Vasculogenic impotence. Arterial and venous surgery

Serum lipocalin-2 and carotid artery intima-media thickness in relation to obesity in eugonadal males over forty with venogenic erectile dysfunction

Obesity is a risk factor for erectile dysfunction and atherosclerosis. Lipocalin-2 is an adipocytokine with proinflammatory properties involved in several disorders with metabolic alterations. Our aim was to study the relation of serum lipocalin-2 and carotid artery intima-media thickness (CIMT) to obesity in erectile dysfunction. Serum lipocalin-2 and CIMT were measured in 25 obese and 25 nonobese eugonadal patients over forty with venogenic erectile dysfunction and 25 healthy controls. Their relation to different patient- and disease-related parameters was studied. Results revealed lipocalin-2 to be significantly higher in obese compared with nonobese patients and with controls, and in nonobese patients compared with controls. CIMT was lower in controls compared with both obese and nonobese patients. In obese and nonobese patients, lipocalin-2 was positively correlated with disease duration, body mass index, waist circumference and end-diastolic velocity. Lipocalin-2 was negatively correlated with the short form of the international index of erectile function scores in both groups. In conclusion, the elevated lipocalin-2 in obese and to a lesser extent in nonobese patients and its association with disease severity points to its potential value as a diagnostic marker and a possible therapeutic target that could ameliorate the metabolic derangement associated with erectile dysfunction.

Surgical niche for the treatment of erectile dysfunction

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.

Erectile dysfunction treated with intracavernous stem cells: A promising new therapy?

In the past decades, great interest has been shown in the development of new therapies for erectile dysfunction. Stem cell therapy has generated promising results in numerous preclinical trials in animal models, which is why has led to the development of the first clinical trials in humans. The main cause involved in the pathophysiology of erectile dysfunction is vascular damage related to endothelial and neuronal injury. The interest in stem cell therapy is justified by their capability to differentiate into specific damaged tissues, including endothelium and nervous tissue, and induction of the host own cell proliferation. Despite the great effort of the many studies carried out to date, knowledge about biological effects, therapeutic efficacy and safety of stem cells therapy for erectile dysfunction is still very limited.

External Mechanical Devices and Vascular Surgery for Erectile Dysfunction

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.

Organic causes of erectile dysfunction in men under 40

There are a significant number of men under 40 who experience erectile dysfunction (ED). In the past, the vast majority of cases were thought to be psychogenic in nature. Studies have identified organic etiologies in 15-72% of men with ED under 40. Organic etiologies include vascular, neurogenic, Peyronie's disease (PD), medication side effects and endocrinologic sources. Vascular causes are commonly due to focal arterial occlusive disease. Young men with multiple sclerosis, epilepsy and trauma in close proximity to the spinal cord are at increased risk of ED. It is estimated that 8% of men with PD are under 40, with 21% of these individuals experiencing ED. Medications causing ED include antidepressants, NSAIDs and finasteride (Propecia), antiepileptics and neuroleptics. Hormonal sources are uncommon in the young population, however possible etiologies include Klinefelter's syndrome, congenital hypogonadotropic hypogonadism, and acquired hypogonadotropic hypogonadism. The workup of young men with ED should include a thorough history and physical examination. The significant prevalence of vascular etiologies of ED in young men should prompt consideration of nocturnal penile tumescence testing and penile Doppler ultrasound. Treatment options that may improve ED include exercise and oral PDE-5 inhibitors.

Korean Society for Sexual Medicine and Andrology (KSSMA) Guideline on Erectile Dysfunction

In February 2011, the Korean Society for Sexual Medicine and Andrology (KSSMA) realized the necessity of developing a guideline on erectile dysfunction (ED) appropriate for the local context, and established a committee for the development of a guideline on ED. As many international guidelines based on objective evidence are available, the committee decided to adapt these guidelines for local needs instead of developing a new guideline. Considering the extensive research activities on ED in Korea, data with a high level of evidence among those reported by Korean researchers have been collected and included in the guideline development process. The latest KSSMA guideline on ED has been developed for urologists. The KSSMA hopes that this guideline will help urologists in clinical practice.

Robot-assisted vessel harvesting for penile revascularization

INTRODUCTION

Ideal candidates for penile revascularization include young patients with documented vasculogenic erectile dysfunction usually resulting from pelvic trauma. Historically, large midline incisions were necessary to harvest the epigastric vessels for penile revascularization. We report our experience with robot-assisted epigastric vessel harvesting for use in penile revascularization procedures.

AIM

To describe our technique and experience with robot-assisted vessel harvesting for use in penile revascularization.

METHODS

Five patients were selected for penile revascularization. Each patient suffered pelvic crush injuries resulting in post-traumatic erectile dysfunction. Each patient had no significant prior medical history and had normal erectile function prior to injury. Penile duplex Doppler ultrasound studies using vasoactive agents demonstrated decreased arterial inflow. Complementary pelvic angiography documented the corresponding arterial lesions. Each patient underwent attempted penile revascularization using a modified Virag-V technique. The epigastric artery was harvested robotically and transposed through a 3 cm incision at the base of the penis. Microscopic revascularization was performed by anastamosing the epigastric artery to the deep dorsal vein. Distal dorsal vein ligation of the subcoronal plexus was performed to limit glans hyperemia.

MAIN OUTCOME MEASURES

Description of a new method of vessel harvesting for penile revascularization.

RESULTS

Penile revascularization was successful in four out of five patients. One patient had complete thrombosis of the deep dorsal penile vein and underwent subsequent penile prosthesis implantation. Each patient undergoing successful revascularization was discharged home two days postoperatively and has reported resumption of sexual activity.

CONCLUSIONS

The robot-assisted approach to epigastric vessel harvesting is an ideal minimally-invasive complement to penile revascularization. This procedure negates the need for a large midline incision and may shorten recovery time. Our described technique offers a novel option for the application of minimally-invasive technology, but longer-term follow-up is needed to further evaluate the success of penile revascularization.

Microcoil embolization of an arteriovenous fistula from the arteria bulbi penis to the corpus spongiosum penis in the treatment of erectile dysfunction: normal function regained immediately after intervention

A 39-year-old man presented with erectile dysfunction that had persisted since its sudden onset 5 years ago. He exhibited none of the classic risk factors, and all attempts at medication had been unsuccessful. An ultrasound examination revealed the presence of an arteriovenous shunt in the corpus spongiosum penis. Selective digital subtraction angiography of the left internal pudendal artery showed an arteriovenous fistula from the arteria bulbi penis to the corpus spongiosum penis. The outflow of venous blood took place via the penile veins into the periprostatic vein plexus. Superselective catheterization of the arteria bulbi penis was performed with a 3 French coaxial catheter (Topaz Micro Coils; Micro Therapeutics, Inc, Irvine, CA) and it was occluded by inserting several platinum coils. 1 week after the procedure, the patient reported normal erectile function, which was subsequently maintained.

EAU Guidelines on erectile dysfunction: an update

The introduction of new oral therapies has completely changed the diagnostic and therapeutic approach to erectile dysfunction. A panel of experts in this field has developed guidelines for the clinical evaluation and treatment based on the review of available scientific information.

ORIGINAL RESEARCH—ERECTILE DYSFUNCTION: Peak Systolic Velocities May Be Falsely Low in Young Patients with Erectile Dysfunction

INTRODUCTION

Introduction of duplex ultrasonography with color flow Doppler analysis after intracavernous injection of vasoactive drugs has been reported to be a minimally invasive and accurate method, and considered the gold-standard technique for evaluating penile hemodynamics. However, several studies have demonstrated that in some cases Color Doppler Ultrasound (CDU) testing may result in wrong diagnosis because of anxiety and increased sympathetic stimulation.

AIM

This study was carried out to evaluate the impact of age on the decision to repeat CDU in patients with initial low peak systolic velocities (PSVs).

METHODS

This is a prospective study involving 71 patients with erectile dysfunction (ED) who presented to the Department of Andrology, Sexology and Sexually Transmitted Diseases at Cairo University between December 2000 and April 2002. An intracavernous pharmacotest and CDU with prostaglandin E1, papaverine, and phentolamine was performed. All patients in the study had poor response to intracavernous pharmacotesting and achieved a low PSV (<30 cm/second) during the initial CDU examination. The CDU was repeated 2 weeks later. The 71 patients were grouped into four according to age: group A (20-29 years old) consisted of 11 patients, group B (30-39 years old) consisted of 19 patients, group C (40-49 years old) consisted of 20 patients, and group D (50-59 years old) consisted of 21 patients.

RESULTS

The group A patients experienced a statistically significant increase (P < 0.05) in their PSV measurements, which reached normal values in the second CDU. None of the patients of groups B, C, or D experienced any statistically significant change (P > 0.05) in their PSV measurements in the second CDU, which remained below normal values. Also, there was a statistically significant difference between the PSV measurements of group A and the other three groups.

CONCLUSIONS

Low PSV measurements in young men (less than 30 years old) with ED should be interpreted with caution. The effect of sympathetic overtone because of the environment in the office and anxiety related to penile injection, together with any underlying psychological disturbance, should be taken into consideration during the evaluation of the results of the CDU. Repetition of the CDU is recommended before considering any additional invasive diagnostic or therapeutic modalities.

An Overview of the Diagnosis and Treatment of Erectile Dysfunction

Epidemiological studies have demonstrated an age-stratified increase in the incidence and prevalence of erectile dysfunction (ED). There is a greater degree of openness today when discussing sexual matters and more information on the treatment of ED is available to the public through the media. Quality-of-life issues are now a matter of great importance to the aging population. Men and their partners are no longer prepared to merely accept ED as a natural consequence of aging. The advent of a simple and effective oral therapy for ED has also indirectly fueled the increase in treatment-seeking behaviour among men. Despite great strides in research into ED, our knowledge and understanding of the pathophysiological mechanisms is still in its infancy. As a result, we are able to treat only the symptom of ED rather than prevent it. Common diseases found in the population, such as diabetes mellitus and coronary artery disease appear to be risk factors for the development of ED. Therefore, physicians need to identify any underlying co-existing organic diseases in their patients presenting with ED. Whenever possible, patients are encouraged to attend their consultation sessions with their partners because ED is a condition affecting 'the couple' and not just the man. Psychogenic aspects of ED should also be explored during the consultation. Efforts need to be made to uncover and address the presence of any psychological stressors, if necessary with the help of a psychosexual therapist. The first-line treatment of ED is oral phosphodiesterase-5 inhibitors. For those who do not respond to oral therapy, there is no defined 'step-ladder' escalation in alternative therapy. It is up to the physician to discuss the options with the patient or couple and reach a decision based on their preference.

Tunica albuginea overlapping: a novel technique for the treatment of erectile dysfunction

Tunica albuginea (TA) in venogenic erectile dysfunction (VED) was found subluxated and flabby because of degeneration and atrophy of its collagen fibres. This had apparently led to derangement of TA veno-occlusive mechanism. We investigated the hypothesis that overlapping of the subluxated and flabby TA would achieve a competent veno-occlusive mechanism during erection. Tunical overlapping was performed in nine VED patients (age 35.6 +/- 1.6 years). Intracorporal pressure (ICP) was measured pre- and postoperatively. After penile degloving, TA on lateral penile aspect was divided along whole length of corpus cavernosum (CC) and tunical double-breasting for 1-1 1/2 cm was performed. A biopsy was taken from TA and stained with haematoxylin and eosin and Masson's trichrome. Clinical efficiency of the operation was evaluated after 6 months. ICP increased (P < 0.01) postoperatively in the nine patients. The increase was maintained during follow-up period in eight patients and decreased to preoperative level in one. Six months after operation, the eight patients had significantly (P < 0.01) improved scores for the erectile function domain over the preoperative scores. Microscopic examination of TA biopsies showed atrophy of the collagen fibres. Tunical overlapping aims at correction of TA flabbiness, corporal tissue support and improving of veno-occlusive mechanism.

Evaluation of penile revascularization for erectile dysfunction: a 10-year follow-up

The objective of this study was to report long-term success rates for penile revascularization (PR) and investigate factors responsible for failures. During the past 10 y, data were obtained on 52 patients who underwent PR. Surgical technique was selected according to preoperative arteriographic findings. The mean age was 28.5 y and the mean follow-up was 70.8 months. Success was defined as satisfactory intercourse without additional therapy. Overall success was 48%. Patients under 28 y showed a 73% success rate vs 23% in the older ones (P=0.0003). Nonsmokers had a 57% success compared to 29% in smokers (P=0.05). The presence of venous leak and type of procedure had an insignificant impact on success (P=0.33 and 0.23 respectively). To conclude, this curative treatment option is limited to a selective population with vasculogenic erectile dysfunction. We found that the cure rate of this procedure is maintained and long-term follow-up shows good results, especially in the young nonsmokers.

Specific aspects of erectile function in urology/andrology

The urologist/andrologist is the specialist responsible for diagnosis and treatment of health problems related to the genitourinary tract, and his or her participation in comprehensive care for a patient with erectile dysfunction (ED) is fundamental and often indispensable. The urologists/andrologists should characterize the origin of ED because of their knowledge and familiarity of all diagnostic tests and second- and third-line therapy. The origin of ED is important to determine for various reasons, such as young people suitable for etiologic treatment, medicolegal reasons, or patients' wishes for a better understanding of their condition. A review of the diagnostic tests available as well as indications for second- and third-line therapy is presented. The close relationship between ED and urological disorders, such as benign prostatic hyperplasia, prostate cancer and their treatments, and renal failure, in association with penile conditions like Peyronie's disease, priapism, and possible androgen deficiency in men older than 50 years, places the urologist at the center of integrated treatment of male ED.

Penile revascularization surgery for arteriogenic erectile dysfunction: the long-term efficacy rate calculated by survival analysis

OBJECTIVE

To determine the subjective and objective outcomes (by survival analysis) after penile revascularization surgery in patients with arteriogenic erectile dysfunction (ED), selected by established strict criteria.

PATIENTS AND METHODS

The study included 51 patients diagnosed with arteriogenic ED caused by localised arterial lesions and who had microscopic penile revascularization surgery between January 1996 and March 2002. Before surgery, all patients had a full examination, including a medical and sexual history, laboratory testing, intracavernosal pharmacological tests, colour Doppler ultrasonography (CDU), pharmacodynamic infusion cavernosometry and cavernosography, and digital subtraction angiography (DSA). Penile revascularization surgery was indicated only in patients aged <50 years and with no history of diabetes mellitus, hypertension or hyperlipidaemia. When there were communicating branches between the dorsal and cavernosal arteries, Hauri's procedure was used; when there were none or there was no evidence for them on both CDU and DSA because of severe narrowing or obstruction in the proximal common penile artery, the Furlow-Fisher modification of the Virag V procedure (FFV5) was used. The patency of the neo-arterial blood flow was assessed by CDU and effective rates calculated using the Kaplan-Meier method. The efficacy rate was recalculated whenever there was a recurrence. When occlusion of the neo-arterial blood was confirmed by CDU the date of occlusion was set as that midway between the last examination showing patency of the donor vessel and the latest examination indicating the occlusion. The patency period was the number of days from surgery to the date of occlusion.

RESULTS

Of the 51 patients, 26 had Hauri's and 23 the FFV5 procedure (median age 32 years, range 21-49); in two patients with a previous pelvic fracture surgery was not possible because of scar formation in the dorsal area at the base of the penis. The mean (sd) subjectively estimated efficacy rate was 85.9 (6.3)% after 3 and 67.5 (10.7)% after 5 years of follow-up. The duration at 75% efficacy was 41.0 (5.6) months. The objectively estimated efficacy rate was 84.9 (7.3)% at 3 and 65.5 (13.5)% after 5 years of follow-up. The duration at 75% patency was 42.4 (9.5) months, and at 50% was 60.6 (19.4) months. There was no significant difference in subjective outcome between the FFV5 and Hauri procedures (P = 0.38, log rank test) and none objective outcome after surgery (P = 0.19, log rank test). Thirteen of the 18 patients in the Hauri group had venous dilatation in the deep dorsal, obturator, prostatic and the internal iliac veins. There were operative complications in four patients (hyperaemia of the glans in two, and one each with haemorrhage from the anastomosis site and scar contracture).

CONCLUSIONS

The long-term efficacy rates (by the Kaplan-Meier method) of the Hauri and FFV5 procedures were both acceptable. The selection criteria gave acceptable outcomes from both procedures. Penile revascularization surgery is a treatment suitable only for young men and therefore attention must be given not only to the long-term outcome but also to long-term adverse events.

[Surgical therapy of erectile dysfunction. Current status]

In the light of the current domination of oral pharmacotherapy for the treatment of erectile dysfunction, the aim of this paper is to give a critical and up-to-date overview of the possibilities of surgical therapy. We evaluate possible therapy options such as penile vein surgery, arterial revascularisation surgery and penile prosthetics surgery. Today, vein surgery has faded into total insignificance due to the efficiency of oral and intracavernous therapeutics, and as a result of the pathomechanism of cavernoveinous insufficiency and the disappointing long-term results published in the literature. A similar fate has been met by penile revascularisation surgery, which today is performed only in a very limited number patients with strict selection criteria such as age and exclusion of diabetes mellitus. Thus, aside from pharmacotherapy, penile prosthetics is the only surgical therapy option maintaining its significance as a cure for erectile dysfunction. There are convincing long-term results with a high degree of patient and partner satisfaction, high patient acceptance and a good functional durability of the mostly three-part hydraulic implants.

Urological manifestations of vascular disease

We have detailed several of the urological manifestations of vascular disease. With the aging of the North American population, urologists will encounter the urological complications of vascular disease with ever-increasing frequency.

Erectile dysfunction and diabetes

Erectile dysfunction (ED) has been the most neglected complication of diabetes. It is a common abnormality that affects more than 20 million American men. The prevalence of ED in the general population between the ages of 40 to 70 years is 52%. In men with diabetes, it ranges from 35% to 75%, and occurs at an earlier age. There have been several advances in the understanding of the physiologic and biochemical mechanisms controlling penile erections. Improved techniques in diagnoses and treatment of impotence have given the male with diabetes some hope in the management of this prevalent and emotionally disturbing complication.