Standard Operating Procedures for Vascular Surgery in Erectile Dysfunction: Revascularization and Venous Procedures

Department of Urology, Markus Hospital, Frankfurt, Germany San Diego Sexual Medicine, Alvarado Hospital, San Diego, CA, USA Andromeda Andrology Center, Hyderabad, AP, India.
Journal of Sexual Medicine (Impact Factor: 3.15). 11/2012; 10(1). DOI: 10.1111/j.1743-6109.2012.02997.x
Source: PubMed

ABSTRACT Introduction.  The impact of penile blood supply on erectile function was recognized some 500 years ago. At the turn of the 20th century first results of penile venous ligation were published and in 1973 the first surgical attempts to restore penile arterial inflow were undertaken. Numerous techniques were published in the meantime, but inclusion criteria, patient selection, and success evaluation differed extremely between study groups. Aim.  To develop evidence-based standard operating procedures (SOPs) for vascular surgery in erectile dysfunction, based on recent state of the art consensus reports and recently published articles in peer-reviewed journals. Methods.  Based on the recent publication of the consensus process during the 2009 International Consultation on Sexual Medicine in Paris, recommendations are derived for diagnosis and surgical treatment of vascular erectile dysfunction. In addition several recent publications in this field not mentioned in the consensus statements are included in the discussion. Main Outcome Measure.  The Oxford system of evidence-based review was systematically applied. Due to the generally low level of evidence in this field expert opinions were accepted, if published after a well-defined consensus process in peer-reviewed journals. Results.  Referring to penile revascularization it may be concluded, that in the face of missing randomized trials, only recommendations grade D may be given: this kind of surgery may be offered to men less than 55 years, who are nonsmokers, nondiabetic, and demonstrate isolated arterial stenoses in the absence of generalized vascular disease. The evidence level for recommendations concerning penile venous ligations may be even lower. Too many unsolved controversies exist and universal diagnostic criteria for patient selection as well as operative technique selection have not been unequivocally established. This kind of surgery is still considered investigational but may be offered in special situations on an individualized basis in an investigational or research setting after obtaining written consent, using both pre- and postoperatively validated measuring instruments of success evaluation. Conclusions.  SOPs for penile revascularization procedures can be developed, concerning a highly selected patient group with isolated arterial stenoses. Based on the available data it is not yet possible to define SOPs for surgical treatment of corporal veno-occlusive dysfunction. Sohn M, Hatzinger M, Goldstein I, and Krishnamurti S. Standard operating procedures for vascular surgery in erectile dysfunction: Revascularization and venous procedures. J Sex Med **;**:**-**.

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    ABSTRACT: IntroductionPenile revascularization (PR) is a potentially curative procedure for young men with isolated arteriogenic erectile dysfunction. Standard preoperative evaluation is erectile hemodynamics (HDX) using duplex Doppler penile ultrasound (DUS) and/or cavernosometry (DIC) and assessment of cavernosal arterial anatomy by selective internal pudendal arteriography (SIPA).AimThe aim of this study was to review our experience with men who sought a second opinion from us regarding their candidacy for PR.Method Study population consisted of men (i) who presented to us for a second opinion regarding PR; (ii) who had DUS/DIC and SIPA; and (iii) had been advised by outside surgeon to undergo PR. Review of the HDX study and SIPA was conducted. Discrepancies between these studies resulted in repeating the DIC in men with normal SIPA or repeating the SIPA in men with normal HDX studies.Main Outcome MeasuresDiscrepancies between HDX and SIPA and the results of repeat HDX or SIPA were the main outcome measures.ResultForty-five patients participated in the study; mean age was 33 years with 4% ≥50 years old. Median vascular risk factor number was 1 (ranged 0–3). A credible trauma history was present in 11%. Thirty-three percent had prior DIC and 49% of patients had a significant discrepancy between HDX study and SIPA, including all patients seen by a community urologist. Thirty-eight percent had a discrepancy between side of abnormality on HDX and SIPA where both studies were abnormal (group A). Seven percent had abnormal HDX and normal SIPA (group B). Four percent had a normal HDX study with an abnormal SIPA (group C). Repeat DIC (n = 20) was conducted in groups A + B and was normal in 70% of cases. Repeat SIPA (n = 2) was conducted in group C and was normal in both patients.Conclusion Almost one half of patients had a significant discrepancy between HDX and SIPA. Of these, 73% had normal repeat studies, making them no longer candidates for penile revascularization. Dabaja AA, Teloken P, and Mulhall JP. A critical analysis of candidacy for penile revascularization. J Sex Med **;**:**–**.
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    ABSTRACT: Erectile dysfunction (ED) affects a growing number of men in the USA and abroad, with significant impacts on sexual function and overall quality of life. The risk factors for ED are numerous and include a strong link to cardiovascular disease, such that men with ED should be screened for cardiovascular disease. The evaluation of men presenting with ED includes a comprehensive history and physical exam to aid in the identification of comorbidities as well as laboratory testing to evaluate hormone and lipid levels and sugar metabolism. Adjunct studies are also available, though their utility is often limited to specific subtypes of ED. Once the etiology of ED is established, treatment can be initiated using appropriate medical therapies, including phosphodiesterase type 5 (PDE5) inhibitors, and transurethral or intracavernosal therapies, with surgical intervention via revascularization or penile prosthesis placement in men demonstrating a lack of response to medical therapy. In all cases of ED, a psychogenic component is present and referral for psychological intervention with or without medical therapy should be considered.
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    ABSTRACT: The treatment of erectile dysfunction (ED) has been a fascination involving multiple medical specialities over the past century with urologic, cardiac and surgical experts all contributing knowledge toward this multifactorial disease. With the well-described association between ED and cardiovascular disease, angiography has been utilized to identify vasculogenic impotence. Given the success of endovascular drug-eluting stent (DES) placement for the treatment of coronary artery disease, there has been interest in using this same technology for the treatment of vasculogenic ED. For men with inflow stenosis, DES placement to bypass arterial lesions has recently been reported with a high technical success rate. Comparatively, endovascular embolization as an approach to correct veno-occlusive dysfunction has produced astonishing procedural success rates as well. However, after a thorough literature review, arterial intervention is only recommended for younger patients with isolated vascular injuries, typically from previous traumatic experiences. Short-term functional outcomes are less than optimal with long-term results yet to be determined. In conclusion, the hope for a minimally invasive approach to ED persists but additional investigation is required prior to universal endorsement.
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