Urol Int 1992;49:40-47
Department of Urology, Bundeswehrkrankenhaus Ulm, FRG
Key Words Venous leakage Deep dorsal vein ligation Spongiosolysis Erectile dysfunction
Venous Surgery in Erectile Dysfunction The Role of Dorsal-Penile-Vein Ligation and Spongiosolysis for Impotence
Abstract
We report here on our surgical experience with venous leakage of the caver nous bodies. Out of 159 patients operated on. 134 were availabe for long-term follow-up. Depending on the cavernosographic findings, one of three different surgical procedures was carried out: ligation of the deep dorsal vein of the penis, spongiosolysis, or ligation of the crura. 18% of the patients undergoing ligation of the deep dorsal vein, postoperatively attained spontaneous erec tions, while 35% needed adjuvant corpus cavernosum autoinjection therapy. Spongiosolysis gave a more favourable result: spontaneous erections in 30% and vasoactive drug-dependent erections in 35%. Crural ligation did not prove successful. No serious complications were encountered postoperatively. Our data suggest that venous surgery should only be offered to a selected group of patients comprising young impotent men with venous leakage, maybe in combination with arterial disease, and patients suffering from distal venous leakage. Old age, neurogenic disorders causing erectile dysfunction, and dia betes mellitus should represent exclusion criteria for venous surgery.
Introduction
Only recently has venous leakage of the cavernous bod ies widely been acknowledged as an important factor in erectile dysfunction. The term ‘venous leakage’ could be defined as pathologically enhanced venous drainage of the corpora cavernosa during erection, preventing the development and maintenance of complete rigidity. As the veno-occlusive mechanism of erection mainly de pends on an adequate arterial inflow and the unimpaired relaxation capacity of the sinusoidal smooth-muscle cells of the cavernous tissue [ 1]. it would be misleading to think of venous leakage as an independent pathological entity causing impotence. Thus, every surgical attempt to treat
erectile dysfunction characterized by venous insufficiency of the cavernous bodies must constitute a symptomatic therapy. This important fact must be born in mind when considering the long-term results of venous surgery, which will be discussed later in this article. Another serious problem concerning venous surgery lies in the complexity of the cavernosal venous outflow. The deep dorsal vein of the penis, and the cavernosal veins which are called crural veins at the site of the crura (or venae profundae penis) represent the main drainage system of the corpora cavernosa. However, multiple and variable connections exist between these veins and the superficial dorsal vein of the penis, the external pudendal veins, the hemorrhoidal veins, let alone the distal shunts
P. Gilbert. MD Bundeswehrkrankenhaus Ulm Akademisches Krankenhaus der Universität Ulm Abteilung Urologie Oberer Kselsberg 40, D-W-7900 Ulm (FRG)
© 1992 S. Karger AG, Basel 0042-1138/92/0491-0040 $2.75/0
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P. Gilbert C. Sparwasser R. Beckert U. Treiber R. Pust
between the glans penis and the cavernous bodies. In addition, one must take into consideration the propensity of all venous vessels to form collaterals after veno-occlusive procedures, a fact which we know from our experi ence with varicocelectomies. It’s as plain as daylight that under these difficult circumstances only accurate diagnos tic and surgical management can lead to successful ve nous surgery, the outcome of which would otherwise be completely uncertain and hazardous, as previous histori cal reports underline [2, 3].
Patients and Methods Diagnostics
Fig. 1. Pharmacocavernosogram of nor mal subject. No venous leak is discernible.
intracorporal pressure drop time will yield more reliable results and thus contribute indispensably to the diagnosis of venous leakage [ 13. 14], We have abandoned cavernosometry in our department because of its uncertain results. Instead, our selection of patients for surgery strictly follows the diagnostic steps mentioned above. Surgical Techniques
The surgical approach in venous incompetence of the corpora cavernosa should be guided mainly by cavernosographic findings. In most cases, venous drainage via the deep dorsal vein of the penis is evident [15]. Therefore, occlusion of this vein is mandatory [ 16], The following section gives a short description of the surgical techniques used in our department. Ligation of the deep dorsal vein of the penis (DDVL) begins with a small infrapubic incision at the penile root (fig. 3). The superficial dorsal veins are dissected, doubly ligated and transsected. Buck’s fas cia is opened and the deep dorsal vein is isolated from both dorsal arteries (fig. 4). Then it is ligated and transsected like the superficial veins. Circumflex veins on the tunica albuginea of the penis are occluded by means of purse-string sutures. The wound is closed in the usual fashion. This surgical approach can also be used for ectopic veins communicating with the external pudendal veins. Venous leakage via the crural veins, however, requires a different management. A perineal incision (fig. 5) allows direct access to the crura. After dissection of the ischiocavernous muscles, crural veins can be identified and transsected (fig. 6). As an alternative, ligation of the crura can likewise be carried out.
41
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To identify the 25-30% of impotent patients suffering from venous leakage [4], and to confirm or rule out concomitant causes of erectile dysfunction, a multidisciplinary investigation programme should be carried out meticulously. This programme, which cannot be discussed in detail in this paper, should consist of a thorough clin ical history, physical examination, sex hormone analysis, psychologi cal and neurological investigations, Doppler sonography and, if nec essary', arteriography of the penile vessels, corpus cavernosum injec tion tests with vasoactive substances, cavernosometry and cavernosography. It is not uncommon that the patient’s history already hints at the diagnosis: either the erections are too short in duration despite ade quate sexual stimulation, or there is a lack of rigidity which may pre vent intromission. In these cases venous leakage is most likely a cause of erectile dysfunction. Equally suspicious are short or incomplete erections after a high-dosage intracavernosal injection test with vasoactive drugs. In our experience the threshold dose per injection is 30-40 pg for prostaglandin E|. and 2-3 ml for a mixture of papav erine and phcntolaminc (15 mg/ml papaverine hydrochloride plus 0.5 mg/ml phentolamine mesylate). Patients requiring a higher dose of cither substance are candidates for pharmacocavernosography. This investigation, which may be complemented by cavernosometry, is of paramount importance in diagnosing venous leakage [5-8]. Under normal conditions the venous outflow of the cavernous bod ies subsides within 20 s once a complete artificial erection has been achieved with the help of intracavernosal injection of 10-20 pg pros taglandin Ei and subsequent filling of the corpora cavernosa with contrast medium (fig. 1). Persistent venous drainage during erection, or the inability to produce penile rigidity in the above-mentioned way due to enhanced cavcrnosal outflow are unambiguous proof of venous leakage. The latter can be clearly localized by pharmacocav ernosography no matter where the pathological drainage takes place (fig. 2). This enables the specialist to make a choice as to the appro priate surgical approach. To quantify venous insufficiency of the corpora cavernosa, intra corporal pressure and volume perfusion monitoring, or simply caver nosometry, can be done as well. To date, this procedure, which is usually performed as pharmacocavernosometry, has not been stan dardized. This may account for the very divergent initiation and maintenance flow rates described by different authors [9-12]. It is questionable whether recently introduced cavernosometric parame ters like pressure decay following cessation of saline infusion, or
42
Gilbcrt/Sparwasser/Beckert/Treiber/Pust
Venous Surgery in Erectile Dysfunction
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Fig. 2. Venous leakage, a Via the deep dorsal vein of the penis (arrow), b Via exter nal pudendal veins into the vena saphena magna. c Distal, d Via an ectopic crural vein.
Fig. 3. Infrapubic approach ( .......) to the deep dorsal vein of the
Fig. 5. Perineal approach (----- ) to the crura of the penis (-----).
penis.
Distal venous leakage consisting of small numerous shunts be tween the distal corpora cavernosa and the corpus spongiosum, con stitutes another surgical problem. This lesion, first described and treated by Ebbehoy and Wagner [17], can be found in 5-10% of patients suffering from venous incompetence of the cavernous bod ies. In these cases spongiosolysis, a surgical procedure which has been developed in our department, offers an alternative to the implanta tion of a penile prosthesis [ 18]. First, circumcision is performed and the skin of the penis is drawn back to the root of the organ, where a tourniquet is placed under tension. The corpus spongiosum is dissected completely in its distal half and the tips of the cavernous bodies are isolated from the
Fig. 6. Exposure of crural vein (riding on vessel loop).
glans penis (fig. 7). Thus, all venous shunts between the corpus spon giosum and corpora cavernosa are transsected. Haemostasis is main tained meticulously throughout the operation. Finally, Buck’s fascia is reapproximated and the penile skin is closed with 4-0 chromic cat gut sutures. A circular pressure bandage is applied for 3 days to pre vent haematomas. In cases of global venous insufficiency, comprising simulta neously venous leakage via the deep dorsal vein of the penis, the cavernosal veins and distal spongio-cavernous shunts, a combination of surgical measures can be necessary. Since distal venous leakage is always associated with an insufficient deep dorsal vein of the penis, spongiosolysis should be complemented with DDVL. Sometimes it is
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Fig. 4. Exposure of the deep dorsal vein prior to ligation and transsection.
Fig. 7a, b. Spongiosolysis: complete isolation of distal corpus cavernosum from glans and corpus spongiosum.
even preferable to completely remove the dorsal vein from the penile root to the coronary sulcus according to the method of Lewis [ 1], as the following example demonstrates. A 62-year-old patient underwent spongiosolysis and DDVL for global venous insufficiency. Normal erections returned after the operation but 6 months later erectile function deteriorated again. Cavernosography revealed distal venous leakage, this time caused by retrograde filling of the glans and the corpus spongiosum via the dis tal portion of the deep dorsal vein (fig. 8). After dissection and removal of this vein, distal venous leakage stopped immediately and satisfactory erections returned.
Results
44
Fig. 8. Pharmacocavernosogram after DDVL and spongiosolysis: retrograde filling of glans and corpus spongiosum via the deep dorsal vein.
Table 1. Venous surgery in erectile dysfunction
Gilbe rt/Sparwasser/Beckert/Treibcr/Pust
n DDVL DDVL + spongiosolysis DDVL + ligation of crura
133 24 2
Total
159
Venous Surgery in Erectile Dysfunction
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From June 1985 to October 1990 we performed ve nous surgery on 159 patients (table 1); 134 were available for follow-up (table 2). Out of 112 patients who had undergone DDVL, only 20 (17.8%) attained satisfactory spontaneous erections, whereas 40 (35.7%) patients needed adjuvant corpus cavernosum autoinjection ther apy (CCAT). The combination of DDVL and spongioso lysis yielded better results with regard to spontaneous erections: 6 patients out of 20 (30%) reported normal erectile function and 7 patients (35%) attained rigidity by mean of CCAT. In the 2 patients in whom DDVL had been complemented by crural ligation, erectile dysfunc tion persisted postoperatively. Our long-term results (with a mean follow-up of 28.5 months) are not very encouraging, especially if we compare them to the former promising short-term results [19] which are depicted in Figure 9. Similar success rates have been reported by dif ferent specialists engaged in venous surgery (table 3).
80
60
*
40
-
Fig. 9. Follow-up-dcpendcnt rate of po tent patients after venous surgery alone (o). or in combination with CCAT (•).
Table 2. Results of venous surgery1
0.5
1
2
3
4
(n=14)
(n = 9)
(n=l»0)
(n=43)
(n =28 !
Follow-up (years)
Operation
Total number of patients
Number of patients with spontaneous erections
CCAT-induced erections
DDVL DDVL + spongiosolysis DDVL + ligation of crura
112 20 2
20(17.8) 6(30.0) 0
40(35.7) 7(35.0) 0
Total
134
26(19.4)
47(35.1)
Values in parentheses are percentages. 1 Mean length of follow-up was 28.5 months.
Table 3. Results of venous surgery in the literature
Author
Number of patients
Wespcs [21] Lewis [22] Austoni et al. [23] Puech-I.eâo et al. [24] Glina et al. [25] Luc [26] Our results
67 50 234 8 47 64 112 20
2
Operation
Success rate
DDVL DDVL DDVL Ligation of crura Ligation of crura DDVL+ligation of crura DDVL DDVL+CCAT DDVL + spongiosolysis DDVL+spongiosolysis + CCAT DDVL+ligation of crura
31 (46) 12(24) 55(23) 7(88) 23 (49) 36(56) 20(18) 40(35) 6(30) 7(35) 0
Values in parentheses are percentages.
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This negative impression is slightly improved if we subdivide our patients into different groups according to the distinct causes of erectile dysfunction (table 4). 22% of patients undergoing DDVL for alteration of the caver nous tissue attained spontaneous erections after surgery, while 35% needed CCAT. Results were not significantly different in the group with cavernous and concomitant arterial disease. Neurogenic causes of impotence, how ever, considerably worsen the outcome of venous surgery: only 1 patient out of 12 experienced spontaneous erec tions, whereas 6 were dependent on CCAT. The triad of cavernous, arterial and neurogenic disease yields the worst results: none of the patients concerned regained the ability to have normal rigid erections. In this context it is not astonishing that patients suffer ing from diabetes mcllitus show an equally poor prognosis concerning venous surgery (table 5). Only 1 patient out of
Table 4. Results of DDVL
Number of Spontaneous patients erections
Cause of erectile dysfunction
Cavernous Cavernous + arterial Cavernous + neurogenic Cavernous + neurogenic + arterial Total
CCAT-induced erections
45 39 12 16
10(22.2) 9(23.1) 1 (8.3) 0
16(35.5) 12(30.8) 6 (50.0) 6(37.5)
112
20(17.8)
40(35.7)
Values in parentheses are percentages.
Table 5. Results of venous surgery in relationship to underlying disease and patient’s age
Number of Spontaneous erections patients
Patient group
Diabetes meliitus Primary erectile dysfunction Postoperative erectile dysfunction Age < 40 years > 40 years
CCAT-induced erections
18 12 3
1 (5.5) 2(16.7) 0
6(33.3) 5(41.7) 0
29 105
12(41.4) 14(13.3)
7(24.1) 40(38.1)
Values in parentheses are percentages.
Haematoma Healing by Lymphatic Hypsecond intention oedema aesthesia DDVL Spongiosolysis Crural ligation
18 reported normal erections postoperatively. 6 patients resumed sexual activities with the help of CCAT. In three patients who had undergone radical retro pubic prostatectomy for cancer of the prostate, venous surgery proved completely unsuccessful. Twelve patients with primary erectile dysfunction yielded a success rate of nearly 60% (spontaneous erections, or with adjuvant CCAT). The patient’s age is a very important predictor of venous surgery outcome: patients below 40 years of age have a far better prognosis (65%) than older patients ( 51 % ).
Complications are infrequent (table 6). DDVL led to a large penile haematoma in 1 case. A temporary lymphatic
46
1 0 0
3 0 0
5 0 0
2 4 0
Urethral stricture 0 1 0
oedema of the penile skin developed in 5 patients. Heal ing by a second intention occurred in 3 cases and hypaesthesia at the penile shaft was experienced by 2 patients. Spongiosolysis caused moderate hypaesthesia of the glans in 4 patients and a distally located urethral stricture in 1 patient. The latter could be treated by Otis’ urethrotomy. All patients who did not respond to venous surgeryalone or to the combination of venous surgery and CCAT were scheduled for penile prosthesis implantation. Recur rences of venous leakage usually occurred within 6 months following the operation, which demonstrates the high collateralization potential of the cavernous veins [ 20],
Gilbert/Sparwasser/Beckert/Treiber/Pust
Venous Surgery in Erectile Dysfunction
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Table 6. Postoperative complications
Conclusion
We have come to the conclusion that venous surgery, like the different arterialization procedures of the caver nous bodies, should only be offered to a selected group of patients. The latter should have the following characteris tics: they should be young ( < 40 years), and venous lcak-
age should occur alone or in combination with only arterial abnormalities or distal venous leakage. These patients will at least stand a fair chance of improved erec tile function. Older patients, and males suffering from neurogenic erectile dysfunction or diabetes mellitus should be excluded from venous surgery.
References 11 Knoll L.D. Furlow WL. Benson RF: Infusion cavernosometry and cavernosography: Our ex perience as an office procedure. Int J Impo tence Res 1989:1:131-136. 12 Lewis RW. Parulkar BG. Johnson CM: Radiol ogy of impotence: in Lytton B. Catalona WJ. Lipshultz LJ. McGuire KJ (cds): Advances in Urology , vol 3. Chicago, '»'ear Book Medical Publishers 1990. pp 132-153. 13 Fitch 111 WP. Charlesworth MG. Huff ME. Moreno JV: Dynamic infusion cavernosome try and cavernosography - A comparison of saline flow and pressure decay as predictors of corporal-venous leak demonstrated by caver nosography. Int J Impotence Res 1990: 2(suppl 2): 117-118. 14 Weiskc W ll: Maintenance flow (MF) and in tracorporal pressure-drop-time (PDT) in 111 patients and results of 200 cavernosographies. Int J Impotence Res 1990:2(suppl 2): 121 —
122. 15 Treiber U. Gilbert P: Venous surgery in erectile dysfunction: A critical report on 116 patients. Urology 1989:34:22-27. 16 Wespes E. Schulman CC: Venous leakage: Sur gical treatment of a curable cause of impotence. J Urol 1985:133:796-798. 17 F.bbehoy J. Wagner G: Insufficient penile erec tion due to abnormal drainage of cavernous bodies. Urology 1979:13:507-510. 18 Gilbert P, Stief C: Spongiosolysis: A new' surgi cal treatment of impotence caused by distal venous leakage. J Urol 1987:138:784-786.
19 Gilbert P: Chirurgie der venösen Insuffizienz ein neues Verfahren zum Verschluss des dista len Lecks: in Bahren W. Altwein JE (eds): Impotenz. Stuttgart. Thieme. 1988. pp 176— 180. 20 Luc TF: Penile venous surgery : Factors affect ing outcome. Int J Impotence Res 1990: 2(suppl 2):363. 2 1 Wespes F: Penile venous surgery for cavcmovenous impotence. World J Urol 1190:8:97— 100. 22 Lewis RW: Venous surgery for impotence. Uroi Clin North Am 1988:15:1 15-121. 23 Austoni E. Bellorofontc C. Mantovani F: Im proved results with intracavernous vasoactive drug infusion following new surgical tech niques for vasculogcnic impotence. World J Urol 1987:5:182-189. 24 Puech-Leäo P. Reis JMSM. Glina S. Reichclt AC: Leakage through the crural edge of corpus cavernosum. EurUrol 1987:13:163-165. 25 Glina S. Puech-Leäo P. Marcondes Dos Reis P. Reichelt AC: Surgical exclusion of the crural ending of the corpora cavernosa: Late results. EurUrol 1990:16:176-180. 26 Lue TF: Penile venous surgery. Urol Clin North Am 1989:16:607-611.
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1 Lewis RW: Venous ligation surgery lor venous leakage. Int J Impotence Res 1990:2:1-19. 2 Wooten JS: L.igation of the dorsal vein of the penis as a cure for atonic impotence. Tex Med J 1902-1903:18:325-328. 3 Lowslcy OS. Bray JL: The surgical relief of impotence: Further excperiences with a new operative procedure. JAMA 1936:107:2029— 2035. 4 Virag R: Impotence: A new field in angiology. Int Angio 1984:3:217-220. 5 Fitzpatrick TJ. Cooper JF: A cavernosogram study on the valvular competence of the human deep dorsal vein. J Urol 1975:113:497-499. 6 Wespes E. Dclcour C. Struyvcn J. Schulman CC: Pharmacocavernosometry-cavernosography in impotence. Br J Urol 1986:48:429—433. 7 Stief CG. Diederichs W. Bénard F. Bosch R. Lue TF. Tanagho FA: The rationale for phar macologic cavernosography. J Urol 1988:140: 1564-1566. 8 Bookstein JJ. Val.ji K. Parsons L. Kessler W: Penile pharmacocavernosography and cavernosometry in the evaluation of impotence. J Urol 1987:137:772-776. 9 Virag R: Revascularization of the penis: in Bennct AH (ed): Management of Male Impo tence. Baltimore. Williams & Wilkins. 1982. pp 219-233. 10 Stief CG. Wettcrauer U: Quantitative and qualitative analysis of dynamic caverncsographies in erectile dysfunction due to venous leakage. Urology 1989:34:252-257.
Department of Urology, Bundeswehrkrankenhaus Ulm, FRG
Key Words Venous leakage Deep dorsal vein ligation Spongiosolysis Erectile dysfunction
Venous Surgery in Erectile Dysfunction The Role of Dorsal-Penile-Vein Ligation and Spongiosolysis for Impotence
Abstract
We report here on our surgical experience with venous leakage of the caver nous bodies. Out of 159 patients operated on. 134 were availabe for long-term follow-up. Depending on the cavernosographic findings, one of three different surgical procedures was carried out: ligation of the deep dorsal vein of the penis, spongiosolysis, or ligation of the crura. 18% of the patients undergoing ligation of the deep dorsal vein, postoperatively attained spontaneous erec tions, while 35% needed adjuvant corpus cavernosum autoinjection therapy. Spongiosolysis gave a more favourable result: spontaneous erections in 30% and vasoactive drug-dependent erections in 35%. Crural ligation did not prove successful. No serious complications were encountered postoperatively. Our data suggest that venous surgery should only be offered to a selected group of patients comprising young impotent men with venous leakage, maybe in combination with arterial disease, and patients suffering from distal venous leakage. Old age, neurogenic disorders causing erectile dysfunction, and dia betes mellitus should represent exclusion criteria for venous surgery.
Introduction
Only recently has venous leakage of the cavernous bod ies widely been acknowledged as an important factor in erectile dysfunction. The term ‘venous leakage’ could be defined as pathologically enhanced venous drainage of the corpora cavernosa during erection, preventing the development and maintenance of complete rigidity. As the veno-occlusive mechanism of erection mainly de pends on an adequate arterial inflow and the unimpaired relaxation capacity of the sinusoidal smooth-muscle cells of the cavernous tissue [ 1]. it would be misleading to think of venous leakage as an independent pathological entity causing impotence. Thus, every surgical attempt to treat
erectile dysfunction characterized by venous insufficiency of the cavernous bodies must constitute a symptomatic therapy. This important fact must be born in mind when considering the long-term results of venous surgery, which will be discussed later in this article. Another serious problem concerning venous surgery lies in the complexity of the cavernosal venous outflow. The deep dorsal vein of the penis, and the cavernosal veins which are called crural veins at the site of the crura (or venae profundae penis) represent the main drainage system of the corpora cavernosa. However, multiple and variable connections exist between these veins and the superficial dorsal vein of the penis, the external pudendal veins, the hemorrhoidal veins, let alone the distal shunts
P. Gilbert. MD Bundeswehrkrankenhaus Ulm Akademisches Krankenhaus der Universität Ulm Abteilung Urologie Oberer Kselsberg 40, D-W-7900 Ulm (FRG)
© 1992 S. Karger AG, Basel 0042-1138/92/0491-0040 $2.75/0
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 8/25/2018 4:30:50 PM
P. Gilbert C. Sparwasser R. Beckert U. Treiber R. Pust
between the glans penis and the cavernous bodies. In addition, one must take into consideration the propensity of all venous vessels to form collaterals after veno-occlusive procedures, a fact which we know from our experi ence with varicocelectomies. It’s as plain as daylight that under these difficult circumstances only accurate diagnos tic and surgical management can lead to successful ve nous surgery, the outcome of which would otherwise be completely uncertain and hazardous, as previous histori cal reports underline [2, 3].
Patients and Methods Diagnostics
Fig. 1. Pharmacocavernosogram of nor mal subject. No venous leak is discernible.
intracorporal pressure drop time will yield more reliable results and thus contribute indispensably to the diagnosis of venous leakage [ 13. 14], We have abandoned cavernosometry in our department because of its uncertain results. Instead, our selection of patients for surgery strictly follows the diagnostic steps mentioned above. Surgical Techniques
The surgical approach in venous incompetence of the corpora cavernosa should be guided mainly by cavernosographic findings. In most cases, venous drainage via the deep dorsal vein of the penis is evident [15]. Therefore, occlusion of this vein is mandatory [ 16], The following section gives a short description of the surgical techniques used in our department. Ligation of the deep dorsal vein of the penis (DDVL) begins with a small infrapubic incision at the penile root (fig. 3). The superficial dorsal veins are dissected, doubly ligated and transsected. Buck’s fas cia is opened and the deep dorsal vein is isolated from both dorsal arteries (fig. 4). Then it is ligated and transsected like the superficial veins. Circumflex veins on the tunica albuginea of the penis are occluded by means of purse-string sutures. The wound is closed in the usual fashion. This surgical approach can also be used for ectopic veins communicating with the external pudendal veins. Venous leakage via the crural veins, however, requires a different management. A perineal incision (fig. 5) allows direct access to the crura. After dissection of the ischiocavernous muscles, crural veins can be identified and transsected (fig. 6). As an alternative, ligation of the crura can likewise be carried out.
41
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To identify the 25-30% of impotent patients suffering from venous leakage [4], and to confirm or rule out concomitant causes of erectile dysfunction, a multidisciplinary investigation programme should be carried out meticulously. This programme, which cannot be discussed in detail in this paper, should consist of a thorough clin ical history, physical examination, sex hormone analysis, psychologi cal and neurological investigations, Doppler sonography and, if nec essary', arteriography of the penile vessels, corpus cavernosum injec tion tests with vasoactive substances, cavernosometry and cavernosography. It is not uncommon that the patient’s history already hints at the diagnosis: either the erections are too short in duration despite ade quate sexual stimulation, or there is a lack of rigidity which may pre vent intromission. In these cases venous leakage is most likely a cause of erectile dysfunction. Equally suspicious are short or incomplete erections after a high-dosage intracavernosal injection test with vasoactive drugs. In our experience the threshold dose per injection is 30-40 pg for prostaglandin E|. and 2-3 ml for a mixture of papav erine and phcntolaminc (15 mg/ml papaverine hydrochloride plus 0.5 mg/ml phentolamine mesylate). Patients requiring a higher dose of cither substance are candidates for pharmacocavernosography. This investigation, which may be complemented by cavernosometry, is of paramount importance in diagnosing venous leakage [5-8]. Under normal conditions the venous outflow of the cavernous bod ies subsides within 20 s once a complete artificial erection has been achieved with the help of intracavernosal injection of 10-20 pg pros taglandin Ei and subsequent filling of the corpora cavernosa with contrast medium (fig. 1). Persistent venous drainage during erection, or the inability to produce penile rigidity in the above-mentioned way due to enhanced cavcrnosal outflow are unambiguous proof of venous leakage. The latter can be clearly localized by pharmacocav ernosography no matter where the pathological drainage takes place (fig. 2). This enables the specialist to make a choice as to the appro priate surgical approach. To quantify venous insufficiency of the corpora cavernosa, intra corporal pressure and volume perfusion monitoring, or simply caver nosometry, can be done as well. To date, this procedure, which is usually performed as pharmacocavernosometry, has not been stan dardized. This may account for the very divergent initiation and maintenance flow rates described by different authors [9-12]. It is questionable whether recently introduced cavernosometric parame ters like pressure decay following cessation of saline infusion, or
42
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Venous Surgery in Erectile Dysfunction
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Fig. 2. Venous leakage, a Via the deep dorsal vein of the penis (arrow), b Via exter nal pudendal veins into the vena saphena magna. c Distal, d Via an ectopic crural vein.
Fig. 3. Infrapubic approach ( .......) to the deep dorsal vein of the
Fig. 5. Perineal approach (----- ) to the crura of the penis (-----).
penis.
Distal venous leakage consisting of small numerous shunts be tween the distal corpora cavernosa and the corpus spongiosum, con stitutes another surgical problem. This lesion, first described and treated by Ebbehoy and Wagner [17], can be found in 5-10% of patients suffering from venous incompetence of the cavernous bod ies. In these cases spongiosolysis, a surgical procedure which has been developed in our department, offers an alternative to the implanta tion of a penile prosthesis [ 18]. First, circumcision is performed and the skin of the penis is drawn back to the root of the organ, where a tourniquet is placed under tension. The corpus spongiosum is dissected completely in its distal half and the tips of the cavernous bodies are isolated from the
Fig. 6. Exposure of crural vein (riding on vessel loop).
glans penis (fig. 7). Thus, all venous shunts between the corpus spon giosum and corpora cavernosa are transsected. Haemostasis is main tained meticulously throughout the operation. Finally, Buck’s fascia is reapproximated and the penile skin is closed with 4-0 chromic cat gut sutures. A circular pressure bandage is applied for 3 days to pre vent haematomas. In cases of global venous insufficiency, comprising simulta neously venous leakage via the deep dorsal vein of the penis, the cavernosal veins and distal spongio-cavernous shunts, a combination of surgical measures can be necessary. Since distal venous leakage is always associated with an insufficient deep dorsal vein of the penis, spongiosolysis should be complemented with DDVL. Sometimes it is
43
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Fig. 4. Exposure of the deep dorsal vein prior to ligation and transsection.
Fig. 7a, b. Spongiosolysis: complete isolation of distal corpus cavernosum from glans and corpus spongiosum.
even preferable to completely remove the dorsal vein from the penile root to the coronary sulcus according to the method of Lewis [ 1], as the following example demonstrates. A 62-year-old patient underwent spongiosolysis and DDVL for global venous insufficiency. Normal erections returned after the operation but 6 months later erectile function deteriorated again. Cavernosography revealed distal venous leakage, this time caused by retrograde filling of the glans and the corpus spongiosum via the dis tal portion of the deep dorsal vein (fig. 8). After dissection and removal of this vein, distal venous leakage stopped immediately and satisfactory erections returned.
Results
44
Fig. 8. Pharmacocavernosogram after DDVL and spongiosolysis: retrograde filling of glans and corpus spongiosum via the deep dorsal vein.
Table 1. Venous surgery in erectile dysfunction
Gilbe rt/Sparwasser/Beckert/Treibcr/Pust
n DDVL DDVL + spongiosolysis DDVL + ligation of crura
133 24 2
Total
159
Venous Surgery in Erectile Dysfunction
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From June 1985 to October 1990 we performed ve nous surgery on 159 patients (table 1); 134 were available for follow-up (table 2). Out of 112 patients who had undergone DDVL, only 20 (17.8%) attained satisfactory spontaneous erections, whereas 40 (35.7%) patients needed adjuvant corpus cavernosum autoinjection ther apy (CCAT). The combination of DDVL and spongioso lysis yielded better results with regard to spontaneous erections: 6 patients out of 20 (30%) reported normal erectile function and 7 patients (35%) attained rigidity by mean of CCAT. In the 2 patients in whom DDVL had been complemented by crural ligation, erectile dysfunc tion persisted postoperatively. Our long-term results (with a mean follow-up of 28.5 months) are not very encouraging, especially if we compare them to the former promising short-term results [19] which are depicted in Figure 9. Similar success rates have been reported by dif ferent specialists engaged in venous surgery (table 3).
80
60
*
40
-
Fig. 9. Follow-up-dcpendcnt rate of po tent patients after venous surgery alone (o). or in combination with CCAT (•).
Table 2. Results of venous surgery1
0.5
1
2
3
4
(n=14)
(n = 9)
(n=l»0)
(n=43)
(n =28 !
Follow-up (years)
Operation
Total number of patients
Number of patients with spontaneous erections
CCAT-induced erections
DDVL DDVL + spongiosolysis DDVL + ligation of crura
112 20 2
20(17.8) 6(30.0) 0
40(35.7) 7(35.0) 0
Total
134
26(19.4)
47(35.1)
Values in parentheses are percentages. 1 Mean length of follow-up was 28.5 months.
Table 3. Results of venous surgery in the literature
Author
Number of patients
Wespcs [21] Lewis [22] Austoni et al. [23] Puech-I.eâo et al. [24] Glina et al. [25] Luc [26] Our results
67 50 234 8 47 64 112 20
2
Operation
Success rate
DDVL DDVL DDVL Ligation of crura Ligation of crura DDVL+ligation of crura DDVL DDVL+CCAT DDVL + spongiosolysis DDVL+spongiosolysis + CCAT DDVL+ligation of crura
31 (46) 12(24) 55(23) 7(88) 23 (49) 36(56) 20(18) 40(35) 6(30) 7(35) 0
Values in parentheses are percentages.
45
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This negative impression is slightly improved if we subdivide our patients into different groups according to the distinct causes of erectile dysfunction (table 4). 22% of patients undergoing DDVL for alteration of the caver nous tissue attained spontaneous erections after surgery, while 35% needed CCAT. Results were not significantly different in the group with cavernous and concomitant arterial disease. Neurogenic causes of impotence, how ever, considerably worsen the outcome of venous surgery: only 1 patient out of 12 experienced spontaneous erec tions, whereas 6 were dependent on CCAT. The triad of cavernous, arterial and neurogenic disease yields the worst results: none of the patients concerned regained the ability to have normal rigid erections. In this context it is not astonishing that patients suffer ing from diabetes mcllitus show an equally poor prognosis concerning venous surgery (table 5). Only 1 patient out of
Table 4. Results of DDVL
Number of Spontaneous patients erections
Cause of erectile dysfunction
Cavernous Cavernous + arterial Cavernous + neurogenic Cavernous + neurogenic + arterial Total
CCAT-induced erections
45 39 12 16
10(22.2) 9(23.1) 1 (8.3) 0
16(35.5) 12(30.8) 6 (50.0) 6(37.5)
112
20(17.8)
40(35.7)
Values in parentheses are percentages.
Table 5. Results of venous surgery in relationship to underlying disease and patient’s age
Number of Spontaneous erections patients
Patient group
Diabetes meliitus Primary erectile dysfunction Postoperative erectile dysfunction Age < 40 years > 40 years
CCAT-induced erections
18 12 3
1 (5.5) 2(16.7) 0
6(33.3) 5(41.7) 0
29 105
12(41.4) 14(13.3)
7(24.1) 40(38.1)
Values in parentheses are percentages.
Haematoma Healing by Lymphatic Hypsecond intention oedema aesthesia DDVL Spongiosolysis Crural ligation
18 reported normal erections postoperatively. 6 patients resumed sexual activities with the help of CCAT. In three patients who had undergone radical retro pubic prostatectomy for cancer of the prostate, venous surgery proved completely unsuccessful. Twelve patients with primary erectile dysfunction yielded a success rate of nearly 60% (spontaneous erections, or with adjuvant CCAT). The patient’s age is a very important predictor of venous surgery outcome: patients below 40 years of age have a far better prognosis (65%) than older patients ( 51 % ).
Complications are infrequent (table 6). DDVL led to a large penile haematoma in 1 case. A temporary lymphatic
46
1 0 0
3 0 0
5 0 0
2 4 0
Urethral stricture 0 1 0
oedema of the penile skin developed in 5 patients. Heal ing by a second intention occurred in 3 cases and hypaesthesia at the penile shaft was experienced by 2 patients. Spongiosolysis caused moderate hypaesthesia of the glans in 4 patients and a distally located urethral stricture in 1 patient. The latter could be treated by Otis’ urethrotomy. All patients who did not respond to venous surgeryalone or to the combination of venous surgery and CCAT were scheduled for penile prosthesis implantation. Recur rences of venous leakage usually occurred within 6 months following the operation, which demonstrates the high collateralization potential of the cavernous veins [ 20],
Gilbert/Sparwasser/Beckert/Treiber/Pust
Venous Surgery in Erectile Dysfunction
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Table 6. Postoperative complications
Conclusion
We have come to the conclusion that venous surgery, like the different arterialization procedures of the caver nous bodies, should only be offered to a selected group of patients. The latter should have the following characteris tics: they should be young ( < 40 years), and venous lcak-
age should occur alone or in combination with only arterial abnormalities or distal venous leakage. These patients will at least stand a fair chance of improved erec tile function. Older patients, and males suffering from neurogenic erectile dysfunction or diabetes mellitus should be excluded from venous surgery.
References 11 Knoll L.D. Furlow WL. Benson RF: Infusion cavernosometry and cavernosography: Our ex perience as an office procedure. Int J Impo tence Res 1989:1:131-136. 12 Lewis RW. Parulkar BG. Johnson CM: Radiol ogy of impotence: in Lytton B. Catalona WJ. Lipshultz LJ. McGuire KJ (cds): Advances in Urology , vol 3. Chicago, '»'ear Book Medical Publishers 1990. pp 132-153. 13 Fitch 111 WP. Charlesworth MG. Huff ME. Moreno JV: Dynamic infusion cavernosome try and cavernosography - A comparison of saline flow and pressure decay as predictors of corporal-venous leak demonstrated by caver nosography. Int J Impotence Res 1990: 2(suppl 2): 117-118. 14 Weiskc W ll: Maintenance flow (MF) and in tracorporal pressure-drop-time (PDT) in 111 patients and results of 200 cavernosographies. Int J Impotence Res 1990:2(suppl 2): 121 —
122. 15 Treiber U. Gilbert P: Venous surgery in erectile dysfunction: A critical report on 116 patients. Urology 1989:34:22-27. 16 Wespes E. Schulman CC: Venous leakage: Sur gical treatment of a curable cause of impotence. J Urol 1985:133:796-798. 17 F.bbehoy J. Wagner G: Insufficient penile erec tion due to abnormal drainage of cavernous bodies. Urology 1979:13:507-510. 18 Gilbert P, Stief C: Spongiosolysis: A new' surgi cal treatment of impotence caused by distal venous leakage. J Urol 1987:138:784-786.
19 Gilbert P: Chirurgie der venösen Insuffizienz ein neues Verfahren zum Verschluss des dista len Lecks: in Bahren W. Altwein JE (eds): Impotenz. Stuttgart. Thieme. 1988. pp 176— 180. 20 Luc TF: Penile venous surgery : Factors affect ing outcome. Int J Impotence Res 1990: 2(suppl 2):363. 2 1 Wespes F: Penile venous surgery for cavcmovenous impotence. World J Urol 1190:8:97— 100. 22 Lewis RW: Venous surgery for impotence. Uroi Clin North Am 1988:15:1 15-121. 23 Austoni E. Bellorofontc C. Mantovani F: Im proved results with intracavernous vasoactive drug infusion following new surgical tech niques for vasculogcnic impotence. World J Urol 1987:5:182-189. 24 Puech-Leäo P. Reis JMSM. Glina S. Reichclt AC: Leakage through the crural edge of corpus cavernosum. EurUrol 1987:13:163-165. 25 Glina S. Puech-Leäo P. Marcondes Dos Reis P. Reichelt AC: Surgical exclusion of the crural ending of the corpora cavernosa: Late results. EurUrol 1990:16:176-180. 26 Lue TF: Penile venous surgery. Urol Clin North Am 1989:16:607-611.
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