. These find‐ 33 ings may help urologists to identify patients for whom active 34 therapeutic protocols are necessary.

Alvin WeeUnited States Speaker How to Build Up a Strong Kidney Transplant Program with Continuing Growth?Transplantation is one of the most complex, highly regulated, multidisciplinary fields in medicine, requiring the coordination and dedication of a highly skilled and collaborative team. At this conference, we’re honored to share our journey—highlighting the challenges, milestones, and strategic innovations that have shaped our transplant program. Through intentional planning, data-driven practices, and a strong team culture, we’ve grown to become the leading transplant center in the nation, recognized for both volume and quality outcomes. Our hope is that by sharing our experience, we can contribute valuable insights to the transplant community and support others in advancing excellence in patient care. Robotic Kidney Transplantation: The Way to Go?!The utilization of robotics in urologic surgery continues to grow, offering enhanced precision, improved outcomes, and faster recovery times. In the field of kidney transplantation, robotic-assisted techniques are now gaining significant momentum. The Cleveland Clinic Main Campus has emerged as the largest single center performing robotic-assisted kidney transplants annually—not only in the United States but also worldwide. With this unparalleled experience, we are well positioned to share key advantages we have observed over traditional open surgical methods. As robotic technology continues to evolve, our experience reinforces its growing role in transforming the field of kidney transplantation and improving patient outcomes.

Wei-Kung TsaiTaiwan Moderator

Tom LueUnited States Speaker Recent Advances in ED: Bridging Innovation and Clinical PracticeRecent Advances in ED: Translating Innovation to Patient Care Tom F. Lue, MD, ScD(Hon), FACS, University of California, San Francisco, USA Ischemic priapism and Peyronie’s disease are two longstanding challenges in urology. When not promptly and appropriately managed, both conditions frequently result in erectile dysfunction. This presentation will review the underlying pathophysiology of each condition and highlight recent innovations that have significantly advanced our clinical approach and improved patient outcomes. Ischemic Priapism Pathogenesis and Management of Ischemic Priapism Although ischemic priapism can result from a variety of underlying conditions, they all converge on a final common pathway: paralysis of the intracavernous smooth muscle, leading to veno-occlusion and cessation of arterial inflow. This vascular stasis causes tissue ischemia, which, if not promptly reversed, progresses to necrosis, fibrosis, and ultimately erectile dysfunction. When priapism is identified within 24 hours, initial management typically includes aspiration of the old cavernosal blood combined with intracavernosal injection of alpha-adrenergic agents such as diluted phenylephrine. These agents stimulate smooth muscle contraction, promoting restoration of venous outflow and arterial inflow. However, once priapism extends beyond 24 hours, prolonged ischemia leads to marked tissue edema, severe smooth muscle dysfunction, and thrombosis of subtunical venules. At this stage, the efficacy of alpha-adrenergic agents is greatly diminished or absent, and surgical intervention becomes necessary. Various shunting procedures have been described to re-establish cavernosal blood flow by diverting it through the glans, corpus spongiosum, dorsal vein, or saphenous vein. In some cases, intracavernous dilation procedures are employed to re-open the proximal-to-distal corporal channels and facilitate drainage through the shunt. These advanced measures aim to salvage erectile tissue and prevent long-term dysfunction. Why Do Many Shunting Procedures Fail? Within the body, exposed collagen acts as a key trigger for blood clotting. Shunting procedures create an opening in the tunica albuginea to divert blood flow toward the glans, corpus spongiosum, or the penile or saphenous veins. However, this procedure exposes collagen fibers in the tunica and surrounding injured erectile tissue, which initiates the coagulation cascade. As a result, blood clots can form within the shunt, causing its closure and leading to recurrence of priapism. Innovation: Peri-Shunting Antithrombotic Therapy Over the past decade, for priapism lasting more than 24 hours, we have routinely administered aspirin combined with low-dose heparin prior to shunting procedures— T-shunts, with or without intracavernous dilation. This is followed by a five-day regimen of aspirin and clopidogrel to maintain shunt patency during the critical post-ischemic hyperemia phase. Using this approach, we have effectively reduced the rate of priapism recurrence to approximately 10%. Peyronie’s disease Pathogenesis Peyronie’s disease (PD) results from a complex cascade of molecular, cellular, and structural changes that cause fibrosis—with or without calcification—in the tunica albuginea, septum, or intracavernous struts of the penis. These fibrotic plaques decrease the tunica’s elasticity, leading to penile curvature, indentation, hourglass deformity, or shortening during erection. The resulting biomechanical disruption, along with the psychological distress it may cause, can contribute to erectile dysfunction. Innovation-Enzyme-based Injection therapy Xiaflex (collagenase clostridium histolyticum) is an enzyme-based injection therapy approved by the U.S. Food and Drug Administration (FDA) for Peyronie’s disease in December 2013. Administered via intralesional injection directly into the fibrotic plaque, Xiaflex contains enzymes that break down disorganized collagen and elastic fibers, gradually reducing and eliminating the plaque. However, injection alone typically does not produce significant correction of the deformity without a subsequent modeling procedure. This procedure—performed manually or with devices such as RestoreX, PeniMaster Pro, or Andropenis—serves as a tissue expansion tool to promote remodeling of the normal tunica, helping to restore penile length and girth. Over the past 11 years, the author has performed more than 11,000 Xiaflex injections and considers this approach superior to surgery for several reasons: (1) It eliminates plaques without creating new plaques, unlike surgical excision or incision with grafting; (2) It facilitates increases in penile length and girth through modeling, in contrast to the shortening often seen after plication procedures; (3) It avoids neurovascular damage and does not cause erectile dysfunction.

Mohamed Salim Al-MarhoonOman Moderator

Geng-Long HsuTaiwan Speaker Penile Fibro-Voruilon Assembly and Venours Stripping Surgery for EDBackgrounds: Humans have existed on earth for 3000 centuries, so does penile fibro-vascular assembly, which is an exclusive milieu for applying Pascal's law if there is no veno-occlusive dysfunction (VOD), or older-termed venous leakage. The corpora cavernosa (CC), incorporated distal ligament, is the primary compartment for establishing bony rigidity. Despite extensive studies for centuries, the medieval illustration of penile fibro-vascular anatomy has prevailed in literature since 1519. Consequently, it has been unsuccessful in all derived penile reconstructive strategies, particularly the merit of penile venous surgery, which has been disputed since 1895, when Duncan introduced it in the United States. Recently, a penile fibro-vascular assembly was proven to be an independent compartment in the cardiovascular system. We sought to report on the male potency reconstructions, specifically the penile venous stripping for erection restoration, refined chronologically since 1985, in Taiwan. Methods: Reviewing a four-decade journey, reciprocating between penile fibrovascular anatomy and Taiwanese penile venous stripping surgery (PVSS) strategy, from the 1986 prototype to the USPTO patent version in August 2012, we reviewed a vast repository in our 3488 surgeries since 1986. Under acupuncture-assisted local anesthesia, the acupoints of Hegu (LI4), Shou San Li (LI10), and Waiguan (TE5) are chosen routinely. All patients received dual cavernosography in which a pilot cavernosograpy demonstrated the innovative, intriguing penile venous anatomy, a PGE-1 test in between, and a pharmaco-cavernosography documented a veno-occlusive dysfunction (VOD). Among them, 3488 PVS surgeries had been performed. Neither an electrocautery nor a suction apparatus is used. All surgeries were conducted on an ambulatory basis with acupuncture-assisted local anesthesia. PVSS entailed the venous stripping of a deep dorsal vein and a pair of cavernosal veins after every emissary vein was fixed firmly closest to the outer tunica albuginea with a 6-0 nylon suture. Meanwhile, segmental ligation was conducted on two pairs of para-arterial veins. Routinely, postoperative cavernosograms were obtained for comparison. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) were used to confirm improvement in preoperative and postoperative follow-up via the INTERNET yearly. Statistically, the Wilcoxon signed rank test and Fisher's exact test were used as necessary. Results: The operation time is 4.7±1.4 hours, varied widely between 3.5 h and 7.5 h with a mean of 4.7h. , and the blood loss is 15.8±4.6 mL. There was a significant difference (both P＜0.01) in preop. And postop. IIEF-5 and EHS scores (9.7±2.8 vs. 20.8±2.3; 1.7±0.6 vs. 3.2±0.2, respectively. Although the intracorporeal retention and erection quality improvement were profound unexceptionally, improved rate was defined as an IIEF-5 increasement of 3 scores out of 25 and EHS up warding at least one scale; accounting for 50.0 to 95.7%; however, the gratifying rate varies between 55.5% to 85.8% with available follow-up for longer than a decade. In the adolescent-onset impotence, natural coitus can be achieved in 3 out of the five patients. Discussion and conclusion: Given that refractory ED prompted most patients to seek our PVSS, it is noteworthy that PVSS appears to be beneficial to most ED patients of all ages. Particularly, with an ultimate understanding of penile fibrovascular assembly involving the erection veins and apagogical erection process through hemodynamic research via fresh and defrosted cadaveric penises, Taiwanese PVSS warrants spreading to young surgeons. Take-home message: The conventional penile anatomy is merely one circumferential layer model of tunica albuginea surrounding the corpora cavernosa (CC) and one deep dorsal vein draining corporeal blood; as evidenced by research, innovative terms such as erection-related veins, penile venous stripping surgery (PVSS), and penile fibro-vascular assembly are underpinned and implemented in Taiwan. Human penile fibrovascular assembly involves the fibrous bi-layered tunica albuginea model with a 360° inner circular and 300° outer coat surrounding the CC; the erection-related veins are one deep dorsal vein (DDV), two cavernosal veins (CVs), and four para-arterial veins. Each vein has emissaries connecting to the CC sinusoids. The relationship between DDV, CVs, and emissaries resembles that of rattan root nodes to a yam vine: multiple smaller yams can sprout if the root remains intact, which occurs at the expense of the main vine's ability to support a single giant yam; this agricultural principle guided the design of our PVSS approach. Taiwanese PVSS requires neither electrocautery nor suction apparatus. Although most of the medical community worldwide does not agree with it, PVSS is beneficial in correcting veno-occlusive dysfunction and has outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually negated with the venous ligation technique superseding venous cautery. Despite not being agreed upon in most of the medical community, penile venous stripping surgery is beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually negated with the venous ligation technique superseding venous cautery. Although many urological surgeons regard the PVSS surgery niche as unreachable, it is achievable, akin to the capability of performing microsurgery on a small rat. Taiwanese PVSS is likely the exclusive physiological way to ensure erection restoration and a natural way of glans expansion. So PVSS, which ought to decline AI assistance, should be shared with young surgeons. Key Words: cavernosal vein, erectile dysfunction, deep dorsal vein, para-arterial vein, veno-occulusive dysfunction, penile venous stripping surgery, penile fibro-vascular assembly, erection-related veins References: 1. Hsu, G. L., Chang, H. C., Molodysky, E., Hsu, C. Y., Tsai, M. H., Yin, J. H., & Chen, M. T. (2025). A detailed analysis of the penile fibro-vascular assembly. The journal of sexual medicine, 22(2), 225–234. https://doi.org/10.1093/jsxmed/qdae177 2. Cho-Hsing Chung, Ko-Shih Chang, Heng-Shuen Chen, Yi-Ying Hsieh, Yu-Hsiang Chang, Geng-Long Hsu, Mang-Hung Tsai, Jeff SC Chueh. Combining Erection Restoration and Factual Penile Enhancement Based on Revolutionary Penile Fibrovascular assembly. Journal Archivos Españoles de Urología, accepted 2025. 3. Cho-Hsing Chung, Heng-Shuen Chen, Yi-Ying Hsieh, Geng-Long Hsu, Cheng-Hsing Hsieh, Ta-Chin Lin, Jeff SC Chueh. Strategy for salvaging the shrinkage soft glans penis and impending prosthesis loss in patients with a penile implant: A case report. Journal Archivos Españoles de Urología, accepted, 2025. 4. Geng-Long Hsu: Physiological Approach to Penile Venous Stripping Surgical Procedure for Patients with Erectile Dysfunction (Patent No: US 8,240,313B2). http://www.google.com/patents/US20110271966 5. Chang KS, Chang YK, Chung CH, et al Emergent Penile Venous Stripping for Treating Adolescent Impotence. Life 2024, 14, 762. 6. Chang KS, Chung CH, Chang YK, et al., Coil Embolization Is Not Justified for Treating Patients with Veno-Occlusive Dysfunction: Case Series and Narrative Literature Review." Life (Basel, Switzerland) 2024; 14:911-23. https:// doi.org/10.3390/life14070911 7. Hsieh CH, Huang YP, Tsai MH, et al. Tunical Outer Layer Plays an Essential Role in Penile veno-occlusive Mechanism Evidenced from Electrocautery Effects to the Corpora Cavernosa in Defrosted Human Cadavers. Urology 2015; 86:1129-1136. 8. Hsu, G-L., & Lu, H-C. (2018). Penis Structure—Erection. In M. K. Skinner (Ed.), Encyclopedia of Reproduction. vol. 1, pp. 367–375. Academic Press: Elsevier. http://dx.doi.org/10.1016/B978-0-12-801238-3.64603-2 9. Hsu GL, Hill JW, Hsieh CH, et al. Venous ligation: A novel strategy for glans enhancement in penile prosthesis implantation. BioMed Research International Volume 2014 (2014), Article ID 923171, 7 pages http://dx.doi.org/10.1155/2014/923171 10. Hsu GL, Hung YP, Tsai MH, et al. Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers. J Androl 2012; 33:176-185. 11. Hsu, G-L. (2018). Erection Abnormality. In M. K. Skinner (Ed.), Encyclopedia of Reproduction. vol. 1, pp. 382–390. Academic Press: Elsevier. http://dx.doi.org/10.1016/B978-0-12-801238-3.64374-X (Invited) 12. Hsu, G-L., & Liu, S-P. (2018). Penis Structure. In M. K. Skinner (Ed.), Encyclopedia of Reproduction. vol. 1, pp. 357–366. Academic Press: Elsevier. http://dx.doi.org/10.1016/B978-0-12-801238-3.64602-0 (Invited) 13. Hsieh CH, Huang YP, Tsai MH, et al., Tunical Outer Layer Plays an Essential Role in Penile veno-occlusive Mechanism Evidenced from Electrocautery Effects to the Corpora Cavernosa in Defrosted Human Cadavers. Urology, 2015, volume 86, issue 6, pages 1129-1136. 14. Hsieh CH, Chen CW, Hung Meng Huang, et al. Penile venous stripping surgery is a viable option for erectile dysfunction after unsuccessful vascular interventions. Clin. Pract. (2017) 14(1): 86-94. 15. Heng-Shuen Chen, Chu-Wen Fang, Raymond WM Tsai, Chih-Yuan Hsu, Geng-Long Hsu1, Hsiu-Chen Lu, Mang-Hung Tsai, Jeff SC Chueh. The Human Penile Fibro-vascular Assembly Requires the Integrity of Ten Fibro-ligaments. Life submitted, 2025.

Norio NonomuraJapan Moderator

William J. HuangTaiwan Speaker Male Infertility: Challenges and Opportunities in AsiaMale infertility contributes to nearly 50% of all infertility cases, with an increasing burden observed across Asia. In parallel, a dramatic decline in birth rates has emerged in several Asian countries—including South Korea, Japan, Taiwan, and Singapore—reaching historically low total fertility rates (TFRs) of under 1.0. While multifactorial in nature, this demographic crisis underscores the urgent need to address all aspects of reproductive health, including the often-overlooked role of male infertility. Epidemiological data reveal significant regional disparities in the prevalence, diagnosis, and treatment of male infertility. Cultural stigma, limited andrology training, fragmented referral systems, and inadequate coverage of assisted reproductive technologies (ART) have impeded timely diagnosis and intervention. Environmental exposures, endocrine-disrupting chemicals, occupational heat, and increased paternal age have all been linked to declining semen quality, as evidenced by longitudinal studies showing decreased sperm concentration and motility in several urban centers across Asia. Current diagnostic tools—including semen analysis, hormone profiling, genetic testing (e.g., Y-chromosome microdeletion, karyotyping), and imaging—enable better etiological categorization. Microsurgical sperm retrieval techniques such as mTESE have provided new hope for patients with non-obstructive azoospermia, while ICSI and sperm cryopreservation have become increasingly utilized where available. Nevertheless, access remains inconsistent, particularly outside metropolitan regions. Recent integration of AI-based systems for semen evaluation, patient triage, and digital counseling offers promising strategies to improve care delivery, especially in under-resourced settings. However, data privacy, regulatory standards, and user trust continue to pose barriers to widespread implementation. Opportunities for systemic improvement include the development of regional male infertility registries, integration of andrology into national reproductive health frameworks, expansion of insurance coverage for fertility services, and public awareness campaigns to destigmatize male infertility. In light of Asia’s fertility decline, repositioning male reproductive health as a public health and demographic priority is essential for sustainable population policy and long-term healthcare planning. The Peri-Operative Care of MIST For Prostate HyperplasiaMinimally invasive surgical therapies (MIST), particularly UroLift and Rezūm, have transformed the treatment landscape for benign prostatic hyperplasia (BPH), offering effective symptom relief with reduced morbidity and preservation of sexual function. However, optimal outcomes depend not only on procedural execution, but also on well-structured peri-operative care protocols encompassing pre-, intra-, and post-operative management. Pre-operative evaluation includes comprehensive assessment of prostate anatomy—especially size, shape, and presence of median lobe—via imaging (TRUS or cystoscopy) to determine candidacy. Careful patient selection is essential: UroLift is typically suited for prostates <80 cc without obstructive median lobes, while Rezūm accommodates broader anatomical variability but may have delayed symptom resolution. Baseline symptom scores (e.g., IPSS), uroflowmetry, and post-void residual volume establish functional benchmarks and guide patient counseling. Anesthesia planning must consider procedural setting and patient comorbidities. UroLift can often be performed under local anesthesia with light sedation, whereas Rezūm may require short general anesthesia or deeper sedation due to thermal discomfort. Appropriate selection reduces intraoperative stress and facilitates same-day discharge. Intraoperative care focuses on minimizing trauma and ensuring device precision. UroLift requires accurate deployment of implants to maintain lateral lobe retraction without compromising sphincter integrity. In Rezūm, the number and duration of vapor injections must be titrated based on lobe size and configuration to balance efficacy and tissue inflammation. Real-time visualization and standardized protocols reduce variability and improve safety. Post-operative management involves anticipating and controlling transient irritative symptoms, such as dysuria, urgency, and hematuria. Alpha-blockers and anti-inflammatory medications are commonly used for 3–7 days post-procedure. Catheterization strategies differ by technique: UroLift may avoid catheter use entirely, whereas Rezūm often requires 7-14 days of catheter drainage due to anticipated edema. Monitoring for urinary retention, UTI, or clot obstruction is critical during the early recovery phase. Follow-up care typically occurs at 2–4 weeks and includes reassessment of voiding function, symptom scores, and patient satisfaction. Reinforcement of realistic expectations is especially important with Rezūm, which may take 4–6 weeks to achieve peak efficacy. Longitudinal studies indicate sustained symptom relief and low retreatment rates when peri-operative care is standardized and patient education is emphasized. Adverse event profiles differ between techniques: UroLift is associated with less dysuria but higher retreatment rates in large prostates, while Rezūm presents higher rates of transient discomfort but favorable durability. Structured peri-operative care pathways—including patient education, standardized medication protocols, and clear complication management plans—enhance recovery, minimize adverse events, and improve overall clinical success.