Preliminary report--combined surgical and radiological penile vein occlusion for the management of impotence caused by venous-sinusoidal incompetence

Erectile Dysfunction Resistant to Medical Treatment Caused by Cavernovenous Leakage: An Innovative Surgical Approach Combining Pre-operative Work Up, Embolisation, and Open Surgery

OBJECTIVE

Thirty per cent of cases of erectile dysfunction (ED)/male impotence are resistant to oral treatment. Half of these cases are due to blood drainage from the corpora cavernosa occurring too soon, due to cavernovenous leakage (CVL). The aim of this study was to report on an innovative treatment scheme combining pre- and post-operative haemodynamic assessment, venous embolisation, and open surgery for drug resistant ED caused by CVL.

METHODS

An analysis of prospectively collected data, with clinical and haemodynamic pre- and post-operative assessment, was carried out. Forty-five consecutive patients operated on for drug resistant ED caused by CVL were evaluated pre-operatively and three months post-operatively by pharmacologically challenged penile duplex sonography (PC-PDS), pharmacologically challenged Erection Hardness Score (PC-EHS), and pharmacologically challenged computed caverno tomography (PC-CCT). Follow up consisted of patient interview, PC-PDS, PC-EHS and if needed PC-CCT.

RESULTS

Mean patient age was 43.9 ± 12.0 years (range 20-67). Forty-nine per cent of patients had primary ED. Patients with diabetes, a smoking habit, hypercholesterolaemia, and hypertension were 18%, 11%, 9%, and 4%, respectively. Three months post-operatively, PC-EHS increased from 2.0 ± 0.7 to 3.1 ± 0.74 (p < .001), with an EHS of 3 being the threshold allowing for penetration. Deep dorsal vein velocity, a haemodynamic marker of CVL, decreased from 14.2 ± 13.0 to 0.9 ± 3.5 cm/s (p < .001). After a 14.0 ± 10.7 month follow up, the primary success rate (clinical EHS ≥ 3, possible sexual intercourse with penetration, no vascular re-operation, no penile prosthesis implant) was 73.3%. Four patients (9%) underwent successful re-operation for persistent ED and CVL. Accordingly, compared with a possible penetration rate of 8.9% before surgery, 37 patients (secondary success rate: 82.2%) were able to achieve sexual intercourse with penetration. Type of ED (primary vs. secondary) and diabetes had no influence on the results. Thirty-two per cent of patients with secondary success achieved penetration with no medication.

CONCLUSIONS

After a 14 month follow up, pre-operative work up, embolisation, and open surgery during the same procedure allowed patients with ED resistant to oral medical to achieve intercourse with penetration.

The role of interventional radiology in the diagnosis and management of male impotence

Erectile dysfunction (ED) is defined as the persistent inability to reach or maintain penile rigidity enough for sexual satisfaction. Nearly 30% of the men between ages 40 and 70 years are affected by ED. A variety of pathologies, including neurological, psychological, or endocrine disorders and drug side effects, may incite ED. A commonly identified cause of ED is vascular disease. Initial diagnostic workup includes a detailed physical examination and laboratory tests. Whilst duplex ultrasound is considered the first-line diagnostic modality, intra-arterial digital subtraction angiography is still considered the "gold standard" for the diagnosis of arteriogenic impotence. Percutaneous endovascular treatment may be offered in patients with vasculogenic ED that has failed to respond to oral medical therapy as an alternative to penile prosthesis or open surgical repair. In arteriogenic ED balloon angioplasty of the aorto-iliac axis, and in veno-occlusive ED, percutaneous venous ablation using various embolization materials has been reported to be safe and to improve sexual performance. Recently, the ZEN study investigated the safety and feasibility of drug-eluting stents for the treatment of arteriogenic ED attributed to internal pudendal artery stenosis with promising preliminary results. This manuscript highlights the role of interventional radiology in the diagnosis and minimally invasive treatment of male impotence.

Erectile Dysfunction

Erectile dysfunction has been defined by the National Institutes of Health as the inability to achieve and/or to maintain an erection for satisfactory sexual intercourse. It may result from psychological or organic causes. With the advent of oral pharmacotherapy, the diagnostic approach has significantly changed over the past decade. The number of patients examined at the radiology clinics has also been decreased. However, evaluation by imaging modalities, such as color Doppler ultrasound, cavernosography, and angiography, still remains the cornerstone of the diagnostic workup of the patients with erectile dysfunction. The aim of this review was to focus briefly on the penile anatomy, the pathophysiology of erection, and radiological techniques for investigating vascular causes of erectile dysfunction and findings on different radiological methods.

Colour Doppler ultrasound of the penis

Because it is a superficial structure, the penis is ideally suited to ultrasound imaging. A number of disease processes, including Peyronie's disease, penile fractures and penile tumours, are clearly visualized with ultrasound. An assessment of priapism can also be made using spectral Doppler waveform technology. Furthermore, dynamic assessment of cavernosal arterial changes after pharmaco-stimulation allows diagnosis of arterial and venogenic causes for impotence. This pictorial review illustrates the range of diseases encountered with ultrasound of the penis.

Pelvic venoablation with ethanol for the treatment of erectile dysfunction due to veno-occlusive dysfunction

OBJECTIVES

To perform pelvic venoablation with ethanol injection into the deep dorsal vein for the treatment of 10 patients with venogenic erectile dysfunction. This procedure was easily performed without any selective embolization technique. The efficacy and safety of this technique are discussed.

METHODS

A total of 10 patients with veno-occlusive dysfunction, severe enough to make vaginal insertion impossible, underwent pelvic venoablation with ethanol. The mean patient age was 67.1 years. Under spinal anesthesia, after the venous leaks were identified by cavernosography, a 20-gauge flexible needle was inserted into the deep dorsal vein. The pelvic venogram obtained with deep dorsal venography was included in what was revealed by the venogram obtained with cavernosography. A mixture of absolute ethanol and contrast medium (4:1) was used as a sclerosing agent. Under fluoroscopic control, the sclerosing agents were injected into the deep dorsal vein through a flexible needle. Success was defined as the ability to achieve vaginal insertion without the aid of any drugs, vasoactive injections, penile prosthesis, or vacuum device.

RESULTS

The follow-up ranged from 25 to 37 months (mean 32.3). At the short-term follow-up visit (less than 6 months), 7 patients (70%) reported erections sufficient for vaginal insertion; at the long-term follow-up visit, 5 men (50%) reported sustained, sufficient potency and 5 (50%) reported persistent erectile dysfunction. No serious complications occurred.

CONCLUSIONS

Our pelvic venoablation technique using ethanol was effective, minimally invasive, and cost-effective.

Male sexual function and its disorders: physiology, pathophysiology, clinical investigation, and treatment

This review is designed to help the reproductive endocrinologist integrate his or her professional activity with those of other disciplines including urology, radiology, neurology, and psychology in order to successfully manage all of the inseparable aspects of male sexual and reproductive functioning. Significant advances in the field of male sexual physiology and pathophysiology and new methods of investigation and treatment of male sexual disorders are outlined. The review synthesizes available data on the following: norms of sexual organs, aging and sexuality, role of central and peripheral neurochemicals in each stage of the sexual cycle, role of corporeal smooth muscles in the hemodynamic control of erection and detumescence, influence of psychological factors, drugs, and disease on all aspects of sexual functioning, and use of nocturnal penile tumescence monitoring, imaging investigations, and neurophysiologic studies in the diagnostic workup of males with sexual dysfunction. Clinical algorithms are presented where appropriate. Extensive discussions on newly developed strategies in psychological and behavioral counseling, drug therapy, tissue engineering, nonsurgical devices, and surgical treatments for all forms of sexual disorders are also provided. Lastly, the effect of sexual dysfunction and its treatment on quality of life in affected men is addressed, along with recommendations for future research endeavors.

Vasculogenic impotence. Arterial and venous surgery

Arterial revascularization and venous ligation procedures have been introduced within the past 2 decades. Each procedure has in common with the other the fact that initial applications of the operations were widespread among the population of men with vasculogenic erectile dysfunction. In each case, disappointing long-term results led to more limited use of surgery targeting specific groups that clearly would benefit from the procedures. The wider application of these procedures in vasculogenic erectile dysfunction is not supported by the available results. The Clinical Guidelines Panel of the American Urological Association supported this view in 1996 after a meta-analysis of literature reports and declared that venous and arterial surgery was not justified in routine use, especially in patients with arteriosclerosis. Further studies are likely to refine patient selection but are unlikely to expand the therapeutic use of these procedures.

Embolotherapy for venous impotence: use of ethanol

PURPOSE

To evaluate the usefulness of embolotherapy with ethanol for the treatment of venous impotence.

MATERIALS AND METHODS

Twenty-three patients with venous impotence underwent embolotherapy. The diagnosis of venous impotence was made by means of pharmacocavernosometry and cavernosography. After exposure of the deep dorsal penile vein, a intravenous catheter was inserted directly into the deep dorsal penile vein and advanced into just front of the preprostatic plexus. Fifty percent ethanol was injected through the catheter and the endpoint of the procedure was determined based on results of venography immediately after injection. The procedure was finished when lack of venous leakage was confirmed.

RESULTS

In all patients, the deep dorsal penile vein was successfully exposed surgically, the sclerosing agent successfully injected, and the endpoint successfully achieved. Immediate clinical therapeutic effect (restoration of erection) was obtained in 20 cases (87%). No severe complications were observed during or after the procedure. The follow-up period was 6-50 months. Long-term therapeutic effect was confirmed for 18 of 23 patients (78%).

CONCLUSION

The authors' findings suggest that this treatment had satisfactory short-term and long-term clinical results and that longer follow-up is necessary to confirm its safety.

Embolization of the deep dorsal vein for the treatment of erectile impotence due to veno-occlusive dysfunction

PURPOSE

We evaluate the effectiveness of deep dorsal vein embolization for the treatment of venous impotence.

MATERIALS AND METHODS

A total of 32 impotent patients with veno-occlusive dysfunction underwent deep dorsal vein embolization. The condition was suspected based on findings of penile Doppler ultrasonography and cavernosometry. The diagnosis was confirmed with pharmacocavernosography that appeared to delineate venous leakage. During the procedure we isolated and cannulated the deep dorsal vein through a small dorsal penile incision with the patient under local anesthesia. We used a mixture of the tissue glue, N-butyl cyanoacrylate, and lipodol for embolization, with a total volume of 5 ml. injected antegrade into the previously catheterized dorsal vein under fluoroscopic control. As soon as we observed the occluded veins we performed repeat pharmacocavernosography. At 3-month followup patients were reassessed with history and cavernosometry. Followup ranged from 12 to 36 months (median 25).

RESULTS

Of 32 patients 22 (68.7%) regained sexual activity, which was confirmed by cavernosometry. The remaining 10 patients (31.3%) experienced little if any clinical response, which correlated with cavernosometry. There were no significant side effects.

CONCLUSIONS

Deep dorsal vein embolization for venogenic impotence is simple, effective and safe, and appears to be cost-effective. The results obtained in this limited number of patients are promising and justify trials in larger groups.

[Surgical treatments of erectile impotence]

Impotence affects 10 to 15% of the male population. Organic factors are recognized in 80% of cases. Intracavernosal injections of vasoactive agents (Virag) have provided advances in the physiopathologic understanding of impotence and provide new ways of treating this incapacity. However this option is inaffective in most organic cases: arteriogenic, venogenic or disorders of smooth cavernous muscle. Vasoactive injections for many reasons are abandoned in about 40% of the cases. Two kinds of surgical management can be performed: microrevascularization in order to restore the arterial penile flow or to reduce penile venous flow during erection; implantation of penile prosthesis when other therapeutic possibilities are exhausted. Arterialization of the deep dorsal vein (DDV) appears to be the best procedure in arteriogenic and principally venous impotence. Erectile function in theses case is restored in 60% of our patients. Two types of prostheses can be implanted: semi-rigid with an axial permanent rigidity and inflatable or hydraulic devices with a flaccid aspect after intercourse. These prostheses are technically successful in 75 to 90% of cases, but partner satisfaction does not match surgical success rates.