Urol Int 1992;49:56-62
D. Hauria G. Alunda M. Spycherb J.L. Fehr* P. Miihlebacha
Venous Leakage A New Therapeutical Concept
a Urological Clinic and h Pathological Institute. University Hospital. Zurich, Switzerland
Key Words
Abstract
Venous leakage Morphological alterations New operative concept
According to our opinion, so-called venous leakage is no venous disease but a result of impaired cavernous tissue. Since in over 90% of all patients with venous leakage also arterial disease was discovered and since ultrastructural degenerative processes in the cavernous bodies were detected, we consider traditional corrective venous surgery as unphysiological and illogical. We sug gest arterial revascularization combined with a mechanical penis banding as a new therapeutical concept.
Treatment of venous leakage by ligation and resection of the veins remains unsatisfactory (fig. 1). In approxi mately 50% of our patients, failure was evident imme diately upon surgery. One third of the remaining patients reported having erection sufficient for intercourse up to 6 months postoperatively. Two years later, less than 10% reported satisfactory results. Arterial revascularization surgery [1] as sole modality proved successful in several patients with mild venous leakage (fig. 2). We therefore investigated all patients with venous leakage by means of selective angiography of the penis, dynamic pharmacocavernosography, cavernosometry and biopsy of the corpora cavernosa. Our results are the following: (1) in over 90% of all patients with venous leakage also arterial disease was detected (fig. 3); (2) ultrastructural examinations confirmed degenerative pro
cesses in the cavernous tissue in all patients with venous leakage (fig. 4, 5). It was concluded that: (a) venous leakage is no venous disease; venous surgery is therefore pointless; (b) it is probably a matter of pathological, maybe degenerative, processes in the cavernous tissue; (c) in numerous pa tients the cavernous body function deteriorates probably because of arterial vascular processes causing insufficient perfusion and thus ischemic disease.
Surgical Concept
Our surgical concept aims at improving the perfusion of the cavernous bodies by means of arterial revasculari zation on the one hand and at blocking the venous return by means of an additional penis banding on the other hand (fig. 6).
Prof. Dr. D. Hauri Urologischc Univcrsitatsklinik Frauenklinikstrasse 10 CH-8000 Zurich (Switzerland)
© 1992 S. Kargcr AG. Basel 0042-1138/92/0491-00 5fi $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Preliminary Remark
Fig. 1. The honest, typical success rate after ligation or resection of the veins at venous leakage. In all reports with favourable results, only the patients on the left part of the graph are considered. Long term results are rarely published. Fig. 2. a Venous leakage at arterially caused erectile impotence, b Disappearance of venous leakage and ability to have erection definitively regained upon arterial revascularization surgery only.
where the urethra is not connected. An approximately 11.5 cm large Gore-tex band is installed between the ure thra and the cavernous bodies, passing below the isolated penile vessels and under moderate tension formed into a ring using a nonabsorbable suture (fig. 7). At this stage, it is important to follow the deep dorsal vein to the entry into the glans penis in the sulcus coronarius and there to
57
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Through a dorsal incision, all penile vessels are identi fied. The superficial dorsal vein of the penis and its branches are removed. Both dorsal arteries and the deep dorsal vein of the penis are dissected at the base of the penis. The urethra which is marked by a catheter is sharply dissected from the cavernous bodies. This should be performed at the bifurcation of the corpora cavernosa
3d
58
Hauri/Alund/Spycher/Fehr/Muhlebach
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Fig. 3. Typical finding in a patient with venous leakage, a Venous leakage, detected by dynamic pharmacocavernosography. b, c Addi tional arterial disease, detected in over 90%: only the dorsal artery is noticeable by obstruction of the deep artery (b). the dorsal artery on the right side can be visualized and over an anastomosis also the dorsal artery on the left side. The deep artery' on the right side stops after a short course (arrow, c). d Same patient after revascularization and banding of the penis with functional erections (arrows = band ing). Fig. 4. a Electron-microscopic section of cavernous tissue in a normally potent patient. T = Endothelium of the trabecula. X 5,400. b Electron-microscopic section of cavernous tissue of an impotent patient with venous leakage: widely spread inclusions (arrows) typi cal for degenerative processes are noticeable as well as the splitted smooth muscles. X 7,200. Fig. 5. a Electron-microscopic section of cavernous tissue in a normally potent patient. M = Smooth muscle cell: N = unmyelinated nerve fibre. X 19,000. b Impotent patient due to venous leakage; electron-microscopic section of cavernous tissue. N = Unmyelinated nerve fibre, pathologically enrobed by collagen (arrows): d - cell detritus that cannot be detected unless there is a venous leakage; c = microcalcifications that can only be detected in case of venous leak age.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
59
Fig. 6. Our surgical concept at venous leakage (see text).
ligate all its branches (fig. 6, 8). If this is not done, distal venous leakage into the glans penis and the corpus spon giosum urethrae results at the beginning of erection be cause of a proximal blockage induced by the Gore-tex band (fig. 9a). Supplementarily, occasionally founded circumferenced veins (fig. 9b) should also be ligated, because they cannot get throttled by the Gore-tex band. This procedure is followed by the already described arterial revascularization [ 1] using a microscope or loupe at 4-6 X magnification. The patient is heparinized perioperatively and then anticoagulized during 6 months.
Impotent patients with venous leakage
40
Postoperatively Potent without adjuvant measures Potent with vasoactive agents intracavernously Still impotent
21 10 9
Check-up time at least 12 months postoperatively.
Conclusions
We have operated according to this concept since 1988 (table 1). Among the 40 operated and followed-up pa tients, 21 achieved functional erections without addi tional measure. In all cases, it was demonstrated that the venous leakage had been successfully treated (fig. 3, 10). Ten patients reported erections sufficient to allow inter course after intracavernous self-injection of vasoactive agents. Because of venous leakage, none of these patients had achieved full erections preoperatively, not even after application of vasoactive agents. In 9 patients, surgery failed despite intracavernous application of vasoactive agents, this probably because of severe preoperative intra cavernous disease.
60
Table 1. Amount of venous-leakage patients operated since 1988
It is known [2] and well documented (fig. 11) that venous return is prevented in the area of the cavernous tissue where the caverns progressively inflate and thus block the veins running in the trabeculae. This is why treatment of venous leakage by means of traditional venous corrective surgery is unphysiological and there fore illogical. We succeeded in proving that in patients with venous leakage, the cavernous tissue is severely, probably degcncrativcly, impaired. Since over 90% of the patients with venous leakage also have pathological changes in the arterial system, it was easy to conclude that most venous leakages are due to an ischemic disease. Our conclusion is increasingly supported in the literature [3-
Hauri/Âlund/Spychcr/Fehr/Mühlcbach
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Results
Fig. 7. Intraoperative site: the Gore-tex band is passed below the penile vessels and formed into a ring. At the sides, the two dorsal arteries and in the middle the deep dorsal vein of the penis can be seen. The superficial dorsal vein was removed previously.
Fig. 10. Cavernosometry. a normal: induction flow. 120 ml/min: maintenance flow for normal intracavernous pressure (90-120 mm Hg), < 2 0 ml/min: time of pressure decrease after stop of mainte nance flow to pressure at beginning. 115s. b Patient with venous leakage: induction flow. 120 ml/min; maintenance flow. 68 ml/min: time of pressure decrease, 8 s. c Patient with venous leakage after revascularization and banding: induction flow. 120 ml/min: mainte nance flow. < 20 ml/min; time of pressure decrease. 19 min.
61
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c
Fig. 11. T he normal physiological intracavcrnous process that blocks the veins and pre vents venous leakage. By means of increasingly inflated caverns, the veins running in the trabeculae arc blocked and the venous return prevented, a Detumesccncc. b Tumescence.
5]. For that reason, our therapeutic concept aims at achieving a better perfusion by means of arterial revascu larization and at mechanically supporting the venous blocking. But since the disease of the erectile tissue cannot be corrected by surgery, the results are inferior to the ones obtained at revascularization of isolated arterial lesions. Patients who preoperatively did not attain erections, but who postoperatively achieved functional erection by ad ditional help of vasoactive agents have a strong favorable
effect on our success rate. All failures indicate that the factor time plays an important role in the pathological process in the erectile tissue. An early and rational exami nation of erectile dysfunction is therefore necessary. Our therapeutical concept is only preliminary and necessitates intensive additional investigation. We try, however, to avert from the hitherto practized venous sur gery with its poor long-time results.
References
62
3
4
Persson C, Dicdcrichs W. Lue TF. Yen TSB. et al: Correlation of altered penile ultrastructure with clinical arterial evaluation. J Urol 1989: 142:1462. Jcvtich MJ, Khawand NY, Vidic B: Clinical significance of ultrastructural findings in the corpora cavernosa of normal and impotent men. J Urol 1990:143:289.
Hauri/Alund/Spycher/Fchr/Miihlebach
5
Wespes E. Depierreux M, Schiffmann S. et al: Computerized analysis of intracavernous smeoth musculature in normal and in impo tent patients. EurUrol 1990:18:62.
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Hauri D: A new operative technique in vasculogenic impotence. World J Urol 1986:4:237. Lue TF, Müller SC, Jüncmann KP. et al: Hämodynamische Veränderungen während der Erektion und funktionelle klinische Diagnostik der penilen Gefässe mittels Ultraschall und ge pulstem Doppler. Act Ural 1987:18:115.
D. Hauria G. Alunda M. Spycherb J.L. Fehr* P. Miihlebacha
Venous Leakage A New Therapeutical Concept
a Urological Clinic and h Pathological Institute. University Hospital. Zurich, Switzerland
Key Words
Abstract
Venous leakage Morphological alterations New operative concept
According to our opinion, so-called venous leakage is no venous disease but a result of impaired cavernous tissue. Since in over 90% of all patients with venous leakage also arterial disease was discovered and since ultrastructural degenerative processes in the cavernous bodies were detected, we consider traditional corrective venous surgery as unphysiological and illogical. We sug gest arterial revascularization combined with a mechanical penis banding as a new therapeutical concept.
Treatment of venous leakage by ligation and resection of the veins remains unsatisfactory (fig. 1). In approxi mately 50% of our patients, failure was evident imme diately upon surgery. One third of the remaining patients reported having erection sufficient for intercourse up to 6 months postoperatively. Two years later, less than 10% reported satisfactory results. Arterial revascularization surgery [1] as sole modality proved successful in several patients with mild venous leakage (fig. 2). We therefore investigated all patients with venous leakage by means of selective angiography of the penis, dynamic pharmacocavernosography, cavernosometry and biopsy of the corpora cavernosa. Our results are the following: (1) in over 90% of all patients with venous leakage also arterial disease was detected (fig. 3); (2) ultrastructural examinations confirmed degenerative pro
cesses in the cavernous tissue in all patients with venous leakage (fig. 4, 5). It was concluded that: (a) venous leakage is no venous disease; venous surgery is therefore pointless; (b) it is probably a matter of pathological, maybe degenerative, processes in the cavernous tissue; (c) in numerous pa tients the cavernous body function deteriorates probably because of arterial vascular processes causing insufficient perfusion and thus ischemic disease.
Surgical Concept
Our surgical concept aims at improving the perfusion of the cavernous bodies by means of arterial revasculari zation on the one hand and at blocking the venous return by means of an additional penis banding on the other hand (fig. 6).
Prof. Dr. D. Hauri Urologischc Univcrsitatsklinik Frauenklinikstrasse 10 CH-8000 Zurich (Switzerland)
© 1992 S. Kargcr AG. Basel 0042-1138/92/0491-00 5fi $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Preliminary Remark
Fig. 1. The honest, typical success rate after ligation or resection of the veins at venous leakage. In all reports with favourable results, only the patients on the left part of the graph are considered. Long term results are rarely published. Fig. 2. a Venous leakage at arterially caused erectile impotence, b Disappearance of venous leakage and ability to have erection definitively regained upon arterial revascularization surgery only.
where the urethra is not connected. An approximately 11.5 cm large Gore-tex band is installed between the ure thra and the cavernous bodies, passing below the isolated penile vessels and under moderate tension formed into a ring using a nonabsorbable suture (fig. 7). At this stage, it is important to follow the deep dorsal vein to the entry into the glans penis in the sulcus coronarius and there to
57
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Through a dorsal incision, all penile vessels are identi fied. The superficial dorsal vein of the penis and its branches are removed. Both dorsal arteries and the deep dorsal vein of the penis are dissected at the base of the penis. The urethra which is marked by a catheter is sharply dissected from the cavernous bodies. This should be performed at the bifurcation of the corpora cavernosa
3d
58
Hauri/Alund/Spycher/Fehr/Muhlebach
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Fig. 3. Typical finding in a patient with venous leakage, a Venous leakage, detected by dynamic pharmacocavernosography. b, c Addi tional arterial disease, detected in over 90%: only the dorsal artery is noticeable by obstruction of the deep artery (b). the dorsal artery on the right side can be visualized and over an anastomosis also the dorsal artery on the left side. The deep artery' on the right side stops after a short course (arrow, c). d Same patient after revascularization and banding of the penis with functional erections (arrows = band ing). Fig. 4. a Electron-microscopic section of cavernous tissue in a normally potent patient. T = Endothelium of the trabecula. X 5,400. b Electron-microscopic section of cavernous tissue of an impotent patient with venous leakage: widely spread inclusions (arrows) typi cal for degenerative processes are noticeable as well as the splitted smooth muscles. X 7,200. Fig. 5. a Electron-microscopic section of cavernous tissue in a normally potent patient. M = Smooth muscle cell: N = unmyelinated nerve fibre. X 19,000. b Impotent patient due to venous leakage; electron-microscopic section of cavernous tissue. N = Unmyelinated nerve fibre, pathologically enrobed by collagen (arrows): d - cell detritus that cannot be detected unless there is a venous leakage; c = microcalcifications that can only be detected in case of venous leak age.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
59
Fig. 6. Our surgical concept at venous leakage (see text).
ligate all its branches (fig. 6, 8). If this is not done, distal venous leakage into the glans penis and the corpus spon giosum urethrae results at the beginning of erection be cause of a proximal blockage induced by the Gore-tex band (fig. 9a). Supplementarily, occasionally founded circumferenced veins (fig. 9b) should also be ligated, because they cannot get throttled by the Gore-tex band. This procedure is followed by the already described arterial revascularization [ 1] using a microscope or loupe at 4-6 X magnification. The patient is heparinized perioperatively and then anticoagulized during 6 months.
Impotent patients with venous leakage
40
Postoperatively Potent without adjuvant measures Potent with vasoactive agents intracavernously Still impotent
21 10 9
Check-up time at least 12 months postoperatively.
Conclusions
We have operated according to this concept since 1988 (table 1). Among the 40 operated and followed-up pa tients, 21 achieved functional erections without addi tional measure. In all cases, it was demonstrated that the venous leakage had been successfully treated (fig. 3, 10). Ten patients reported erections sufficient to allow inter course after intracavernous self-injection of vasoactive agents. Because of venous leakage, none of these patients had achieved full erections preoperatively, not even after application of vasoactive agents. In 9 patients, surgery failed despite intracavernous application of vasoactive agents, this probably because of severe preoperative intra cavernous disease.
60
Table 1. Amount of venous-leakage patients operated since 1988
It is known [2] and well documented (fig. 11) that venous return is prevented in the area of the cavernous tissue where the caverns progressively inflate and thus block the veins running in the trabeculae. This is why treatment of venous leakage by means of traditional venous corrective surgery is unphysiological and there fore illogical. We succeeded in proving that in patients with venous leakage, the cavernous tissue is severely, probably degcncrativcly, impaired. Since over 90% of the patients with venous leakage also have pathological changes in the arterial system, it was easy to conclude that most venous leakages are due to an ischemic disease. Our conclusion is increasingly supported in the literature [3-
Hauri/Âlund/Spychcr/Fehr/Mühlcbach
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Results
Fig. 7. Intraoperative site: the Gore-tex band is passed below the penile vessels and formed into a ring. At the sides, the two dorsal arteries and in the middle the deep dorsal vein of the penis can be seen. The superficial dorsal vein was removed previously.
Fig. 10. Cavernosometry. a normal: induction flow. 120 ml/min: maintenance flow for normal intracavernous pressure (90-120 mm Hg), < 2 0 ml/min: time of pressure decrease after stop of mainte nance flow to pressure at beginning. 115s. b Patient with venous leakage: induction flow. 120 ml/min; maintenance flow. 68 ml/min: time of pressure decrease, 8 s. c Patient with venous leakage after revascularization and banding: induction flow. 120 ml/min: mainte nance flow. < 20 ml/min; time of pressure decrease. 19 min.
61
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
c
Fig. 11. T he normal physiological intracavcrnous process that blocks the veins and pre vents venous leakage. By means of increasingly inflated caverns, the veins running in the trabeculae arc blocked and the venous return prevented, a Detumesccncc. b Tumescence.
5]. For that reason, our therapeutic concept aims at achieving a better perfusion by means of arterial revascu larization and at mechanically supporting the venous blocking. But since the disease of the erectile tissue cannot be corrected by surgery, the results are inferior to the ones obtained at revascularization of isolated arterial lesions. Patients who preoperatively did not attain erections, but who postoperatively achieved functional erection by ad ditional help of vasoactive agents have a strong favorable
effect on our success rate. All failures indicate that the factor time plays an important role in the pathological process in the erectile tissue. An early and rational exami nation of erectile dysfunction is therefore necessary. Our therapeutical concept is only preliminary and necessitates intensive additional investigation. We try, however, to avert from the hitherto practized venous sur gery with its poor long-time results.
References
62
3
4
Persson C, Dicdcrichs W. Lue TF. Yen TSB. et al: Correlation of altered penile ultrastructure with clinical arterial evaluation. J Urol 1989: 142:1462. Jcvtich MJ, Khawand NY, Vidic B: Clinical significance of ultrastructural findings in the corpora cavernosa of normal and impotent men. J Urol 1990:143:289.
Hauri/Alund/Spycher/Fchr/Miihlebach
5
Wespes E. Depierreux M, Schiffmann S. et al: Computerized analysis of intracavernous smeoth musculature in normal and in impo tent patients. EurUrol 1990:18:62.
Venous Leakage - A New Therapeutical Concept
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 6:17:45 AM
Hauri D: A new operative technique in vasculogenic impotence. World J Urol 1986:4:237. Lue TF, Müller SC, Jüncmann KP. et al: Hämodynamische Veränderungen während der Erektion und funktionelle klinische Diagnostik der penilen Gefässe mittels Ultraschall und ge pulstem Doppler. Act Ural 1987:18:115.
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