José María Gil-Vernet Sedó (Barcelona, 1957) first graduated in Pharmacy at the University of Barcelona (UB) and then in Medicine and Surgery at the Autonomous University of Barcelona (UAB). Next came the MIR exam and the urology residency stage at the Hospital Clínic in Barcelona. Dr Gil-Vernet Sedó belongs to the last of three generations dedicated to the study of urology. His grandfather, Salvador Gil Vernet, his father, José María Gil-Vernet Vila, and he himself have all been pioneers in the most commonly used modern techniques for treating urinary system conditions.
In addition to his research, he also works as a physician and a surgeon. He recently brought the memory of his grandfather back to life in a beautiful book of scientific dissemination, titled The Art of Transforming Science. We’re sitting down with José María in his practice at the Quirón Teknon Hospital to talk about his grandfather, the exciting prostate world, and to answer all our questions about the male genital system, surrounded by wonderful artistic laminates depicting the detailed dissections of the urinary system.
Photos: Jorge Quiñoa
You come from three generations of urologists. Tell us a bit about your grandfather. Who was Salvador Gil Vernet?
Salvador was always very passionate about biology. As a child, when he was finishing school in Tarragona and returning to Vandellós, he would spend his holidays having fun, classifying and studying a wide range of plants using a botany identification key. His grand ambition was to become a Professor of Natural Sciences. He studied the baccalaureate at the Tarragona General and Technical Institute. He was a good student, and his grades were excellent. After finishing high school, and for reasons unknown to me, he switched from botany to medicine. His parents, Josep and Ángela were illiterate and worked as farmers tending and working the land of Jaime Vernet, a landowner and cousin of Salvador’s mother. Jaime, who didn't have any children, left them his whole fortune with the sole condition that they gave each of their four children a career or profession. This man really made it possible for both my grandfather Salvador and his brother Emilio to become doctors.
What were his early years as a university student like?
He arrived in Barcelona aged 17 and started studying at Medical School, and that’s when his interest in anatomy emerged, which is hardly surprising because a good biologist is passionate about morphology. He used to observe and classify plants with a linen tester, and he was now looking at human corpses. The change can’t have been easy, but after spending long hours dissecting, his teachers identified his excellent skills and offered him the chance to do increasingly complex dissections, and from there he entered the Department of Anatomy as an assistant professor and an internship tutor. We have a photo from that period in which, alongside his students, he’s completing a dissection on what was a small extension of the old cemetery of the former Santa Cruz hospital. In 1920, he sat his first ‘oposiciones’ (Spanish civil service entrance exam) with Santiago Ramón y Cajal as president of the tribunal, but didn’t pass. He resat at the next opportunity, and obtained the professorship of anatomy at the University of Salamanca and then won the contest for transfer to the University of Barcelona, where he would also head the Urology Clinic at the Hospital Clínico y Provincial.
At that same time in Barcelona, there was another great urologist, Antonio Puigvert. Both represented different concepts within the field, and led two diverging medical trends that have been continued by their disciples. What did these diverging trends consist of?
Okay, my grandfather was an anatomist and not just a urologist. He viewed urology more scientifically, closer to its biological bases, to ethiopathogeny and pathological anatomy, i.e. which doesn’t just focus on clinical urology but is also very interested in establishing the scientific bases for the field. He was 50 years ahead of his time in terms of what we currently call Urology. Puigvert covers the field of practical urology, with significant contributions in the study of renal tuberculosis and urological endoscopy. My grandfather mapped out, based on a precise knowledge of topographic, microscopic and comparative anatomy, new surgical techniques and was therefore able to design surgical techniques that would be less aggressive, less deforming and more effective. In anatomy and physiology, a limited view of the medical field can block certain biological perspectives, so Salvador would say: “I’m a doctor, and I’ll apply my knowledge as such, but I also want to know.” He wanted to know more about the biology and physiology of the bladder and the prostate, he was interested in not just the what and the why, but also the what for.
What theoretical contributions were there? What surgical techniques did your grandfather leave us? Is it true that he was a Nobel prize candidate on several occasions?
I’ve read about the Nobel in several places, but I don’t have a formal documented record. Salvador was President, the only Spanish urologist to achieve such an honour, of the International Urology Society for several years, from 1967 to 1973. At that time, prostate operations were done by perineal excision, and with the techniques used, urinary incontinence and sexual impotence were common after effects. So, he sought to develop new techniques that didn’t damage the sphincter, and that spared the erection nerves - the cavernous nerves. How was this done? By studying and dissecting corpses and realising that what was published in anatomy books was not, in fact, accurate. That was a big leap forward, because it was thought, at the beginning of the twentieth century, that descriptive anatomy was complete. He realised that the macroscopic dissection of the corpse was already outdated, and began to study the microscopic anatomy of the urogenital region, with major discoveries in the muscle of the bladder and the urethra, and in the neuroanatomy of the pelvic plexus and the cavernous nerves. He wanted an anatomy that explained the functioning of the bladder, which muscles contracted and which muscles relaxed. He was getting close to the function, and this proximity to the function and its prospects in the clinic made his works really impressive, not just in their scale but also in their depth. Salvador therefore proposed to systematise the prostate to the exact millimetre, and with the help of the microscope, he realised that in the prostate there are different zones: a cranial zone, an intermediate zone and a caudal zone. For the first time in history, an anatomic model of the prostate was described, a model that would soon be copied by English-speaking physicians. His works are currently cited in scientific literature, and so far this century, there have been over twenty references in books and journals. Not many researchers age so well!
For a long time, these advances in anatomy had been down to English-speaking physicians...
There was a piece I published in the European Journal of Anatomy a few months ago, where I compare the two regional anatomy models of the prostate, and even some of the terms used are the same. My grandfather described three zones, the cranial and the caudal, and between both a transition zone, which he called the intermediate gland. After fifteen years, a North American pathologist would call it the transition zone. What a coincidence, right? And the funny thing is, he never cited Salvador’s works in his bibliography. This anatomical model would continue, and was improved with the English-speakers’ work, but the point is his works, particularly those describing the prostate anatomy, were plagiarised. It’s the consequence of what López Piñero, the medical historian, calls ethnocentrism. Ethnocentrism is thinking that the social and scientific advances in your country are the only ones that mater. This did a lot of damage, especially to Cajal and Spanish medicine at the beginning of the 20th century, because anything that wasn’t published in German, French or English wasn't read.
Your father also devoted himself to this, and was the first man to perform a kidney transplant in Spain, the first testicle transplant and the first pancreas transplant. What did your father represent for the world of transplants?
I think he was only missing the liver transplant. He is a great surgeon; my grandfather was a great morphologist and my dad took this legacy and added all this knowledge of topographic anatomy to surgery. He's always been very skilled, and managed to create numerous surgical techniques based above all on the morphological and functional knowledge that my grandfather had previously described. From there, he developed numerous surgical techniques in kidney stone treatment, and in replacing the bladder with segments of the intestine, in urethra surgery, in kidney transplants, etc.
Rafael Matesanz, when we interviewed him, told us that the first transplants were done by the nephrologists. What impact has urological surgery had on organ transplants?
A transplant is always performed by a urological surgeon, and not a nephrologist. Nephrologists are vital because they control kidney function, electrolyte balance and the immunosuppressant treatment, which prevents rejection. It was a team of nephrologists led by Antonio Caralps, and of immunologists led by Jordi Vives, who were alongside my father for the landmark first successful kidney transplant in Spain.
Some say that the nephrologist is a urology physician. How are these two specialists related? What is a nephrologist?
The term “urology” was coined by a French doctor, Leroy d’Etiolles, in the mid-19th century. Previously, it was known as diseases of the urinary tract. Nowadays, urology is a medical and surgical field of expertise covering the whole urinary system, both in men and women, from the kidney to the urethra, and also concerns the male genitalia; its areas of interest are now so far-reaching that they split into numerous sub-specialities (edourology, urological oncology, urodynamics, kidney transplant, andrology, etc.). Nephrology is a medical field, not a surgical one, which broke off from internal medicine and in the selection and preparation of patients for kidney transplants; it also covers glomerulonephritis.
In 1995, you wrote a chapter on “Renal colic in emergency treatment”. Your father, I think, had also published, in 1965, “New surgical concepts in the elimination of kidney stones.” What differences are there between when your father’s paper was published, and when your one was published? How has kidney stone surgery evolved?
When he started, in the 1950s, with kidney stone surgery, endoscopic surgery for kidney and ureteric stones didn’t yet exist. Kidney surgery was very aggressive back then, because on many occasions it required damaging the parenchymal to be able to extract the stone. My father discovered, after anatomic studies, that through the renal sinus, the renal calyxes could be reached without crossing the parenchymal and it was possible, this way, to extract the stones without damaging the kidney tissue. From the 80s onwards, extracorporeal shock-wave lithotripsy emerged, along with percutaneous renal surgery and ureteroscopy, the latter developed by the Spanish urologist Enrique Pérez-Castro. Now, with flexible ureteroscopy, we can navigate through the ureter and reach the pelvis and the kidney calyxes where, using a laser, we can break the stones into a fine grit and then extract them. The next task is to find out how the stones are formed, and how to prevent it. There’s still a great deal of research to be done in the field. We need to know which metabolic and genetic changes take place in the biology of the nephrolithiasis.
You have a paper where you tackle this exact problem. Is research carried out on how the stones are created, or are there no theories for orientation?
There are several theories, and from a physico-chemical perspective, we know how they are formed, but the problem is how to prevent stone formation, how we can help prevent them. We must consider that kidney stone formation is a disease in wealthy countries and is directly related to sedentary lifestyles and obesity. Think about the fact that during war and post-war, there are hardly any stones, due to the lack of food and, specifically, the scarcity of proteins derived from animals. In third world countries, which have rice and vegetables as a staple diet, there are hardly any kidney stones. We know that an excess of proteins from animals and salt, and a reduction in the consumption of fibre, fruit and vegetables, predispose people to kidney stones.
Ortega y Gasset wrote that: “the 20th century was going to be time when the body, flesh, reclaimed its value,” and look how it became true; beauty, cosmetic surgery, the gym, body-building, etc. It really was a century when the cult of the body was extremely important. This trend of consuming animal protein excessively to strengthen muscles, to get a perfect body, resulted in us witnessing a significant increase in the incidence of this disease.
And vegans?
Vegans have less kidney stones because they only eat plant protein and consume whole grains, fruits and vegetables abundantly. The daily amount of protein from animals that we consume in the first world is excessive. We consume protein from meat, fish, eggs, cold meats, etc. It’s outrageous. This excess means the kidney removes more calcium, oxalate and uric acid in urine and all this causes stone formation.
With such famous relatives, how did you decide to follow in their footsteps? Did you feel intimated or were you confident?
I studied at the Jesuit School in Sarriá and had some chemistry and biology teachers who were really outstanding. Their influence was decisive when deciding which degree I was going to study. In the end I choose a mix of chemistry and biology, a Pharmacy degree, a subject that covered both subjects. I finished Pharmacy and, after working for a few months with a research grant on antiplatelet medicines in the pharmaceutical industry, I saw that the lab wasn’t my cup of tea and that same year I enrolled in the UAB School of Medicine. I completed Medicine in five years because with the validations, I could do my first and second year during the same academic year, with just the Anatomy I and II and Psychology courses. Then came the MIR exam and the Urology residency period at the Hospital Clínic, Barcelona.
As well working as research in your early days, then as a physician, a surgeon, you came to enter the world of dissemination. You recently showcased The Art of Transforming Science. What’s the book about? Why is it in English? Is it paying homage to your grandfather? Tell us a bit about the book.
The drawings, diagrams and notes my grandfather had in his house were graphical material of the highest quality that, in addition to the scientific utility, many were printed in his books and had incredible artistic value. Over these last few years, I have been collecting and cataloguing all the material that was found in my grandfather’s house, and what appeared abandoned and in poor condition at the Hospital Clínic and the School of Medicine during renovation works carried out in the 80s, and sadly, many drawings were lost. The problem was that the drawings were not catalogued, and some just had a letter and a code, with no description. I had to check what each drawing represented and which cut/dissection it corresponded to, if it was a cut on a coronal, sagittal, transverse, etc. plane. This required knowing other data: what technique was the cut performed with, if it belonged to a foetus or an adult, if it was a normal part or a pathological part, etc. There was also a huge collection of topographic anatomy done by two draughtsmen hired by the School of Medicine. They were professional medical illustrators. One was F. Núñez, probably the best urology draughtsman of the 20th century, and who we know very little about. I don’t even know his first name, or if he’s alive or not. If he’s alive, he must be about 94, like my father. F. Núñez drew with the same ability as Max Brödel, who was star illustrator at the John Hopkins University in the United States.
We don’t know who he is?
We know he was Argentinian. I hired a private detective and he found one of his drawings, of a musician playing a violin, but there’s nothing else. If anyone reading this interview has met him or knows anything about him, it would be great to get some help, to be able to send his grandchildren what their grandfather did. It’s not fair that they haven’t seen it.
Let’s see if we manage to find him, right?
We haven’t been able to so far. He worked in the School of Medicine and had a draughtsman’s ID card issued by the University of Barcelona. You can’t just walk in off the street and enter a necropsy room, not even the surgeons can. He needed some ID. We sent a researcher from the publishing house to search the university archives, but he didn’t find anything. It's a shame, because Núñez’s drawings are, along with Max Brödel’s, the finest of the 20th century.
Who was the other draughtsman?
Rafael Alemany. He was the medical illustrator at the Barcelona School of Medicine from 1922 until 1947. He worked for Hermenegildo Arruga, Agustín Pedro Pons, Antonio Caralps and Francisco Gallart. The ophthalmologist Ramón Castroviejo, who worked in the United States, was impressed by the quality of his drawings and convinced him to move to the USA, where he arrived in 1947. After 1944, Núñez and Alemany began a close partnership with my grandfather Salvador. They are two exceptional draughtsmen who would work in the Anatomy Department, and for my grandfather, this was a really a unique chance to tap into the talent of these two great artists. So far, we’ve recovered 186 drawings by Núñez and 51 by Alemany. Colour photography back then, just after the Spanish Civil War, was very expensive and was only used occasionally. The rest had to be drawn. Additionally, good anatomical drawings are always better than photography from an educational perspective, because illustration is not just a copy. You express what is important and make the object drawn understandable and approachable. You’re not seeking a perfect representation. With photographs, you have too much information and the key parts are diluted, without being able to highlight what is superfluous. The draughtsman remains today, as was the case 500 years ago, a key element in teaching and research in medicine, botany and zoology.
Does the title - The Art of Transforming Science - have anything to do with the draughtsman as part of this transformation?
Sure, how the draughtsman becomes a key tool for understanding and explaining the latest anatomical or anatomopathological findings, or the new surgical techniques. The illustrations selected in the book bear witness to the tremendous advances that, led by Salvador Gil Vernet, Spanish urology underwent in the mid-20th century, which gave rise to its international exposure. In this book, you find that, through illustration, you combine extraordinary precision and great beauty, something very difficult to attain and that requires a special mix of physician and artist. The great effort and talent are enshrined in this unique graphic work.
Were all the anatomical draughtsmen who worked with your grandfather professionals?
No. Many were 2nd year Medicine students. They were asked: “Okay, can any of you draw well?” They took care of the microscopic anatomy drawings, with microscope preparation and the help of a camera lucida, projected the image on the wall to define the scales and then, looking through the eye-piece, drew first in pencil then in Indian ink. I was lucky enough to meet two of them - one is a pathologist in Barcelona and the other is a radiologist, and of course, both are now retired-. The draughtsmen could take months to finish the illustrations and the drawings were then used in conferences, serving to illustrate science lectures and books, and in particular, their aim was to help in the spatial reconstruction of the anatomic structures. The work of these boarding students is immense. The former students remembered the uroanatomy laboratory with a little wood stove for the extremely cold winters, and I’m surprised that between the 50s and the 70s, with very limited economic resources, the Urology Service of my grandfather became a famous global centre. Ian Thompson arrived from Texas, Oswald Lowsley from New York, Ermanno Mingazzini from Rome, as well as some French urologists such as Pierre Aboulker and Adolphe. The small uroanatomy laboratory became a pioneering centre in global urology research. At the time, work was being done on benign hyperplasia and prostate cancer. New surgical techniques were designed that would be less invasive, the anatomy and the innervation of the external sphincter were defined, as were the muscles of the bladder and urethra, the prostate regional anatomy, i.e. lots of original works of research came to fruition in this thirty-year period.
Why did you write your book in English?
Because there are lots of foreign urologists who are familiar with my grandfather’s work: Italians, Americans, French, etc., because he was the first Spanish urologist who published in English, in 1968. It was an Italian publishing house, Cánova, from Treviso (Italy). My idea was to write a book that combined art and science, to tell the history of urology for those thirty years that were so important for the field globally, and to tell it through drawing, and that drawing was the real star of the show.
A turning point in your career as a researcher was ejaculation-related...
The topic of the physiology of ejaculation was very unknown. Nobody had ever seen what happened inside the organism during ejaculation. I thought, well, why can’t we see what happens in real time? Then it occurred to me, with the help of a young volunteer and through ultrasound, to see what happened in the bladder neck, with the prostate and the seminal vesicles, and how the different muscles contracted when leading to the expulsion of semen, and to see the journey through the urethra, something no one else in the world had seen up to that point. What I saw then was not very close to the explanations given in theories on ejaculation. For me, it was a remarkable sensation, because you’re seeing something for the first time and, from there, you can explain the ejaculatory mechanics from a completely new point of view. We started to describe sphincter behaviour, but, above all, the interesting part was what my grandfather said about the prostatic urethra muscle. I saw it then and could prove what he’d suspected. What he’d hypothesised, I was able to see, and that was amazing. We published it in 1994 in the British Journal of Urology and on YouTube. We have a video that's already had over 500,000 hits.
Then you stopped researching and switched to clinical medicine. Then came dissemination. What are your biggest interests?
I’m interested in the fields where we can be pioneers. I’m now working on research projects on urogenital anatomy with the Anatomy Department of the School of Medicine of the Complutense University of Madrid, and we’ve just published a piece on the arterial vascularisation of the prostate with practical applications on the embolization techniques of the prostate for treating BPH. In any case, I still like research and the idea is to continue my morphological science studies. I’m passionate about anatomy. I believe in anatomy, especially in everything urogenital-related. There's still lots to uncover. Anatomy is really exciting. But, well, I’ll look into it. (Laughter).
You’re also a big fan of botany, and in this sense there’s a connection with your grandfather, right?
Yes. I learned that my grandfather liked botany when I’d already finished studying Pharmacy and I liked botany and gardening, and then I see my grandfather, older now, and he loves botany, like me, roses, gardening and botany. Just a coincidence. He wanted to know everything. He didn’t care if the work he was doing could be applied instantly. At that time, students were influenced by Ramón y Cajal, who received the Nobel Prize when Salvador was still just a boy. His first steps were towards the plant nervous system. To a certain extent, he wanted to follow in Cajal’s footsteps, but as the central system had already been exhausted, he chose to study the autonomic nervous system and the innervation of the intrapelvic organs.
You run the Gil-Vernet urology centre. What do you specialise in?
Now, probably prostatic pathology, benign hyperplasia, in uro-oncology, (prostate, kidney and bladder cancer). Also in reconstructive urethra surgery, kidney stones and andrology.
Do you have female patients?
Sure! Because they have a urinary system, urinary incontinence problems, stones, etc. (laughter).
Men tend to visit, upset with prostate problems. For those who don’t know, what is the prostate for?
The prostate is an accessory sexual organ, i.e. it helps sperm cells navigate in a safe and stable environment. It contracts during ejaculation, and by contracting, releases a secretion that helps the sperm cells become more viable, i.e., along with the secretion of the seminal vesicles, allows the sperm cells to travel in an appropriate environment and maintain their capacity to reach the egg and fertilise it; that’s all it serves for. The prostate is poorly designed in humans. Among mammals, man and old dogs are the only ones to experience prostate problems. Dolphins, horses and cats don’t suffer from prostate pathologies. Dogs have hyperplasia and cancer when they are very old. This gland’s pathology is really the foundation of the urology field. All primitive urology, the perineal size up to kidney stones, when operations were performed in the 16th and 17th centuries, and even earlier, were to solve problems caused by prostate growth.
Benign prostate hyperplasia affects approximately 50% of men between 50 and 60 years old. What is BPH? How does it occur, and what should we do?
From a histological perspective, it really begins to form from 30 to 45 years old. It’s a benign tumour growth that takes place in the prostate zone around the urethra, and in many cases, this tissue obstructs the flow of urine. Nowadays, we have highly effective pharmacological and surgical treatments.
Can it be prevented?
No. It used to be said that ideally, excessive sex should be moderated, heavy, spicy meals should be avoided, and alcohol and coffee consumption should be lower, but truth be told, these factors have nothing to do with it. It appears that obesity and an increase in body mass affect the degree of severity of the disease. We don’t know why BPH occurs. Growth, genetic and hormonal factors are probably involved.
For BPH treatment, what does Urolift involve?
It’s a technique using some small tensioners, which are placed in the prostatic urethra and they widen the urethra, i.e., open a channel to facilitate the passing of urine. The prostate problem when we operate is that we destroy the fibres of the internal vesical sphincter, a muscle that closes during ejaculation. Therefore, a common after-effect with prostate operations is retrograde ejaculation - the patient has orgasms without releasing semen. Urolift is not an invasive procedure. It’s easy to carry out, under local anaesthesia as well, and above all, doesn't change the ejaculation mechanics.
Among the tests used to examine the prostate, there's the famous “digital rectal examination”. Are there people who still have a problem with this test?
We are now using it less and less because we have markers such as the PSA. If the PSA is regular, we don’t need to do it, but it’s always recommended, because its combination with the PSA gives us more information about the prostate. It also helps us to know the size of the BPH, or the degree of local extension of the disease for prostate cancer.
For men, prostate cancer is the most diagnosed, even more than breast cancer in women, however the media coverage is much smaller. Why do you think this is?
The incidence of both tumours is very similar, around 13% for prostate cancer and 12% in breast cancer. In Spain, around 6,000 women die every year due to breast cancer, and around 5,000 thousand men die from prostate cancer, but the average age of death from breast cancer is 66 whereas for prostate cancer it’s 75; more women die, and at a younger age, so this explains the difference in terms of media coverage. Prostate cancer, when it’s low aggression and highly located, can be left without treatment, because you know that the growth will be very slow; we therefore propose what we call a “watchful waiting” - we perform periodic checks with PSA and multiparametric MRI scans every six months and, if necessary, we repeat the biopsies, and if this tumour doesn’t grow or get more aggressive, you can keep it under observation.
What are the most common urological emergencies? Are there cases of penis fractures? Can a penis be fractured during sexual intercourse?
In emergencies, renal colic is the most common - acute urinary retention, i.e., the patient can’t urinate, and the patient has blood in his/her urine. Cases of penis fracture are rare. The most common are due to trauma to the erect penis and during sexual activity, when in some positions the penis can strike against the partner’s pubic bone or perineum, so there is a significant increase of pressure in the cavernous body which exceeds the resistance of the tunica albuginea of testis - the fibrous covering the cavernous bodies - and this breaks, usually near the base of the penis.
According to the neuro-scientist and disseminator José Ramón Alonso, the most interesting lecture of all time was given by Giles Brindley in 1978, at the annual congress of the American Association of Urologists held in Las Vegas. Are you familiar with it? Tell us about nitric oxide. What is it for?
Yes, I’m familiar with it, but it was in 1983 and at a congress of the Urodynamics Society. There, Professor Brindley injected papaverine in a penis and showed his audience its impressive erection. It was the first time that an intracavernous injection of a vasodilator was shown to be an effective treatment for erectile dysfunction. Subsequently, the role of nitric oxide was demonstrated in the relaxing of the cavernous body smooth muscle, which results in erection. We should remember that it was a Spanish urologist, Dr. Íñigo Sáenz de Tejada, who pioneered the discovery of nitric oxide and its relationship with the erection mechanism. Viagra appeared at the end of the 90s, the first oral treatment for erectile dysfunction, and its action is based on inhibiting the deterioration of a molecule that intervenes, via nitric oxide, in erection maintenance.
How does a urologist diagnose erectile dysfunction? What exams are carried out, in addition to what the patient says?
Mainly through the medical history. We do a test, the IIEF-5, and through a series of questions, establish the level of erectile dysfunction. We investigate the medical history for psychosocial factors, which medication is the patient taking, and the risk factors such as obesity, hypertension, dyslipidemias and cardiovascular diseases. Smoking, both active and passive, is a high-risk factor because it causes lesions in the cavernous arteries that prevent blood flow. We also request analytical studies to obtain a hormonal profile, and to know the condition of the cavernous arteries, we do an ultrasound that, after injecting a vasodilator drug; we are able to exam the blood flow speed, and measure the blood flow in the cavernous body. Often, when erectile dysfunction is vascular in origin, it’s a warning sign and indicates that it may coexist with a cardiovascular pathology, and it’s therefore important that the patient is seen by a cardiologist.
Is psychology also a factor?
Fifty years ago, it was thought that 50% of erectile dysfunction was due to psychogenic causes, but nowadays, with advances in erection biochemistry and physiology, it is believed that only 10% are due to psychological problems. Psychological causes in the disease aetiology have often been used when we don’t know how to explain the bases of the pathological processes. The same thing happened with schizophrenia, autism and bipolar disorder. Half a century ago, they were thought to be psychological disorders, and we now know that they are diseases caused by genetic and neurobiological alterations. What we know for certain is that patients with erectile dysfunction tend to display anxiety disorders, low self-esteem and even depression.
Does anyone lie about erectile dysfunction? Does anyone think they have it and in reality, don’t have it?
I don’t think so. There are patients in their 60s who want to have a sex life like in their 20s and think they have erectile dysfunction, but they are sexually active in a manner which, for their age, is very normal. The same thing happens with hearing and sight, as well as urination, because the bladder doesn’t empty the same way when you’re 60 as it did in your 20s. We also need to know how to differentiate between what is merely natural aging and what is pathological.
What differences are there between the Viagra, Levitra, Cialis or Extender drugs?
All these drugs have a similar molecular structure and the same action mechanism, but their pharmacokinetic properties, i.e., the time they need to take effect and their duration, and their side effects, vary. To be honest, their effect is similar and none are any better than the others. The Extender is a device that, via traction, is used to increase penis length, but isn’t able to extend it more than a centimetre, and we still don’t have reliable scientific documentation concerning the long-term results.
Nowadays, Viagra is in fashion as a recreational drug, even combined with Dapoxetina, which you can buy online. What problems can arise due to abuse of these drugs?
Viagra and the other drugs are used recreationally, because they enhance erections and reduce the refractory period, i.e. The time between the orgasm and the next erection. The problem is that if sexual desire is inhibited, whether due to alcohol consumption or other recreational results, these drugs aren’t going to work, even substances such as methamphetamine or cocaine have adverse effects, making an erection difficult. Dapoxetine is the first drug approved for treating premature ejaculation and it is commonly paired with drugs such as Viagra. However, we don’t recommend its use without prior medical evaluation, and its online purchase may entail significant risks, because we are unable to know what its true composition is, and the adulterants it has.
We’ve read that the delay in treating priapism can cause permanent erectile dysfunction. Is this the case?
It is. Over four hours of continuous erection is what we call priapism and if not urgently treated, it can cause, due to ischaemic injury from a lack of blood supply, destruction of the cavernous tissue and irreversible erectile dysfunction.
Are there non-pharmacological treatments for erectile dysfunction? What benefits do they have?
Lately, we've been applying treatment through extracorporeal shock waves, which is getting good results. They are sound waves that focus on the cavernous tissue and trigger the release of a series of substances, as growth factors that attain a neovascularisation of the tissue, improving blood flow. It’s a treatment that doesn’t hurt at all, is non-invasive, and has no side effects.
When you use a penile prosthesis to treat erectile dysfunction, what type of prosthesis are there?
The penile prosthesis was first used in the 70s and there are two types, those called flexible prosthesis and the hydraulic prosthesis. The former is a silicone cylinder around a central metal core. The latter are more common, because they permit a far more natural erection, having some cylinders placed inside the cavernous bodies that are automatically filled when the device is activated. The most recent models don’t just allow a diameter increase, but also an increase in length. After intercourse ends, they empty and the penis returns to a flaccid state.
In which cases is a penile prosthesis recommended?
For patients who don’t respond or don’t tolerate the pharmacological treatment, the insertion of a penile prosthesis allows a regular sex life to be recovered.
In your experience as a physician, do you think penis size is related to self-esteem?
Yes. In many cultures penis size is related to virility, strength and power. Many patients are concerned about the size of their penis, both flaccid and during erection, although they have a normal size. It’s called “small penis syndrome”, compared to those who really do have a small penis or micropenis. 90% of women don’t value a man for the size of his penis, and when they do, they prefer a thick one to a long one. For white men, the average length during erection is about 15-16 cm, but 45% of men want a longer penis; we must remember that porn has led to unrealistic expectations. We would only talk about a micropenis when a penis is less than 7 cm.
And the G spot?
The G spot and female ejaculation don’t exist. Stimulation of the forward vaginal face may lead to orgasm, but it’s due to activating the female erectile organs, i.e., the clitoris.
Can penis size be increased?
Yes. It can be increased via surgical techniques although, unless it’s for a micropenis, I wouldn’t recommend it. When you explain the results and risks of surgery to patients, most decide against it.
There are lots of ads online, so it’s not a good idea, right?
No, not at all. The only way not to suffer serious and irreversible complications is to consult a urologist or a plastic surgeon.
Is there much demand for aesthetic genital surgery? Is it in fashion?
No, genital plastic surgery is not a field I’m interested in. We only operate on patients with a micropenis or those who have suffered pelvic trauma and the penis has been buried, so then we can split the suspensory ligament and get up to an extra 2 cm in length.
Have you worked with people who have mutilated themselves?
Yes, we’ve seen some cases and it’s called Van Gogh syndrome, after the painter’s self-mutilation, because these patients mutilate their own penis. They are usually schizophrenics during a psychotic break, who hear voices telling them to amputate their penis. We’ve seen a couple of cases. In the 80s there was an epidemic of amputations in Thailand, following the infidelity of their partners, many women decided to get a knife and cut off the root cause of the problem - a drastic solution to deal with marital infidelity.
Concerning circumcisions, are they sometimes done for aesthetic reasons, or are they always medical problems, e.g. shortness of the preputial skin? Or sometimes for religious issues?
Yes, Jews practice for religious matters here in Spain. For aesthetic matters I don’t recommend it. I would say that if the foreskin isn’t really choking the gland and the preputial skin is long, if we operate, we're going to hit a lot of nerves and sensitivity will be lost.
For religious reasons, does a rabbi accompany the person undergoing the circumcision?
I had a case with a Jewish boy, before starting the operation the rabbi recited some psalms and then I gave him the foreskin (laughter).
What technological advances lie in store in urology? Robotic surgery already exists, right?
That’s the big question. Urology, since its emergence as a field in the 19th century and during the 20th century, has made great progress, because we’ve advanced, e.g. with kidney stones, from open surgery to be able to access the stones via a ureter with digital optic systems that allow you to see the urinary tract perfectly. The miniaturisation of the instruments and the application of lasers have revolutionised urolithiasis treatment. Laparoscopic and robotic surgery with 3D vision allow very precise and less invasive surgery, and soon, they’ll improve by offering surgeons sense of touch. The minimally invasive techniques in prostate cancer such as cryotherapy, RMN-guided HIFU (high energy ultrasound), photodynamic therapy), photothermic therapy and irreversible focal electroporation are opening new paths in uro-oncology. Nanotechnology is taking its first steps in bladder and prostate cancer treatment. The use of stem cells in tissue bio-engineering will allow the formation of artificial tissues to use in reconstructive bladder and urethra surgery, and 3D printing will perhaps one day allow us to make a kidney. Pharmacology has also taken giant strides forward. We have effective drugs for treating benign prostate hyperplasia, for treating unstable bladders, for erectile dysfunction, etc. In the field of uro-oncology, we’ll see very big steps forward, led by genetics and immunotherapy, with the development of new tumour markers, immunomodulatory drugs and vaccines. Additionally, we must support campaigns against smoking and alcohol consumption, which cause numerous illnesses. In urology, smoking is public enemy No 1.
How do you know smoking is the cause? Is it due to correlation, statistics or is there actually a mechanism?
Smoking is the main cause of bladder cancer. It’s via the nitrosamines that remove urine and come into contact with the vesical mucous and the urinary tract. These nitrosamines cause DNA changes that eventually become the normal cells in cancerous cells. Smoking is also related to kidney cancer and with erectile dysfunction. The urologist’s work is very important, not just in trying to cure cancer, but also for preventing and treating smoking. The other big threat is alcohol. The relationship between alcohol consumption and cancer (liver, colorectal, breast, pharynx, larynx, oesophagus) is increasingly better understood. There’s no maximum daily alcohol consumption that is safe. A glass of wine a day is not healthy - that’s a lie. It has an anti-oxidant that doesn’t compensate for the damage the alcohol is going to do to your body.