Article

Insufficient Response to Venous Stripping Surgery: Is the Penile Vein Recurrent or Residual?

Authors:
  • Hsu's Andrology
  • Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation
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Abstract

There is currently controversy on whether the insufficient response to penile venous surgery done in an attempt to restore erectile function is due to recurrent or residual veins. In order to elucidate this issue, we report a study on those patients who failed to respond to the first venous surgery and subsequently underwent or declined a second operation. From July 1996 to July 2003, a total of 83 patients, aged 25 to 83, who were dissatisfied with their first venous surgery and were later diagnosed with a persistent veno-occlusive dysfunction via our dual cavernosography, were recruited into our study. Subsequently, 45 men underwent penile venous stripping surgery for a second time and were assigned to the surgery group, whereas the remaining 38 men were subject to follow-up and routine management and were assigned to the control group. All were evaluated with the abridged 5-item version of the international index of erectile function (IIEF-5) every 6 months for 1 to 5 years and cavernosogram, if necessary. In the surgery group their preoperative IIEF-5 score was 10.1 +/- 3.7, which increased to 17.1 +/- 3.2 (P < .001) after the first surgery and further increased to 20.7 +/- 3.1 (P < .001) after a second venous stripping of the cavernosal vein that was consistently demonstrated on the cavernosogram. Overall, 41 men (91.1%) reported a positive response to further venous surgery, with more satisfactory coitus, after the residual veins were stripped thoroughly, although eventually 4, 3, and 3 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. The follow-up period ranged from 12 months to 72 months, with an average of 37.0 +/- 11.5 months. In the control group, however, their corresponding IIEF-5 score changed from 17.4 +/- 2.9 to 16.9 +/- 3.2 (P > .05). Finally, 11, 7, and 8 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. Although there was no statistical significance between the 2 groups in the first postoperative IIEF-5 scores, there was a significant difference in their IIEF-5 after further venous surgery. In this study, we propose that the clinical relapse of erectile dysfunction is a result of "residual" veins rather than "recurrent" ones.

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... Despite the drawbacks of venous surgery reported by others, we have applied a refined penile venous stripping technique in a large patient population because of encouraging outcomes, minimal complications, and negligible morbidity under a local anesthesia on an outpatient basis (Hsu et al, 2006). We reported earlier that venous stripping was superior to venous ligation only in terms of erectile function restoration, with no recurrent venous leakage in a follow-up imaging study of up to 17 years after surgery (Chen et al, 2005). ...
... Although challenging, penile venous surgery, with the application of local anesthesia, allows the procedure to be conducted on an ambulatory basis, sparing the patients possible adverse effects from general anesthesia. Consequently, the surgery morbidity appears to be negligible, although the overall outcome is less promising than that indicated in a previous report (Hsu et al, 2006). ...
Article
Full-text available
Disappointing functional outcome and penile deformity are major concerns of penile venous surgery. Consequently, it has been abandoned by most urologists. To explore whether penile deformity is correctable and erectile function can be improved, we report our experience in patients who had undergone surgery elsewhere. From 1986 to 2008, 16 consecutive patients sought our assistance because of poorer erectile capability or/and penile deformity from previous venous surgery elsewhere. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) was used to score the patients when it became available in 1998. Accordingly, 3 and 13 patients were categorized into the non-IIEF and IIEF groups, respectively. A median longitudinal pubic incision and a circumferential or semicircumcision were made to relieve the fibrotic tissues for accessing the deep dorsal veins, which were stripped thoroughly and ligated with 6-0 nylon sutures. The cavernosal veins were managed in a similar manner. The paraarterial veins were ligated only segmentally. Finally, the wound was approximated while an assistant consistently stretched the penile shaft. The operation time was 5.2 to 8.5 hours. The follow-up period ranged from 0.6 to 23.0 years. Overall, all patients reported satisfactory penile morphology postoperatively. In the IIEF group, the difference in preoperative and postoperative scores was significant (P < .001). In the non-IIEF group, 2 of the 3 patients reported natural coitus. This series of salvaging venous surgeries, although technically challenging, are helpful in correcting penile deformity and restoring erectile function in some patients who had poorer outcomes from prior venous surgeries.
... Thus, preservation of anatomical integrity (Hsu et al, 2004b) can be firmly ascertained. New insights into penile venous anatomy (Hsu et al, 2003a) are essential, so that residual veins are not regarded as recurrent ones (Hsu et al, 2006). Thermal injury of the sinusoidal tissue is unavoidable if a surgeon cannot handle the vascular structure by ligation and has to resort to electrocautery (Hsu et al, 2004a). ...
... The sinusoid of the corpora cavernosa is the most ideal milieu to apply the Pascal principle if no venous leakage exists (Hsu et al, 2006). The law describes how pressure applied to any part of an enclosed fluid at rest is transmitted undiminished to every portion of the fluid and to the walls of the containing vessel (Halliday, 1997). ...
Article
Penile venous surgery might not be considered an appropriate treatment for erectile dysfunction (ED) because of disappointing functional outcomes and unacceptable, seemly unavoidable, penile deformity. We report results of a refined penile venous stripping method in patients with veno-occlusive dysfunction (VOD). From 2000 to 2003, 341 of 467 men with ED were diagnosed with VOD via cavernosography and Doppler sonography. Patients were excluded from undertaking cavernosography if they had an untreated chronic systemic disease. Patients who had undergone the first penile venous surgery in other institutes were also excluded from this study because of the protracted surgical time and unpredictable functional outcomes, because severe fibrosis may prevent patients from completing penile venous removal. Of these 341 men, 178 were treated with a refined venous stripping surgical method (surgery group) and 163 patients were treated without this surgery (control group). In the surgery group, 167 were available for long-term follow-up using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system. The operative time ranged from 2.1 to 5.0 hours. The follow-up period ranged from 5.1 to 8.2 years, with an average of 7.7 +/- 1.4 years. The difference between the preoperative (9.7 +/- 3.9) and postoperative (21.6 +/- 2.8) IIEF-5 scores was significant (P < .001). Overall, 90.4% of the surgery group (151 of 167) reported improvements after surgery. A significant decrease in IIEF-5 scores (10.4 +/- 3.8 vs 7.9 +/- 3.2, P < .001, n = 121) during the same period of follow-up was, however, noted in the control group. This refined penile venous stripping surgery delivered favorable results and is a viable alternative for treating VOD.
... Might we not infer then that a fully rigid erection may depend upon the drainage veins as well, rather than just on the intracavernosal smooth muscle? Therefore, might we not look at venous malfunction [49,50] – a phenomenon manifest in a variety of other disease entities, including hemorrhoids [51], varicose veins of the leg [52], and varicocele testis [53] – with a renewed appreciation for its critical role in ED? It is understandable that veins are susceptible to dysfunction in dependent portions in upright animals, implying that these various diseases could, to a large extent, be avoided if man walked on 4 feet. ...
Article
Recent studies substantiate a model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat spanning from the bulbospongiosus and ischiocavernosus proximally and extending continuously into the distal ligament within the glans penis. The anatomical location and histology of the distal ligament invites convincing parallels with the quadrupedal os penis and therefore constitutes potential evidence of the evolutionary process. In the corpora cavernosa, a chamber design is responsible for facilitating rigid erections. For investigating its venous factors exclusively, hemodynamic studies have been performed on both fresh and defrosted human male cadavers. In each case, a rigid erection was unequivocally attainable following venous removal. This clearly has significant ramifications in relation to penile venous surgery and its role in treating impotent patients. One deep dorsal vein, 2 cavernosal veins and 2 pairs of para-arterial veins (as opposed to 1 single vein) are situated between Buck's fascia and the tunica albuginea. These newfound insights into penile tunical, venous anatomy and erection physiology were inspired by and, in turn, enhance clinical applications routinely encountered by physicians and surgeons, such as penile morphological reconstruction, penile implantation and penile venous surgery.
... 127 Furthermore, Hsu inferred that clinically relapsed ED occurred in patients receiving prior venous surgery as a sequela of residual rather than recurrent veins of the penis. 128 Wen et al. proposed a remedy for CVOD through the synergistic effects exerted by venous surgery and medication with oral sildenafil. 129 For the treatment of ED, a summary of evaluations appraising penile venous surgery is adapted in Table 3. 33 Complications Complications can occur during or after a surgical procedure. ...
Article
Penile erection implicates arterial inflow, sinusoidal relaxation and corporoveno-occlusive function. By far the most widely recognized vascular etiologies responsible for organic erectile dysfunction can be divided into arterial insufficiency, corporoveno-occlusive dysfunction or mixed type, with corporoveno-occlusive dysfunction representing the most common finding. In arteriogenic erectile dysfunction, corpora cavernosa show lower oxygen tension, leading to a diminished volume of cavernosal smooth muscle and consequential corporoveno-occlusive dysfunction. Current studies support the contention that corporoveno-occlusive dysfunction is an effect rather than the cause of erectile dysfunction. Surgical interventions have consisted primarily of penile revascularization surgery for arterial insufficiency and penile venous surgery for corporoveno-occlusive dysfunction, whatever the mechanism. However, the surgical effectiveness remained debatable and unproven, mostly owing to the lack of consistent hemodynamic assessment, standardized select patient and validated outcome measures, as well as various surgical procedures. Penile vascular surgery has been disclaimed to be the treatment of choice based on the currently available guidelines. However, reports on penile revascularization surgery support its utility in treating arterial insufficiency in otherwise healthy patients aged <55 years with erectile dysfunction of late attributable to arterial occlusive disease. Furthermore, it is noteworthy that penile venous surgery might be beneficial for selected patients with corporoveno-occlusive dysfunction, especially with a better understanding of the innovated venous anatomy of the penis. Penile vascular surgery might remain a viable alternative for the treatment of erectile dysfunction, and could have found its niche in the possibility of obtaining spontaneous, unaided and natural erection.
... Now therapeutic methods of VED mainly included oral administration of PDE-5 inhibitors, contraction of corpus cavernosum and albuginea, [12] ligation/decollement/insertion of corpus cavernosum veins and prosthesis implantation. [13][14][15] The oral drug therapy had certain effects for mild VED, however, it had poor effects on moderate and severe VED. The prosthesis implantation had good effects for moderate and severe VED. ...
Article
Background: The precise pathophysiology of venous erectile dysfunction (VED) was still unclear. Dynamic infusion cavernosometry and cavernosography (DICC) was the gold standard approach for the diagnoses of VED. However, a standard operative procedure of DICC was needed and it was unclear whether DICC could show promise in accurate assessment and treatment of VED. The aim of this study was to establish an optimized operation process of DICC and evaluate the efficacy of DICC in the diagnoses and therapy of VED. Methods: One hundred and forty-seven VED patients identified by the color doppler duplex ultrasonography (CDDU) were included. Then the method of DICC was adopted to assess the severity of VED and all patients were divided into 4 groups, including (1) non-VED; (2) mild VED; (3) moderate VED and (4) severe VED. All patients received the treatment of psychotherapy. Drug therapy, the intervention embolism of corpus cavernosum and the implantation of penile prosthesis were applied if psychotherapy was ineffective for patients. The international index of erectile function (IIEF-5) scores of patients were collected and compared before and after treatment. Results: IIEF-5 score of non-VED group after psychotherapy (19.35 ± 3.59) and drug therapy (23.31 ± 0.75) was higher than that before psychotherapy (15.30 ± 2.72, t = -4.31, P < 0.01) and drug therapy (16.62 ± 1.50, t = -19.13, P < 0.01). IIEF-5 scores of mild VED (18.25 ± 2.60) and moderate VED group (14.83 ± 4.17) after treatment was improved significantly by intervention embolism of corpus cavernosum when compared with those before treatment (mild: 15.50 ± 2.14, t = -2.31, P < 0.05; moderate: 11.83 ± 2.86, t = -1.45, P < 0.05). However, drug therapy and intervention embolism (IE) of corpus cavernosum showed poor effects on patients with moderate and severe VED patients (P > 0.05). IIEF-5 score of severe VED group was increased under the treatment of implantation of penile prosthesis (23.25 ± 0.71) compared with that before treatment (8.00 ± 0.39, t = -53.25, P < 0.05). Conclusion: DICC was a valid diagnostic tool that could identify patients with VED. And DICC had great effect on the diagnosis and individual therapy for patients with VED in varying degrees. Moreover, the manipulation of DICC needed uniform standards.
... This evaluation furnished information of angulations. All these patients underwent salvage surgery under local anesthesia on an ambulatory basis (Hsu et al, 2003(Hsu et al, , 2007b, using finer suture materials (Hsu et al, 2001(Hsu et al, , 2006, to align the collagen bundles of the outer longitudinal layer (Figure 2A). Before July 1998, a total of 10 patients received tunical salvage surgery using 4-0 polyglactin sutures and were designated the polyglactin group. ...
Article
It is commonly believed that coarser suture materials should be used to provide sufficient tenacity in surgery for penile curvature correction. We report our 15-year experience of fine sutures in a second operation in 31 patients who underwent prior curvature correction elsewhere with coarser sutures, resulting in recurrent penile curvature. Suture materials used in prior surgeries in these patients were either 2-0 or 3-0 nylon sutures. In this series, all 31 patients underwent a modified Nesbit procedure at the level of the collagen bundles using finer sutures. Prior to July 1998, 10 men underwent salvage surgery using 4-0 polyglactin sutures. Thereafter, we adapted 6-0 nylon sutures for another 21 patients. We categorized the patients into the polyglactin (n = 10) and nylon (n = 21) groups respectively. Overall, 29 patients were available for follow-up while using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system, with 21 patients in the nylon group. We have found cavernosography a practical and reliable method to objectively assess penile morphology in these patients. The penile morphology both subjectively and objectively was excellent in all patients, except for 1 in each group. Erectile function restoration showed a trend of satisfaction in the polyglactin group and based on IIEF-5 was significantly improved in the nylon group (14.2 ± 3.6 vs 21.9 ± 2.1, n = 20, P < .001). These results suggest that in penile tunical surgery, fine sutures such as 6-0 nylon may result in better penile morphology and functional outcomes.
... Именно поэтому при выраженной ВН многие авторы сразу же рекомендуют прибегать к радикальному способу леченияфаллоэндопротезированию. Однако данная операция далеко не всегда оправданна для выполнения у молодых пациентов [4,5,[10][11][12][13][14]. ...
Article
Full-text available
Venogenic erectile dysfunction (ED) is 20 to 60 % of all causes of erection problems. In most cases, the choice of surgical treatments depends on the degree and pattern of vascular disorders in the genesis of ED. The authors use the alternative treatment procedure X-ray endovascular occlusion of veins in the prostatic plexus. There is a significant improvement in the quality of erection in the first 3 months after surgery. The application of this innovative technology permits safe, mini-invasive and pathogenetically sound treatment for ED caused by abnormal venous drainage from the cavernous bodies.
... There is controversy on whether the insufficient response to penile venous surgery in an attempt to restore erectile function results from the recurrent veins or residual veins. Hsu et al 45 propose that the clinical relapse of ED results from residual veins rather than recurrent veins. ...
Article
Full-text available
In the physiologic model of normal erectile function, a healthy veno-occlusive mechanism is essential to initiate and maintain a rigid erection. The surgical treatment of patients with venous leakage, which is synonymous with corporoveno-occlusive dysfunction (CVOD), was based on the decreased venous outflow during the erection process. The initial reports of short-term results were promising, but the long-term benefits of penile venous ligation surgery were limited. Most clinical guideline panels concluded that surgeries performed in an attempt to limit the venous outflow of the penis were not recommended. Consequently, this surgery was nearly abandoned in most medical societies worldwide. These unfavorable postoperative outcomes seemed attributable to the indispensable usage of electrocautery and insufficient venous management, based on conventional penile venous anatomy. Advances in better understanding of human penile venous anatomy has enabled the development of refined penile venous stripping surgery. The thorough stripping surgery is an even more radical procedure, which is an even more radical procedure, and seems to be a viable option for the treatment of CVOD, however, there is still a need for further study with well-defined diagnostic criteria, and standardized patient and partner outcome assessment.
... Could it be that ERVs might in fact be the predominant factor that underlies erectile rigidity? Certainly, and in the light of the increased understanding of the penile vasculature, it would at least warrant a re-evaluation of the role of venous surgery for ED [16]. Briefly, the CC and skeletal muscle components unite with smooth muscle components to meet the requirements for erection, and only allow vascular and nervous tissue to communicate with the systemic circulation. ...
Article
Full-text available
Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal’s law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.
Chapter
Erectile dysfunction is an extremely prevalent medical condition among adult men. The causes of erectile dysfunction can be multifactorial, which necessitates a systemic approach to both diagnosing and treating this disease. In this chapter, we will discuss the intricacies that physicians should be aware of when evaluating and managing patients who present with erectile dysfunction.
Article
The field of erectile dysfunction (ED) is evolving and there is a need for state-of-the-art information in the area of treatment. Aim. To develop an evidence-based, state-of-the-art consensus report on the treatment of erectile dysfunction by implants, mechanical devices, and vascular surgery. To provide state-of-the-art knowledge concerning treatment of erectile dysfunction by implant, mechanical device, and vascular surgery, representing the opinions of 7 experts from 5 countries developed in a consensus process over a 2-year period. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. The inflatable penile prosthesis (IPP) is indicated for the treatment of organic erectile dysfunction after failure or rejection of other treatment options. Comparisons between the IPP and other forms of ED therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis. Organic ED responds well to vacuum erection device (VED) therapy, especially among men with a suboptimal response to intracavernosal pharmacotherapy. After radical prostatectomy, VED therapy combined with phosphodiesterase type 5 therapy improved sexual satisfaction in patients dissatisfied with VED alone. Penile revascularization surgery seems most successful in young men with absence of venous leakage and isolated stenosis of the internal pudendal artery following perineal or pelvic trauma. Currently, surgery to limit venous leakage is not recommended. It is important for the future of the field that patients be made aware of all treatment options for erectile dysfunction in order to make an informed decision. The treating physician should be aware of the patient's medical and sexual history in helping to guide the decision. More research is needed in the area of revascularization surgery, in particular, venous outflow surgery.
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To investigate clinical features of Chinese patients with severe primary erectile dysfunction (S-PED) and to identify the ideal treatment options for this population. Patients with PED were screened for enrollment in our study. Sexual history, marital status, and erectile function were evaluated by inquiry including International Index of Erectile Function-5. Individuals with severe PED (defined as refractory to management with phosphodiesterase type 5 inhibitor [PDE5i]) underwent serum hormone analysis, penile color duplex Doppler ultrasound, neuroelectromyogram, and cavernosography as appropriate. Long-term treatment results were determined. Among 220 PED patients, 72 (32.7%) suffered from severe PED (PDE5i nonresponse). Mean age was 31.5 +/- 4.5 years and mean duration of attempts at sexual activity was 2.4 +/- 3.2 years, Sixty-eight men (94.5%) had organic etiologies for erectile dysfunction, including arteriogenic (n = 13), venogenic (n = 35), endocrinologic (n = 6), neurologic (n = 9), and cavernosal fibrosis (n = 5). Sixteen men (22.2%) had been divorced. Mean erectile function and quality-of-life were significantly improved (P <.001) in the 25 men (34.7%) who were treated by penile prosthesis implantation, at a mean follow-up of 5.6 years. Satisfaction with penile prosthesis for patients and partner was 93.4% and 92.3%, respectively. Severe PED has a major impact on young couple's life quality. Venous leak is the most common cause of severe PED. Penile prosthesis implantation is safe and effective for severe PED.
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We report our long-term results of penile venous surgery with crural ligation for primary venous leakage in men with erectile dysfunction. The study included 26 men with erectile dysfunction who underwent penile venous surgery for primary venous leakage with at least 1 year of postoperative followup at a single university hospital. All patients underwent penile venous surgery, including resection of the superficial and deep dorsal veins, ligation of the cavernous vein and 2 crura proximal to the entrance of the cavernous artery with umbilical tapes, and preservation of the dorsal artery and nerve on each side. Postoperative evaluation included the 5-item version of the International Index of Erectile Function, physical examination, duplex ultrasound and cavernosography, as necessary. Improvement in erectile functions and patient satisfaction were also assessed as complete, partial and none. The mean +/- SD International Index of Erectile Function score increased from 6.7 +/- 3.61 to 16.3 +/- 6.4, which was a highly statistically significant difference (p = 0.001). Postoperatively erectile function improved completely in 11 men (42.3%) and partially in 8 (30.8%), and it remained unchanged in 7 (26.9%). A total of 12 patients maintained satisfactory erection with phosphodiesterase-5 inhibitors, which had not been effective preoperatively. Patient satisfaction with no additional treatment or with phosphodiesterase-5 inhibitors was complete in 15 (57.7%) and partial in 8 (30.7%), while 3 (11.6%) were not satisfied with surgery. These 3 patients underwent penile prosthesis implantation with a 3-piece device. Penile venous surgery with crural ligation for venous leakage has excellent long-term results and patient satisfaction. Therefore, it should be offered to young men with primary cavernous erectile dysfunction. Young patients with normal penile arterial system and no risk factors such as diabetes have the best chance for improved postoperative success.
Article
Purpose To evaluate retrospectively the safety and efficacy of anterograde embolization of the periprostatic venous plexus (AEPV) via percutaneous access of the deep dorsal vein of the penis for erectile dysfunction (ED) resulting from veno-occlusive dysfunction (VOD). Materials and Methods From September 2009 through December 2012, 18 patients with moderate to severe ED secondary to insufficiency of physiologic venous occlusion as diagnosed by color Doppler evaluation of the penis after direct pharmacologic stimulation were treated. Preliminary diagnoses were also confirmed with dynamic cavernosography. Selective AEPV was achieved using a combination of N-butyl cyanoacrylate and endovascular coils. Follow-up consisted of collecting International Index of Erectile Function questionnaire (IIEF-6) scores and repeated color Doppler evaluation. Results Immediate technical success was achieved in 16 of 18 patients (88.8%). Follow-up data were obtained at a mean of 13.3 months ± 7.5. In 12 of the patients with technical success, the mean IIEF-6 score improved from 10.5 ± 5.2 to 20.6 ± 8.4 after the procedure (P = .0069). At 3-month short-term follow-up, clinical success defined by an end-diastolic velocity of < 5 cm/s on color Doppler was noted in 81% (13 of 16 patients). Of these 13 patients, 7 patients had continued erectile function at the end of follow-up, and the other 6 patients reported progressive diminishment in the benefit over time. No major complications and two minor complications were encountered. Conclusions AEPV for ED secondary to VOD is a safe alternative to surgical treatment that demonstrates promising short-term and midterm efficacy.
Article
The human erectile mechanism is an intricate interplay of hormonal, vascular, neurological, sinusoidal, pharmacological, and psychological factors. However, the relative influence of each respective component remains somewhat unclear, and merits further study. We investigated the role of venous outflow in an attempt to isolate the key determinant of erectile function. Dynamic infusion cavernosometry and cavernosography was conducted on fifteen defrosted human cadavers, both before and after the systematic removal and ligation of erection-related penile veins. Preoperatively, an infusion rate of <28.1 mL/min (from <14.0-85.0) was required to induce a rigid erection (defined as intracavernosal pressure [ICP] exceeding 90 mmHg). Following surgery, we were able to obtain the same result at a rate of 7.3 mL/min (from 3.1-13.5) across the entire sample. Thus, we witnessed statistically significant postoperative differences (all p ≤ 0.01), consistently remarking increased ICP, lower perfusion volumes, and a general reduction in time taken to attain rigidity. The cavernosograms provided further evidence substantiating the critical role played by erection-related veins, while histological samples confirmed the postoperative integrity of the corpora cavernosa. Given that our use of cadavers eliminated the influence of hormonal, arterial, neurological, sinusoidal, pharmacological, and psychological factors, we believe that our study demonstrates that the human erection is fundamentally a mechanical event contingent on venous competence.
Article
Changes in sexual function are common in patients following radical prostatectomy for prostate cancer. Sexual rehabilitation after radical prostatectomy requires a complex process in which the diagnosis is refined, and an accurate treatment program is chosen. Penile Doppler ultrasound is a commonly used method for diagnosing erectile dysfunction and it is very useful in certain cases after surgery to improve the assessment of arterial evaluation, venous leaks, and quality of the cavernous tissue and fascia. A literature search was conducted using the databases from Google and PubMed to identify original and review articles that examined the uses of penile Doppler ultrasound in post-radical prostatectomy evaluation or post-surgery rehabilitation. Search terms included: Erectile dysfunction post radical prostatectomy, sexual function post radical prostatectomy, Penile evaluation postprostatectomy, Diagnosis of erectile function after radical surgery, Penile Doppler ultrasound AND prostatectomy, Penile Doppler ultrasound AND sexual rehabilitation. The initial search resulted in 415 articles. After applying additional filters, 46 studies were included in the present review. Backgrounds of the most relevant guidelines were cited: Standard practice in sexual medicine, Standard operating procedure in sexual medicine, International Consultation on Sexual Medicine, and the EAU and AUA guidelines. Information on the use of penile Doppler ultrasound before surgery is extremely inconsistent in the literature. The recommendations for a successful evaluation of post-radical prostatectomy patients were included. Sexual rehabilitation after radical prostatectomy requires a complex process. There is great inconsistency in the literature with respect to the definition of what is considered normal erectile function before surgery and what may be considered normal erection after radical prostatectomy. The cost of penile Doppler ultrasound is a modest component of the penile post-radical prostatectomy rehabilitation process. Current evidence does not support the systematic use of penile Doppler ultrasound, but it must be included in the management algorithm of the patient undergoing radical prostate surgery so that erectile function can be properly evaluated. © 2018 Sociedad Mexicana de Urologia. Colegio de Profesionistas A.C.. All rights reserved.
Article
Background: A refined penile venous stripping has been found effective in treating Erective Dysfunction (ED) for nearly three decades. It appears more viable chronologically while several modifications have been made. We sought to report on the most advanced method. Materials and Methods: The study included 98 male patients treated from February 2003 to March 2006. All they were diagnosed with ED secondary to Veno-Occlusive Dysfunction (VOD) and were refractory to prior medical treatment. Among them 35, 32, and 31 men were allocated to the circumferential, semi-circumferential, and control group respectively. The two treatment groups received penile venous stripping via a circumferential or semicircumferential approach correspondingly, while the control group received only simple follow-up. After degloving the tissues superficial to Colles’ fascia, the confluent channel of the Deep Dorsal Vein (DDV) was identified. It was then clamped 2.0 cm proximal to the retrocoronal sulcus, and thoroughly stripped and ligated proximally and distally using 6-0 nylon sutures with a pull-through maneuver. The Cavernosal Veins (CVs) were managed with the same technique, while the Para-Arterial Veins (PAVs) were only segmentally ligated. A median longitudinal public incision was then made to resort the DDV and CVs stripped proximally till the infrapubic angle. Lastly, all wounds were fashioned layer by layer, while penile shaft was being stretched consistently by an assistant. Results: The operative times were 2.4 ± 0.2 and 3.1 ± 0.4 hours respectively for the circumferential and semicircumferential groups. The follow-up periods ranged 3.2-7.2 years with an average of 5.4 ± 1.3 years. The operative time, postoperative frenulum edema (3.2 ± 1.6 vs. 11.9 ± 2.1 days) and satisfaction rate of surgical course were significantly different (p<0.01) in favor of the circumferential approaches although no difference was noted in postoperative infection among two different approaches. Differences in erectile function were significant between the treatment groups and the control group in terms of preoperative IIEF-5 (9.8 ± 2.3 and 9.6 ± 2.1) scores compared to postoperative (21.6 ± 2.5 and 20.8 ± 2.7) ones respectively (both p<0.001) although no difference was found between the two surgical approaches. Overall, 51 patients in the treatment groups (51/67; 90.4%) reported significant improvement; whereas some worsening in IIEF-5 scores was noted in the control group during the same period of follow up time. Conclusion: A circumferential along with median longitudinal pubic incision was found to be a viable physiological approach with favorable outcomes and negligible morbidity for treating ED secondary to VOD.
Article
Full-text available
We evaluated the effectiveness of pelvic vein embolization with aethoxysclerol in aero-block technique for the treatment of impotence due to venous leakage in men using sildenafil for intercourse. The aim of the procedure was to reduce the use of sildenafil. A total of 96 patients with veno-occlusive dysfunction, severe enough for the need of PDE5 inhibitors for vaginal penetration, underwent pelvic venoablation with aethoxysclerol. The mean patient age was 53.5 years. Venous leaks were identified by Color Doppler Ultrasound after intracavernous alprostadil injection. Under local anesthesia a 20-gauge needle was inserted into the deep dorsal penile vein. The pelvic venogram was obtained through deep dorsal venography. Aethoxysclerol 3% as sclerosing agent was injected after air-block under Valsalva manoeuver. Success was defined as the ability to achieve vaginal insertion without the aid of any drugs, vasoactive injections, penile prosthesis, or vacuum device. Additionally, a pre- and post- therapy IIEF score and a digital overnight spontaneous erections protocol (OSEP) with the NEVA™-system was performed. At 3 month follow-up 77 out of 96 patients (80.21%) reported to have erections sufficient for vaginal insertion without the use of any drug or additional device. Four (4.17%) patients did not report any improvement. Follow up with color Doppler ultrasound revealed a new or persistent venous leakage in 8 (8.33%) of the patients. No serious complications occurred. Our new pelvic venoablation technique using aethoxysclerol in air-block technique was effective, minimally invasive, and cost-effective. All patients were able to perform sexual intercourse without the previously used dosage of PDE5 inhibitor. This new method may help in patients with contra-indications against PDE5 inhibitors, in patients who cannot afford the frequent usage of expensive oral medication or those who do not fully respond to PDE5-inhibitors.
Article
Introduction: The field of sexual medicine is continuously advancing, with novel outcomes reported on a regular basis. Given the rapid evolution, updated guidelines are essential to inform practicing clinicians on best practices. Aim: To summarize the current literature and provide clinical guidelines on penile traction therapy, vacuum erection devices, and penile revascularization. Methods: A consensus panel was held with leading sexual medicine experts during the 2015 International Consultation on Sexual Medicine (ICSM). Relevant literature was reviewed and graded based on Oxford criteria to develop evidence-based guideline and consensus statements. Main outcome measures: The development of clinically relevant guidelines. Results: Penile traction therapy is a viable therapy to modestly improve penile length as a primary therapy, before penile prosthesis placement in men with decreased penile length or after surgery for Peyronie's disease. It also might have a role in the acute phase of Peyronie's disease but has inconsistent outcomes in the long-term phase. Vacuum erection devices are effective in creating an erection satisfactory for intercourse, even in difficult-to-treat populations. They also might be used in the post-prostatectomy setting to maintain penile length but have insufficient evidence as a penile rehabilitation therapy. For vasculogenic erectile dysfunction, men with suspected arterial insufficiency can be evaluated with penile Duplex Doppler ultrasonography and confirmatory angiography. Penile revascularization procedures have consistently demonstrated benefits in very select patient populations; however, inadequate data exists to suggest the superiority of one technique. Men with vascular risk factors are likely poor candidates for penile revascularization, although veno-occlusive dysfunction and age are less significant. Therapies for treating primary veno-occlusive dysfunction are not recommended and should be reserved for clinical trials. Conclusions: Since the prior ICSM meeting, multiple developments have occurred in external mechanical devices and penile revascularization for the treatment of erectile and sexual dysfunction. Sexual medicine clinicians are encouraged to review and incorporate recommendations as applicable to their scope of practice.
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Resumen La disfunción venoclusiva peneana (VOD), está siendo reconocida como una causa importante de disfunción eréctil en especial en pacientes jóvenes. Recientemente se han sugerido fisiopatologías novedosas y se han mejorado notablemente los métodos diagnósticos, lo que genera un campo en redescubrimiento con nuevos enfoques de tratamiento disponibles. La ligadura de fuga venosa dorsal ha tenido dificultades a través de la historia para ser estandarizada. El artículo enfatiza que el diagnóstico adecuado es la base del éxito en esa patología, para cuya resolución presentamos una técnica quirúrgica asequible, aún en sitios con limitaciones tecnológicas, reproducible y con buenos resultados a corto y mediano plazo. Cuando se sospecha de una fuga venosa dorsal profunda que cause alteraciones hemodinámicas con un cierto tipo de disfunción eréctil, con penes que en erección alternan en estados de duro-blando, se configura un síndrome especial, con hallazgos clínicos y ecográficos típicos. Aunque existen algunas opciones médicas de tratamiento, se propone la corrección quirúrgica de la fuga venosa como el método ideal de tratamiento definitivo.
Article
The common surgery for venous leakage was not very successful; unsatisfactory long-term results have reduced the indications for venous surgery for erectile dysfunction (ED). To assess the outcomes of embedding the deep dorsal vein of the penis (EDDVP), a new surgical technique used in patients with penile deep dorsal venous leakage of ED. Between December 2001 and November 2007, 17 patients diagnosed with penile deep dorsal venous leakage of ED underwent embedding the deep dorsal vein of the penis. All cases were available for follow up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and penile color Doppler ultrasound. Dynamic cavernosography were also assessed in three patients at 3 months postoperatively. After surgery, 14 patients were able to achieve satisfactory intercourse and three had sufficient erection after oral sildenafil (50-100 mg). The IIEF-5 scoring changed from a preoperative mean IIEF-5 score of 8.8 +/- 3.9 to 20.8 +/- 4.1 (P < 0.05). Peak systolic velocity (average of right and left cavernosal arteries) changed from 41.9 +/- 7.7 cm/second to 44.2 +/- 9.2 cm/second (P > 0.05), resistance index changed from 0.79 +/- 0.1 to 1.00 +/- 0.0 (P < 0.05), and venous velocity changed from 8.4 +/- 4.0 cm/second to 0.0 +/- 0.0 cm/second (P < 0.05). Dynamic cavernosography demonstrated a smooth flow of the deep dorsal vein during the flaccid phase. During the tumescent phase, the deep dorsal vein of the penis was compressed between the dilated sinusoidal spaces and the tunica albuginea and resulted in venous drainage blockade. And then the hardness of erection was improved and maintained. The new surgical technique of EDDVP is a simple operative procedure, which seems to be efficient in the treatment of penile deep dorsal venous leakage of ED.
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We now know that outflow restriction is essential for maintaining a rigid erection, which can be achieved after satisfactory smooth muscle relaxation. The aim of this study was to assess retrospectively the efficacy of penile vein surgical ligation in patients with a follow-up of at least 3 years. Thirty-two men with impotence due to cavernovenous occlusive disease underwent penile vein ligation for management of organic erectile dysfunction. Cavernovenous occlusive disease was diagnosed by gravity cavernosometry. Long-term evaluation revealed sustained potency without adjunctive therapy in only 7 patients (21.87%). Twenty-five patients (78.12%) did not show any improvement in the erectile mechanism. Associated complications included penile shortening in 4 (12.5%), hypoesthesia of the glans area in 2 (6.25%), and Peyronie's disease in 1 (3.2%). Based on these data, we conclude that the long-term success of penile vein ligation is poor.
Article
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To investigate the anatomy of the ischiocavernosus muscle, bulbospongiosus muscle, and tunica albuginea and to determine their relationships to smooth muscle, which is a key element of penile sinusoids, we performed cadaveric dissection and histologic examinations of 35 adult human male cadavers. The tunica of the corpora cavernosa is a bilayered structure that can be divided into an inner circular layer and an outer longitudinal layer. The outer longitudinal layer is an incomplete coat that is absent between the 5-o'clock and 7-o'clock positions where 2 triangular ligamentous structures form. These structures, termed the ventral thickening, are a continuation of the anterior fibers of the left and right bulbospongiosus muscles. On the dorsal aspect, between the 1-o'clock and 11-o'clock positions, is a region called the dorsal thickening, a radiating aspect of the bilateral ischiocavernosus muscles. In the corpora cavernosa, skeletal muscle contains and supports smooth muscle, which is an essential element in the sinusoids. This relationship plays an important part in the blood vessels' ability to supply the blood to meet the requirements for erection, whereas in the corpus spongiosum, skeletal muscle partially entraps the smooth muscle to allow ejaculation when erect. In the glans penis, however, the distal ligament, a continuation of the outer longitudinal layer of the tunica, is arranged centrally and acts as a trunk of the glans penis. Without this strong ligament, the glans would be too weak to bear the buckling pressure generated during coitus. A significant difference exists in the thickness of the dorsal thickening, the ventral thickening, and the distal ligament between the potent and impotent groups (P < or =.01). Together, the anatomic relationships between skeletal muscle and smooth muscle within the human penis explain many physiologic phenomena, such as erection, ejaculation, the intracavernous pressure surge during ejaculation, and the pull-back force against the glans penis during anal constriction. This improvement in the modeling of the anatomic-physiologic relationship between these structures has clinical implications for penile surgeries.
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In this study, we aimed to determine the hemodynamic mechanisms through which cigarette smoking, as an independent risk factor, induces erectile dysfunction (ED). We performed a standard ED evaluation that included history; a physical exam; and serum glucose, testosterone, and prolactin levels. We then excluded ED patients with abnormal androgen profiles and patients with ED risk factors other than smoking. A total of 109 ED patients entered the study, including 71 current smokers and 38 nonsmokers. All patients then underwent extensive evaluation, including nocturnal penile tumescence and rigidity (NPTR) monitoring with Rigiscan, followed by pharmacopenile duplex ultrasonography (PPDU) and redosing pharmacocavernosometry (RPC). Results of the above tests were compared in the smoker and nonsmoker groups. We also performed receiver operating characteristic (ROC) curve analysis to determine which diagnostic parameter is most affected by cigarette smoking. The 4 most significant variates served as input features for a logistic regression model, designed to predict smoking. The average age for smokers and nonsmokers was 44.3 and 51.2 years, respectively (P = .02). Eighty-six percent of smokers had abnormal NPTR testing compared with 55% of nonsmokers (P = .02). The average peak systolic velocity (PSV) was 26.8 and 31.2 cm/s for smokers and nonsmokers, respectively, and this difference was not found to be statistically significant (P = .19) in this study. On performing RPC, an abnormal maintenance flow (MF) of >5 mL/min was detected in 89% of smokers and in 47% of nonsmokers, and the difference was significant (P < .01). With the use of smoking as the outcome, the ROC area of different diagnostic parameters was as follows: 0.79 for penile base rigidity, 0.58 for PSV, and 0.77 for MF. A logistic regression model that used the 4 most significant variates as input features yielded a ROC of 0.857. The results of NPTR testing in our smoker and nonsmoker groups indicated that ED in smokers is mainly of organic etiology. On the basis of the PPDU findings and the higher incidence of abnormal MF in the smoker group and its relatively high ROC value, we concluded that dysfunction of penile veno-occlusive mechanisms plays a substantial role in the development of ED in smokers.
Article
PurposeThe American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data.Materials and MethodsThe panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery.ResultsEstimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery.ConclusionsFor the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.
Article
Forty-one patients underwent penile venous ligation surgery for pure cavernosal venous leakage diagnosed by infusion cavernosometry and cavernosography. Before surgery, arterial integrity was assessed by pelvic angiography, and all patients were found to have a normal penile arterial system. The patients were divided into two groups on the basis of the type of venous operation performed. The overall complete-potency success rate was 46% (19 of 41 patients). Postoperative complications were minimal. Our experience shows that penile venous surgery remains an acceptable option for treatment of carefully selected patients with documented pure cavernosal venous leakage of a mild degree who have no evidence of arterial insufficiency and who do not prefer, or are not suitable for, other medical or surgical treatment options. Patients who had more severe degrees of cavernosal venous leakage had a poor result from this procedure. For patients with moderate to severe venous leakage, we now perform a combined surgical procedure, deep dorsal vein arterialization and venous ligation.
Article
Dynamic cavernosometry and cavernosography can be used to identify patients with corporeal venous incompetence as a cause of erectile dysfunction. We reviewed our series of 16 patients with venous leakage who underwent surgical correction of the specific abnormality identified on cavernosography. Short-term and long-term results were obtained, and while at least temporary improvement was noted in 89.5% of the patients the long-term results tended to show a reversion to the preoperative status in the majority.
Article
Recent data suggest that approximately 80 per cent of the men with vasculogenic impotence have evidence of failure to store blood (venous leakage) within the corpora cavernosa. To identify the venous channels into which corporeal blood drains in impotent men, we performed cavernosograms after intracorporeal injection of papaverine in 44 consecutive men presenting with erectile dysfunction and these were compared to studies in 10 potent men. The cavernosograms were examined for evidence of venous drainage from the penis and the site of leakage was identified. It was determined that among the impotent population with vasculogenic impotence 37 of 40 evaluable men (92.5 per cent) demonstrated contrast medium in the venous system draining the penis: the deep dorsal vein was visualized in 55 per cent, proximal cavernosal and crural veins in 55 per cent, deep dorsal and proximal veins in 22.5 per cent and corpus spongiosum in 25 per cent. Only 2 of the 10 potent men demonstrated contrast medium in the venous channels draining the penis. From these observations we conclude that in men suspected of having venogenic impotence identification of the drainage vessels by cavernosography appears to be important in planning any surgical approach to occlude these veins. However, the finding of a venous leak by cavernosography must not be considered a sine qua non diagnosis of venogenic impotence, since a certain percentage of potent men will demonstrate this radiographic finding.
Article
Excessive venous flow during erection is an acknowledged cause of impotence. At the turn of the century, Wooten and Lydston reported a cure rate of roughly 50 per cent after ligation of the deep dorsal vein of the penis. In 1979, Ebbehoj and Wagner restored potency in three of four patients with venous leakage. Later, Virag reported the diagnostic technique of dynamic cavernosography and proposed deep venous ligation. In 1985, Wespes and Schulman reported an 80 per cent success rate for correction of venogenic impotence by ligating the deep dorsal vein and its tributaries. Since then, Bennett and associates have achieved success in six of eight patients, and Lewis and Puyau report a 50 to 75 per cent success. With the technique described above, after careful selection and proper diagnostic testing, impotence has resolved or erection improved in more than 80 per cent of our patients.
Article
Venous surgery for impotence is in a dynamic state. The drainage of the corpora cavernosa normally occurs through the crural veins or the cavernous veins and the deep dorsal penile vein. Patients with drainage seen on cavernosography only into a superficial system that persists after injection of intracavernous vasoactive agents are likely to have good results if this drainage is eliminated. This type of patient is not common. A surgical approach that attempts to eliminate the deep dorsal penile system or the crural veins is not as successful. Perhaps subtle arterial disease, concurrent presence of neurologic disease, and collateralization all add to the significant failure rate. Many failures of spontaneous erection will, however, respond to intracavernous injection of vasoactive agents postoperatively. Deep dorsal vein arterialization probably should be reserved for those patients who have an arterial component to their impotence as well as a venogenic cause.
Article
Blood drainage of the corpora cavernosa is made by the deep dorsal vein and by the deep crural veins. The root of the corpora can be compressed against the ischium during papaverine test or cavernometry. In a series of patients with cavernosal leakage, this maneuver demonstrated that the crural edge of the corpora is the point of leakage in many of them. Exclusion of the crural edge by ligation of the corpora proximal to the entrance of the arterial supply caused improvement of erections in 7 of 8 patients.
Article
A multidisciplinary approach was used to diagnose 12 patients with vasculogenic impotence. Deep dorsal vein ligation was performed in 8 men to treat venous incompetence. Venous arterialization according to the technique of Virag was used in 4 men to treat arterial inflow insufficiency. A 75 per cent success rate was noted for the correction of venous incompetence. With an average followup of 1 year, excellent success was achieved in re-establishing corporeal blood flow with the technique of venous arterialization plus creation of a venocorporeal shunt.
Article
While the arterial aspects of erectile impotence recently have received considerable attention, the venous component of normal and impaired erection has been ignored. In this study venous leakage was demonstrated by inducing passive erections using a controlled perfusion of the corpora cavernosa with continuous pressure monitoring. In 20 patients with impaired erectile activity under a standardized flow (80 to 120 ml. per minute) no rigid erections were obtained and the perfused liquid was demonstrated to escape through the deep dorsal vein of the penis. After ligation of this vein the erections improved sufficiently to allow satisfactory intercourse in 16 of the 20 patients. The 4 failures had serious arterial lesions. In patients with organic impotence the venous pathological condition should be assessed routinely, since it represents an easily correctable anomaly if arterial inflow is not severely impaired.
Article
To review the long-term results and satisfaction of patients after venous leak surgery for the management of impotence caused by a failure of passive venous occlusion. Twenty-seven patients (mean age 56 years, range 26-63) with erectile failure due to venous leakage, diagnosed on colour Doppler imaging (CDI) and pharmacocavernosometry and cavernosography, underwent venous leak surgery. In all cases the deep dorsal vein of the penis was excised and ligated along with any other large accessory veins. Patients were reviewed in out-patients at 3 months and asked to complete a questionnaire 1 year after surgery. Three months after surgery, 19 of 27 patients (70%) had been able to resume sexual intercourse, 17 (63%) had spontaneous erections and two (7%) required papaverine/prostaglandin E1. One year after surgery, 14 of 22 patients were able to achieve erections sufficient for sexual intercourse, although four of these required self-injection with papaverine. There were no serious complications, and when asked whether or not they would undergo the operation again, 13 of 20 said they would. We conclude that venous leak surgery is a useful treatment modality in patients with pure venous leakage proven by pharmacocavernosometry and/or cavernosography, and in whom arteriogenic impotence has been excluded using CDI. These are often desperate patients who would rather accept the risk that this relatively minor procedure may fail in preference to undergoing implant surgery in the first instance or use a vacuum device. However, well-informed consent is essential.
Article
Penile vein ligation for venogenic impotence was performed on 15 patients between 1989 and 1992. Preoperative evaluation included color flow Doppler ultrasound, and dynamic infusion cavernosogram and cavernosometry with vasoactive substance injection. All operations were performed by 1 surgeon via an inguinoscrotal incision by excising the deep dorsal, cavernous and, if necessary, crural veins. All patients were interviewed using a structured telephone questionnaire from 19 to 45 months (mean 29) postoperatively. Postoperative potency was defined as erections sufficient for unaided coitus on more than 75% of attempts and was present in 9 patients (60%). The 2 failures had temporary improvement within the first 6 months. The only significant preoperative variable in assessing postoperative potency was the duration of erectile dysfunction before penile vein ligation: median 60 months (range 48 to 120) in the impotent group and median 24 months (range 12 to 168) in the potent group (p < 0.05, Mann-Whitney test). No correlation was found with systolic and diastolic arterial flow or resistive index as assessed by color flow Doppler evaluation, sites of leakage or patient age at operation. Similarly, no correlation was found with preoperative dynamic infusion cavernosometry maintenance rates. The most common complication was contracture of the penis in 6 patients (40%), although only 1 complained of a functional disturbance. We demonstrated favorable long-term results with an extensive venous ligation. While preoperative assessment with color flow Doppler ultrasound, dynamic infusion cavernosography and cavernosometry, and vasoactive substance injection establishes a diagnosis of corporeal veno-occlusive dysfunction, this evaluation provides no predictive indicators for successful outcomes in penile vein ligation.
Article
We have performed penile vein ligation on 35 patients with venogenic impotence from July 1989 to December 1991. The criteria for surgery were (1) age less than 60 years; (2) negative vasoactive agent intracavernous injection but normal penile arterial function, and (3) abnormal venous leakage documented by dynamic infusion cavernosometry and cavernosography. The procedure in venous ligation is excision of the deep dorsal vein from coronary sulcus to pubic arch, and ligation of cavernous veins after identification. The average follow-up was 27.5 months (range 12-37 months) for 30 patients. The 2 patients who revealed no erection at all immediately after operation had dense adhesion of penile hilar region caused in one case by severe pelvic trauma and in the other by pubic bone fracture. Twenty-eight (93.3%) patients were found to sustain excellent erection within 3 months postoperatively. However, only 12 (40.0%) patients sustained spontaneous erection at long-term follow-up, while another 7 (23.3%) responded to intracavernous injection. It is worth mentioning that tortuous and marked dilation of the deep dorsal vein and/or cavernous veins were found intraoperatively in 6 patients who were observed to have excellent erections postoperatively. Inadequate elimination of the leakage veins, especially crural veins, is the most likely factor in those who had a recurrence of erectile dysfunction. However, the corpus cavernosum, particularly a myopathic condition or inadequate neurotransmitters, also plays an important role. Complications included shortness of penis (3 patients), penile deviation (3), numbness of glans penis (4) and wound infection (1).(ABSTRACT TRUNCATED AT 250 WORDS)
Article
From February 1987 to September 1991, 122 men with erectile impotence and confirmed cavernosal venous leakage underwent penile venous surgery. After a postoperative follow-up of 36 months, only 18.8% of the patients had satisfactory erections without further therapy. Another 32.5% postoperatively converted to responders to intracavernous injection therapy with vasoactive drugs. Therefore, a total of 51.3% benefitted from the operation. Dynamic pharmacocavernography proved to be the most important examination in terms of establishing indication and prognosis. According to our results, there are two basically different forms of cavernosal venous leakage with different postoperative outcomes: primary and secondary corporeal incompetence. In many cases, an arterial cofactor was determined.
Article
Between 1986 and 1991, 46 men with organic impotence documented by dynamic pharmacocavernosometry and cavernosography to have venous leakage underwent penile vein ligation. Despite initial improvement in erections allowing normal intercourse in 34 men (74%) within the first 6 months, long-term (more than 12 months) evaluation revealed sustained potency without adjunctive therapy in only 11 (24%). Of the remaining 35 men 6 (13%) progressed to a penile prosthesis, 8 (17%) required intracavernous vasoactive injection therapy and 21 (46%) have not sought further therapy despite continued impotence. Of the 14 patients who had isolated distal leakage 6 (43%) had sustained erectile function while only 5 of the 32 patients (16%) with proximal leakage maintained potency. Associated complications included penile shortening in 20 (43%) and penile hypoesthesia in 9 men (20%). Therefore, we conclude that the long-term success of penile vein ligation is poor, with only 24% of the patients able to have normal intercourse more than 1 year later, although those patients with distal penile shaft leakage appear to have a greater chance of success than those with more proximal leakage.
Article
We investigated the pathophysiology of structurally based corporeal veno-occlusive dysfunction. We prospectively evaluated 24 impotent patients (mean age plus or minus standard error 46 +/- 3 years) who had exposure to vascular risk factors and/or disorders inducing diffuse trabecular structure alterations and who underwent penile prosthesis insertion. Preoperative indexes of veno-occlusive function (flow to maintain, venous outflow resistance and pressure decay measurements using repeat dosing pharmacocavernosometry) were correlated with postoperative erectile tissue computer assisted color histomorphometry (percent trabecular smooth muscle to total erectile tissue area). To develop further study findings and correlate histomorphometric findings with molecular biological properties molecular biological studies (ribonuclease protection analysis, reverse transcription-polymerase chain reaction assay for expression of transforming growth factor-beta 1 messenger [m] ribonucleic acid [RNA] and protein affinity labeling techniques for specific transforming growth factor-beta receptors) were performed in representative patients with high (39 to 43%), intermediate (30 to 37%) and low (13 to 29%) trabecular smooth muscle content (normal 42 to 50%). Flow to maintain, venous outflow resistance and pressure decay values significantly correlated with trabecular smooth muscle cell content (r = -0.89, 0.82 and -0.85, respectively). In the high, intermediate and low smooth muscle content subgroups flow to maintain, venous outflow resistance and pressure decay values were 1 to 5, 9 to 30 and 50 to 120 ml. per minute, 17 to 84, 3 to 9 and 1 to 2 mm. Hg/ml. per minute, and 40 to 60, 48 to 80 and 110 to 120 mm. Hg decrease in 30 seconds from 150 mm. Hg, respectively. There were no significant differences in patient age or prevalence of risk factors among the 3 subgroups. Patients representative of all 3 subgroups had transforming growth factor-beta 1 mRNA, auto-induction of transforming growth factor-beta 1 mRNA and induction and/or increased availability of all 3 types of transforming growth factor-beta receptors. The pathophysiology of structurally based corporeal veno-occlusive dysfunction is related to elevated corporeal connective tissue content. Based on our data and those in the literature corporeal fibrosis is hypothesized to develop secondary to abnormalities in the regulation of normal collagen synthesis and degradation, most likely associated with adverse influences of chronic ischemia.
Article
The American Urological Association convened the Clinical Guidelines Panel on Erectile Dysfunction to analyze the literature regarding available methods for treating organic erectile dysfunction and to make practice recommendations based on the treatment outcomes data. The panel searched the MEDLINE data base for all articles from 1979 through 1994 on treatment of organic erectile dysfunction and meta-analyzed outcomes data for oral drug therapy (yohimbine), vacuum constriction devices, vasoactive drug injection therapy, penile prosthesis implantation and venous and arterial surgery. Estimated probabilities of desirable outcomes are relatively high for vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis therapy. However, patients must be aware of potential complications. The outcomes data for yohimbine clearly indicate a therapy with marginal efficacy. For venous and arterial surgery, based on reported outcomes, chances of success do not appear high enough to justify routine use of such surgery. For the standard patient, defined as a man with acquired organic erectile dysfunction and no evidence of hypogonadism or hyperprolactinemia, the panel recommends 3 treatment alternatives: vacuum constriction devices, vasoactive drug injection therapy and penile prosthesis implantation. Based on the data to date, yohimbine does not appear to be effective for organic erectile dysfunction and, thus, it should not be recommended as treatment for the standard patient. Venous surgery and arterial surgery in men with arteriolosclerotic disease are considered investigational and should be performed only in a research setting with long-term followup available.
Article
Published studies on the epidemiology of erectile dysfunction and the physiology/ pathophysiology of erectile function are reviewed. A literature search of more than 400 studies of the epidemiology and pathophysiology of impotence and erectile dysfunction published during the last 3 decades was conducted and the most pertinent articles are discussed. It has been estimated that the prevalence of erectile dysfunction of all degrees is 52% in men 40 to 70 years old, with higher rates in those older than 70 years. Erectile dysfunction has a significant negative impact on quality of life. Risk factors for erectile dysfunction include aging, chronic illnesses, various medications and cigarette smoking. A nitric oxide/cyclic guanosine monophosphate mechanism has an important role in mediating the corporal smooth muscle relaxation necessary for erectile function. Other mechanisms involving neuropeptides, gap junctions and ion channels also may modulate corporal smooth muscle tone. Erectile dysfunction can be due to vasculogenic, neurogenic, hormonal and/or psychogenic factors as well as alterations in the nitric oxide/cyclic guanosine monophosphate pathway or other regulatory mechanisms, resulting in an imbalance in corporal smooth muscle contraction and relaxation. Erectile dysfunction is a common condition associated with aging, chronic illnesses and various modifiable risk factors. Normal penile erection is a hemodynamic process that is dependent on corporal smooth muscle relaxation mediated by parasympathetic neurotransmission, nitric oxide, and possibly other regulatory factors and electrophysiological events. As more knowledge is gained of the physiology and regulatory factors that mediate normal erectile function, the mechanisms involved in the pathophysiology of erectile dysfunction should be further elucidated.
Article
The structure of the human penile venous system has been well studied, but disappointing outcomes of penile venous surgery in certain patients have called into question on the anatomy. We planned to extend the anatomic knowledge with the ultimate goal of improving operative success. Thirty-five patients, who had undergone penile venous surgery, complained of poor erection developed gradually 6 months to 7 years postoperatively. Cavernosography was performed again during their return visit. Seven new patients underwent spongiosography followed by immediate cavernosography. Eleven male cadavers were carefully dissected. The anatomical findings were applied to venous surgery in 155 patients, who were then followed with the International Index of Erectile Function Questionnaire-5 (IIEF-5). Imaging observation demonstrated that the deep dorsal vein served as a common vessel of the corpora cavernosa and corpus spongiosum. A prominent cavernosal vein was found coursing along each corpus cavernosum distally to the glans, in contrast to its reported description as a short segment at the penile hilum. All cadavers had two sets of para-arterial veins sandwiching the dorsal artery. In 148 men available for follow-up, their mean IIEF-5 score was 9.3 preoperative and increased to 22.7 after the operation. The 88.5% (131/148) of the patients believed that venous stripping was a worthy treatment modality. Five cases required sildenafil to maintain their potentia, which was not working preoperatively. The failure of penile venous surgery has traditionally been ascribed to penile vein regeneration. However, our finding of a long and independent cavernosal vein and an independent set of para-arterial veins may be the principal cause in patients experiencing poor postoperative results.
Article
Although local anesthesia for penile surgery has been widely reported, its application for penile venous patch, however, has not been published. We evaluated an anesthetic and surgical technique on an outpatient basis. From March 1993 to September 2001, a total of 29 men with penile deformity, aged 27 to 77 years (mean 55 years) received a penile venous patch for morphologic correction. They received autologous grafting of the deep dorsal vein under local anesthesia as an outpatient procedure. The anesthetic effect and postoperative results were satisfactory. The average available area of the deep dorsal vein was 5.7 x 2.5 cm(2). The common immediate side effects included puncture of the vessels, subcutaneous ecchymosis, and transient palpitation, but there were no significant late complications. All patients returned home uneventfully. This has been proven to be a cost-effective, simple, and safe method with fewer complications. It offers the advantages of lower morbidity, protection of privacy, fewer adverse effects of anesthesia, and a more rapid return to activity with minimal complications.
Article
Priapism is a condition first described by Tripe in 1845. It has been defined as a pathological condition of penile erection that persists beyond or is unrelated to sexual stimulation. Two variants of priapism have been well described. The ischemic priapism (also known as low-flow priapism) and nonischemic priapism (or high flow priapism) have unique and distinct causes. It is important to distinguish these two conditions as the treatment for each is different. This review will focus on the two types of priapism and the appropriate diagnostic work-up for each. As well, the medical and surgical treatment options for these two conditions will be described in detail. A third entity known as stuttering priapism will also be discussed as will its unique treatment alternatives.
Article
The human penile venous system has been well studied and described but the demonstration of extra venous channels in imaging films prompted us to seek refinement of our anatomical knowledge of this venous system. Cavernosography in 37 patients who had venous stripping surgery and now suffered recurrent erectile dysfunction consistently showed an independent vein, smaller than the deep dorsal vein, running almost in the same position of the deep dorsal vein even though the latter had been removed unequivocally in previous surgery. Cavernosography in 9 patients who underwent intraoperative films also demonstrated the presence of this cavernosal vein in addition to the deep dorsal vein. Meticulous dissection of the penis under the microscope was then performed in 21 male cadavers and we found a cavernosal vein coursing along each corpus cavernosum all the way distally to the glans and draining directly into the Santorini's plexus in 19 subjects. This is in contrast to the previous description that this cavernosal vein was a short vein in the penile hilum. Two sets of para-arterial veins, which have not been reported in the literature, were found to accompany each dorsal artery in all 21 subjects. This more extensive and extra venous drainage might have important implication for venous stripping surgery in the treatment of erectile dysfunction.
Article
We give an overview of patients who have undergone removal of the deep dorsal vein for venous grafting in treating Peyronie disease with or without a Bovie effect. From June 1998 to May 2002, 23 men received grafting of the deep dorsal vein for morphologic correction. Among them, 7 men underwent electrocoagulation treatment of bleeders per surgeons' customary practice during the entire procedure and were categorized as the electrocoagulation group. Sixteen patients received simple ligation of bleeding stumps, with 6-0 nylon sutures, and were classified as the ligation group. All were followed for satisfaction of penile morphology and assessed by the abridged 5-item version of the international index of erectile function (IIEF-5) scoring for erectile capability. In the electrocoagulation group, a mean preoperative IIEF-5 score of 22.5 +/- 1.6 decreased to a mean postoperative IIEF-5 score of 17.9 +/- 4.1. Among them 2 men (28.6%) had sustained postoperative infection. Follow-up cavernosograms showing relatively poor filling are commensurate with intracavernosal fibrosis. In the ligation group, however, the mean IIEF-5 score was 22.3 +/- 1.9 preoperative and 22.9 +/- 2.0 postoperative. Although there was no statistical significance between the 2 groups in preoperative IIEF scores, there was a significant difference between groups postoperatively. Application of electrocoagulation appears to be disadvantageous in preserving erectile tissues. A Bovie effect should be avoided in this erectile organ in order to preserve erectile capability and avoid infection.
Article
Our aim was to study retrospectively the destiny of the deep dorsal vein of the penis in the event of its stripping surgery or its simple ligation in patients diagnosed with venoocclusive dysfunction 17 years ago. From June 1986 to May 1987, a total of 31 men were seen for erectile dysfunction due to venous leakage resulting from priapism, aging, or congenital or idiopathic factors. Of these, 23 men underwent venous stripping of the deep dorsal vein and are referred to as the stripping group. The remaining 8 patients received a simple ligation of the deep dorsal vein and are classified as the ligation group. A total of 21 patients (16 of the 23 and 5 out of the 8) were available for follow-up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and cavernosograms. In the ligation group, the imaging demonstrates some compensatory veins that are commensurate with impotence postoperatively. In the stripping group, however, the follow-up cavernosograms disclosed no venous recurrence, but residual ones that were not crucial to the rigidity. The IIEF-5 scoring in the ligation group changed from a preoperative mean IIEF-5 score of 10.0 +/- 4.5 to 9.8 +/- 3.6 postoperatively. In the stripping group, however, the mean preoperative IIEF-5 score of 9.8 +/- 4.1 increased to a mean postoperative IIEF-5 score of 18.9 +/- 2.1. Although there was no significant difference between the 2 groups' preoperative IIEF-5 score, there was a statistically significant difference between treatments (P <.001). The penile venous vasculature bears no evidence of regeneration even as long as 17 years after their removal. This finding is in contrast to what is commonly believed, that erectile dysfunction will recur about 2 years after ligation of the deep dorsal vein. We therefore believe that the clinical recurrence may not be due to venous regeneration, and penile venous surgery, if properly performed, may be durable, although larger studies will be required.
Article
Although penile venous surgery has almost been abandoned and the venous factor eliminated as a contributing factor to erectile dysfunction, new concepts of erection-related veins has recently been described and reported in literature. We sought to conduct a haemodynamic study on human cadavers in order to elucidate to what extent penile veins act in erection, and to explore the possible role of erection-related veins as an important contributor to impotence. From November 2002 to December 2003, seven fresh human cadavers of men who had no sexual activity for at least 6 months prior to death, and in whom the penis was intact were used for this study. Infusion cavernosometry was carried out with an induction flow of 150 mL/min before and after the erection-related veins were removed. A rigid erection was attained in all subjects, lasting significantly longer (p = 0.043) after removal of erection-related veins. Similarly, there were significant differences in the maintenance flow (p = 0.043), T(max) (p = 0.043), V(max) (p = 0.043), and pressure loss (p = 0.043). In cadaveric penises, a rigid erection could be maintained in spite of the fact that the low flow rate of 21 mL/min is much lower than the average arterial perfusion rate observed in cases of arterial insufficiency. We therefore concluded that penile veins may play a significant role in attaining sufficient erection, and further research is required to study this possible clinical implication.
Article
A possible synergistic effect between penile venous surgery and oral sildenafil was inadvertently found in treating patients with erectile dysfunction in our clinic. We therefore sought to elucidate the possible synergic effect between venous surgery and sildenafil through studying patients who were non-responders preoperatively. From July 1998 to July 2003, 128 patients were diagnosed with veno-occlusive dysfunction. Subsequently, 65 of them underwent penile venous surgery and were assigned to the surgical treatment group. The remaining 63 men were assigned to the control group, and were subject to a simple re-exposure of oral sildenafil. All patients were evaluated with the international index of erectile function (IIEF-5) scoring. Sildenafil (12.5-100 mg) was prescribed postoperatively to all surgical patients as venous surgery alone was unsatisfactory and similarly, 100 mg preparation was prescribed for patients in the control group. The IIEF-5 scoring in the control group changed from a preoperative mean IIEF-5 score of 9.4 +/- 3.9 to 10.7 +/- 3.5 postoperatively. In surgical patients, however, the mean preoperative IIEF-5 score of 9.2 +/- 5.0, which increased to 15.1 +/- 5.0 (p < 0.001) postoperatively, further increased to 20.1 +/- 5.4 (p < 0.0001) after the addition of sildenafil. Although there was no significant difference between the two groups characteristics, there was a statistically significant difference between treatment results (p < 0.001). Overall, 61 men (93.8%) reported a positive response to sildenafil after venous stripping surgery. In contrast, only eight patients (12.7%) felt a beneficial response in the control group (p < 0.001). Forty-one of 65 patients had scores of > or =22, and 19 of these had a score of 25. No response was found in three (4.6%), and a decrease of 7 was seen in one (1.5%). In summary, patients in whom sildenafil was not effective preoperatively can become excellent responders after careful penile venous surgery. It appears that together, oral sildenafil and penile venous surgery may provide an encouraging solution to impotent patients with veno-occlusive dysfunction who are non-responders to sildenafil.
Article
To summarize recent advances in human penile anatomy, hemodynamics and their clinical applications. Using dissecting, light, scanning and transmission electron microscopy the fibroskeleton structure, penile venous vasculature, the relationship of the architecture between the skeletal and smooth muscles, and erection hemodynamics were studied on human cadaveric penises and clinical patients over a period of 10 years. The tunica albuginea of the corpora cavernosa is a bi-layered structure with inner circular and outer longitudinal collagen bundles. Although there is no bone in the human glans, a strong equivalent distal ligament acts as a trunk of the glans penis. A guaranteed method of local anesthesia for penile surgeries and a tunical surgery was developed accordingly. On the venous vasculature it is elucidated that a deep dorsal vein, a couple of cavernosal veins and two pairs of para-arterial veins are located between the Buck's fascia and the tunica albuginea. Furthermore, a hemodynamic study suggests that a fully rigid erection may depend upon the drainage veins as well, rather than just the intracavernosal smooth muscle. It is believed that penile venous surgery deserves another look, and that it may be meaningful if thoroughly and carefully performed. Accordingly, a penile venous surgery was developed. Using this new insight into penile anatomy and physiology, exact penile curvature correction, refined penile implants and promising penile venous surgery, as well as a venous patch, for treating Peyronie's deformity might be performed under pure local anesthesia on an outpatient basis.
Penile enhancement: an outpatient technique
  • Hsu Gl
  • Hsieh
  • Ch
  • Wen
  • Chen Yc Hs
  • Lj Liu
  • Kang
  • Tj
  • Yang
  • Sd
  • Chiang
Hsu GL, Hsieh CH, Wen HS, Chen YC, Liu LJ, Kang TJ, Yang SD, Chiang HS. Penile enhancement: an outpatient technique. Eur J Med Sexol. 2002;11:6–10.
The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable?
  • Hsu Gl
  • Hsieh
  • Ch
  • Ling
  • Py
  • Wen Hs
  • Huang Hm
  • Liu
  • Chen Cw Lj
  • Wu
  • Sw
  • Chua
Hsu GL, Hsieh CH, Ling PY, Wen HS, Huang HM, Liu LJ, Chen CW, Wu SW, Chua C. The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable? J Androl. 2005 (revised).
Penile enhancement: an outpatient technique
  • G L Hsu
  • C H Hsieh
  • H S Wen
  • Y C Chen
  • L J Liu
  • T J Kang
  • S D Yang
  • H S Chiang
Hsu GL, Hsieh CH, Wen HS, Chen YC, Liu LJ, Kang TJ, Yang SD, Chiang HS. Penile enhancement: an outpatient technique.
The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable?
  • G L Hsu
  • C H Hsieh
  • P Y Ling
  • H S Wen
  • H M Huang
  • L J Liu
  • C W Chen
  • S W Wu
  • C Chua
Hsu GL, Hsieh CH, Ling PY, Wen HS, Huang HM, Liu LJ, Chen CW, Wu SW, Chua C. The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable? J Androl. 2005 (revised).