Long-term results of deep dorsal penile vein transsection in venous impotence

Sub-gluteal ligation of the internal pudendal vein for management of veno-occlusive erectile dysfunction (Shaeer's Vein Ligation-I): the cadaveric study

Vein ligation for veno-occlusive erectile dysfunction is being abandoned due to the recurrence rate. Among the reasons for failure is inability to ligate the deep system of veins; the internal pudendal vein. The vein exits the pelvis in the gluteal region, from the lesser sciatic foramen to the greater sciatic foramen, coursing over the ischial spine and sacro-spinous ligament, under the gluteus maximus. This work aims to verify feasibility of the first surgical procedure to ligate the internal pudendal vein through the gluteal approach. This cadaveric study involved five formalin-fixed cadavers. A surface anatomical landmark was designed to identify the ischial spine, at the intersection of two lines: a vertical line from posterior superior iliac spine to ischial tuberosity, and a horizontal line extending from sacro-coccygeal joint, laterally. An incision is cut encompassing the target point. Subcutaneous fat is dissected down to the gluteus maximus, which is split along the direction of its fibers. The vein can be found crossing over the ischial spine. "Shaeer's Vein Ligation - I" appears to be surgically feasible. A protocol for a surgical study is registered at clinicaltrials.gov, and is open for participation.

Barry shunt for treatment of a 76-hour stuttering priapism without subsequent erectile dysfunction

INTRODUCTION

This paper reports treatment of a 76-hour low-flow priapism with a shunting procedure that was first described by Barry in 1976. We were able to observe the preservation of erectile function despite the long period of ischemia. A review of the literature shows that there are few reports of erectile function recovery after a priapism of similar duration.

MATERIALS AND METHODS

A 42-year-old patient presented with a 76-hour priapism, probably caused by consumption of alcohol and illegal drugs. A Barry Shunt procedure was performed. The erectile function of the patient was assessed by means of International Index of Erectile Function score over a follow-up period of 30 months. Moreover, we reviewed different surgical options for treatment of priapism in the literature.

RESULTS

Partial return of erection without sexual arousal occurred on two occasions during the 10-day hospitalization, but was treated by manipulation of the penis, ie, by milking the tumescence into the shunt. After 3 months, the shunt was still palpable as a subcutaneous swelling. Six months postoperatively, the residual swelling had disappeared. The International Index of Erectile Function score was of 21 without phosphodiesterase type 5 inhibitors after a follow-up of 2.5 years.

CONCLUSION

Barry shunt is an effective alternative surgical option for the treatment of low-flow priapism. In the case of our patient, it was also effective after a 76-hour-lasting priapism.

Long-term results of dorsal penile vein ligation for symptomatic treatment of erectile dysfunction

About 20% of patients with erectile dysfunction do not react to intracavernous pharmacological treatment (SKAT) because of a cavernous leak. The first attempt to treat venous insufficiency goes back as far as the beginning of the century. Ligature and resection of the superficial and deep veins of the penis (DPVL) were performed in 122 patients (nonresponders to SKAT with a maintenance flow of less than 40 ml min-1). Twenty-four patients suffered from primary dysfunction and 98 from secondary dysfunction. The average age of the patients was 49 years, and the average duration of the preoperative erectile dysfunction 4.4 years. Postoperative follow-up was carried out for 70 months. In 98% of the patients, cavernosography revealed a dorsal leak. Twenty-six per cent had ectopic veins, 38% a leakage through the crural veins and 24% a glandular or spongiosal shunt. After the 70-month follow-up, only 14% of the 122 patients were able to achieve an adequate spontaneous erection and 19% also responded to SKAT. Depending upon the time elapsed since the operation, the rate of spontaneous reaction was reduced. It was found that younger patients with a short history of erectile dysfunction, no arterial cofactor, a maintenance flow of less than 100 ml min-1 and a severe dorsal leakage from a DPVL were the most likely to benefit from this procedure. Since degeneration of smooth muscle cells of the cavernosa is in most patients the cause of the venous leakage, penis vein surgery is to be regarded as symptomatic treatment.

Surgical treatment of penile veno-occlusive dysfunction: is it justified?

OBJECTIVES

Veno-occlusive dysfunction is a commonly diagnosed cause of impotence. Surgical removal of the intermediate (deep dorsal vein and its tributaries) venous system of the penis has been advocated as an effective treatment but recurrence of the dysfunction is common after a few months. We studied prospectively the first 100 cases of veno-occlusive dysfunction undergoing surgical treatment at our institutions.

METHODS

One hundred consecutive patients undergoing penile venous ligation surgery were evaluated. All patients had a comprehensive workup prior to therapy. Surgery involved excision of the intermediate venous drainage. Short-term results were investigated by personal interview, and long-term outcome was determined by separate telephone interview of patients and their partners when available.

RESULTS

Short-term success (3 months) was 62%, and long-term success (45 months) was 31%. Historical factors, preoperative testing results, and histologic assessment of the surgical specimens were not found to be helpful in predicting outcome.

CONCLUSIONS

Despite the mediocre long-term results of the surgical procedure and lack of preoperative predictive factors, we believe that venous leak surgery could be offered to well-selected patients in whom the only other available alternative would be a prosthetic device.

Long-term results with penile vein ligation for venogenic impotence

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.