Cornell University

NEW YORK
CORNELL
Cornell University
Weill Medical College

Cornell Institute for Reproductive Medicine

Center for Male Reproductive Medicine and Microsurgery

"State-of-the-Art Compassionate Care for the Infertile Couple"

Vascular Surgery for ED

Introduction

For the young male with ED that is either congenital (primary ED) or the result of pelvic/perineal trauma Vascular Surgery offers an option for potential CURE.

Penile Artery Bypass Surgery

Penile revascularization is one of the treatments that have the potential to permanently cure patients, that is, allow return of spontaneously developing erections without the necessity for any medications or internal/external devices. This procedure has undergone many refinements since its first description 1973. The specific objective of the surgery is to increase the erection (cavernosal) artery blood inflow in patients with blood flow related ED secondary to trauma. Young men, without other vascular risk factors (diabetes, high blood pressure, lipid disorders, cigarette smoking), who have ED due to pure artery blockage, represent the ideal patient population for this procedure.

All young patients with a history suggestive of trauma-associated impotence (pelvic fractures and perineal trauma) undergo routine hormonal evaluation to ensure adequate circulating levels of testosterone. The patients undergo a night-time penile erection test to rule out nerve damage or psychological ED. Finally, they undergo blood flow assessment, using either duplex Doppler ultrasound of the penis or dynamic infusion cavernosometry/cavernosography (DICC). The purpose of the investigation is to ensure that the ED is the result of a pure artery blockage. In these cases, an angiogram is performed to identify the site of the blockage and the presence of a donor and recipient artery.

A list of criteria have been developed that the patient and surgeon must meet to ensure optimum results. The criteria include: (a) patient must have strong sex drive, (b) patient must experience a consistent reduction in erectile hardness during sexual activity, (c) normal hormonal evaluation (d) normal neurologic evaluation (e) arterial insufficiency on vascular testing (f) arterial blockage located in the common penile artery or cavernosal artery (g) the presence of a donor (inferior epigastric) artery of sufficient length and (h) the surgeon must be trained in microvascular surgery. The operation that Dr. Mulhall, a fully-trained urologic microvascular surgeon, performs at the Sexual Medicine Program at The New York Presbyterian Hospital joining the dorsal artery of the penis, to the inferior epigastric artery.

The operation is generally performed in a 23-hour fashion (the patient returns home the day after surgery). Complications are minimal and include abdominal or scrotal pain/swelling and occasional temporary numbness on the top surface of the penis. Abstinence from sexual activity involving the erect penis is recommended for the first 6 weeks after the operation. In the hands of a surgeon trained to perform this procedure, this form of surgery is potentially curative for the carefully selected patient with ED. Any young male with ED that may be related to pelvic fracture, trauma to the perineum or prolonged bicycling may be a candidate for this form of surgery.

Venous Ligation Surgery

In general, the long-term benefits of venous ligation surgery have been limited, with short-term success rates cited between 30-50%. Venous leak is believed to be a manifestation of structural changes in the erectile tissue and the concept that ligation of venous channels external to the corporal body itself can remedy venous leak in a long-term fashion has little scientific basis. Venous ligation surgery is currently recognized as a purely investigational form of surgery. However, preliminary evidence supports the use of such surgery in young men with traumatic or congenital leakage from the most posterior portions of the erectile bodies, the crura.

At the Sexual Medicine Program at The New York Presbyterian Hospital, ligation of the crura is used to combat crural venous leak. No long-term data are available in a large cohort of patients and at this time this procedure is considered investigational. Prior to being considered for this procedure, young men need to undergo routine evaluation and the vascular study, DICC. If venous leak is identified to be present solely in the crura of the penis, then the patient is counseled about this form of surgery.

Suggested Reading

1 Goldstein I et al: Vascular diseases of the penis: impotence and priapism., in Pollack HM: Clinical Urography. Philadelphia, W.B. Saunders, 1990.
2 Hassan AA, et al: Long-term results of penile venous ligation for corporeal venous occlusive dysfunction. Canadian Journal of Surgery. 38: 537-41, 1995.
3 Lue TF: Penile venous surgery. Urologic Clinics of North America 16: 607-11., 1989.
4 Lue TF: Surgery for crural venous leakage. Urology. 54: 739-41., 1999.
5 Rogers RS et al.: Penile venous surgery benefits patients under 40 years of age. Journal of Urology 161: 258, 1999.
6 Wespes E et al: Venous leakage: surgical treatment of a curable cause of impotence. Journal of Urology. 133: 796-8., 1985.
7 Hatzichristou, DG et al.: Arterial bypass surgery for impotence. Current Opinion in Urology 1: 1991
8 Microvascular Arterial Bypass Surgery For Arteriogenic Erectile Dysfunction. Mulhall JP et al. In Carson et al (eds). Textbook Of Erectile Dysfunction, p309-316. ISIS Medical Media, Oxford, 1999.



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