Urol Int 1992;49:63-68
Institute of Urology (Head: Prof. E. Pisani). University of Milan, Italy
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
Key Words
Abstract
Impotence Penile haemodynamics Venous surgery
The therapeutic rationale of venous surgery is to create an effective obstacle to the pathologically increased venous outflow, determined by an intrinsic pathology of the cavernous bodies. In the last 15 years, many techniques have been proposed, and our therapeutic approach has evolved with our knowledge of penile haemodynamics. Up to October 1990, we performed 316 operations for the relief of impotence. In a 2-year follow-up our recurrence rates were as follows: DDV plus corporpexy (n = 50): 26% (n = 13); DDV plus crura plica tion (n = 34): 47% (n = 16); DDV plus collateral vein ligation (n = 48): 62.5% (n = 30).
Definition of Venous Leakage and Number of Operations Performed
Erectile failure due to venous leakage can be described as the inability of the penile vascular system to trap blood within the corpora cavernosa and, therefore, as a failure to increase the intracorporeal pressure in excess of the systolic blood pressure. The venogcnic impotent patient cannot maintain a firm erection and achieve tumescence sufficient for intercourse. Numerous factors can contrib ute to determine excessive cavernous vein outflow: pathological changes of the cavernous smooth muscles, abnormal local venous drainage, insufficient neurotrans mitter release, or alteration of the cavernous endothelium [1-3]. Other elements which can interfere with the control mechanism of cavernosal venous outflow are certainly
neurological disorders and, in our experience, defects of the suspensory ligament of the penis. Moreover, there is a frequent association between penile arterial disease and veno-occlusive insufficiency of the corpora cavernosa. Some authors suggest that arterial insufficiency may be one of the causes of corporal ischaemic injury, thus pro ducing cavernosal veno-occlusive failure [4], The consequence of such aetiological uncertainty is the current surgical therapy, the so-called ‘venous surgery’. The therapeutic rationale behind this kind of surgery is to create an effective but mere hindrance to the pathologi cally increased venous outflow. During the last 15 years, many techniques have been proposed, and our thera peutic approach has evolved with our knowledge of penile haemodynamics. In the early 80s, we have performed 39 operations using Virag’s techniques [5] - arterialization of the deep
Prof. E. Austoni Istitutodi Urologia Via Commcnda. 15
© 1992 S. Karger AG. Basel 0042-1138/92/0491-0063 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/26/2018 12:32:47 AM
E. Austoni F. Colombo F. Mantovani A. Trinchieri
64
Procedure for Diagnostic Management: Role of Pharmacological Testing, Standards of Flow Rates, Value of Intracavernosal Pressure, Value of Cavernosography
The diagnostic management of patients suspected of venous leakage developed at the Institute of Urology of the University of Milan includes the following steps: (1) his tory (sexual intercourse, ability to obtain a firm erection, therapy with beta blockers, diuretic drugs, etc.); (2) physi cal examination (recurvatum, fibrosis, PP); (3) psychologi cal evaluation; (4) endocrine panel (testosterone, folliclestimulating hormone, luteinizing hormone prolactin, and estrogen); (5) nocturnal penile tumescence monitoring (Rigiscan, 3 consecutive nights); (6) intracavernous pa paverine injection test (20 mg, 1 cm3, after informed con sent has been obtained); (7) penile Doppler sonography, with the penis in the flaccid state and after intracavernous injection of 8 mg of papaverine; (8) cavernosometry after intracavernous injection of papaverine (Wicst-Cavomat, roller infusion pump), monitoring the infusion flow and intracavernous pressure; (9) cavernosography, in case of pathological response by cavernosometry, and (10) neuro logical evaluation (bulbocavernous reflex by electromyo graphy and/or evoked potential). When patients do not reach an effective erection fol lowing the papaverine test (20 mg. intracavernous injec tion) we have to discriminate between insufficient arterial inflow and excessive venous outflow (venous leakage) [7], For this purpose, we perform a dynamic infusion caver nosometry [8], Both corpora cavernosa and the glans are punctured through with 19-gauge butterfly needles after a local anaesthetic spray (lidocaine 15%) is applied. A saline infusion pump device is connected to one but terfly needle, while the other one is attached to a manom eter to allow continuous intracorporeal pressure monitor ing (Wiest-Cavomat roller pump device). The initial resting intracorporeal pressure of the nonerect penis is recorded. We begin the examination with the saline flow rate at 40 ml/min, increasing to 20 ml/min every 30 s until erection occurs or until the flow rate has reached 160 ml/min for more than 60 s. If no erection is obtained, we apply 90 s digital compres sion on the cavernous crura (perineum), noting the intraca vernous pressure increase; after 1 min we repeat the 90-sec ond digital compression, but this time on the infrapubic ar ea. In this way we obtain information about the main ve nous outflow pathways (V DP and collaterals or cavernous). We consider as normal values an erection flow < 140 ml/min and a maintaining erection flow < 7 0 ml/min.
Austoni/Colombo/Mantovani/Trinchicri
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/26/2018 12:32:47 AM
dorsal vein (DDV), with consequent venous blocking which gave us immediate positive results in 28% of oper ated cases, but we later abandoned these procedures because of frequent complications, such as thrombosis of the shunts and hypervascularization of the glans. The latest technological advances in the diagnostic field (cavernous biopsy, cavernoscopy) have made it pos sible to show anatomo-pathological factors affecting the corpora cavernosa (such as fibrosis and sclerosis of erec tile tissue) that seem to play a major role in erectile fail ure. Neurological processes, such as adrenergic hyperto nus (which constricts the sinusoidal and penile microarterial tissue) significantly contribute to complete the dysrcactivc erectile syndrome. For this reason DDV arterialization techniques have been reconsidered by some au thors (as well as by some of us) [6]. Some precautions, such as the preliminary ligations of the cavernous-glandular distal venous connections and the proximal DDV ligation, have to be respected to avoid the above-mentioned collateral effects (glans hyperacmia and erectile tissue fibrosis due to the high pressure caused by the anterograde arteriocavcrnous shunt). These techni cal measures render circumflex veins the only pathways of the arterial haematological increase. At the same time they absorb arterial systolic impulses (with a smaller risk of thrombosis or of cavernous fibrosis, which is typical of direct cavernous arterialization) and create such a light and continuous endocavernous hyperdistension that it opposes and counter-balances the adrenergic hypertonus. At our institution, our experience with these modified techniques is still at an early stage, but the first haemody namic data (peroperativc and short-time follow-up) looks encouraging, especially in patients who suffer from ve nous leakage. In earlier years, we performed 135 DDV simple liga tions. under local anaesthetics using a short longitudinal mid-incision on the dorsal face of the penis. Subsequent ly, we moved to the technique of progressive ligations of the veins with peroperative cavernometry. Using this technique, the following operations have been carried out: (1) DDV + collateral veins ligation (Kelamy access; n = 53); (2) spongiosoglandular lysis (n = 11), and (3) DDV ligation plus tightening of the cavernous crura (n = 37). During the last 3 years, we have also treated 80 venous leakage patients by DDV ligation fol lowed by proximal dorsal tightening of the cavernous bodies by means of 4-6 non-absorbable stitches, perform ing corporopubic suspension (corporopexy) at the same time. Up to October 1990 we performed such 316 opera tions.
Management of an Arterial (Co)factor in Diagnosis and Treatment
There is a frequent association between veno-occlusive insufficiency and penile arterial disease. Investigations performed on a canine model [10] showed a possible aetiologic relationship between acute, subacute, and chronic pudendal arterial obstruction and failure of the veno-occlusive mechanism. These authors suggested that the venous leakage may be secondary to some ischaemic injury. In our management, all patients undergo Doppler son ography, and, if pudendal arterial insufficiency has been shown, venous surgery is not performed. If the patient is under the age of 60 years, and the angiographic evaluation does not show diffused atherosclerosis, he can undergo arterial revascularization of the dorsal artery of the penis (we perform epigastrodorsal double anastomosis, orthoand backflow: 68 patients between 1986 and 1990).
On the contrary, if the patient is over 60, or arteriogra phy shows plaques of atheroma inside the main arteries (especially the internal iliac artery) we prefer to resort to prosthetic implant. In doubtful cases, these patients are treated with a weekly intracavernous injection of papav erine and phentolamine for a period of 6 months. Some patients improved their erection response following this treatment. In non-responder cases, we perform a pros thetic implant. The choice between Subrini’s prosthesis and inflatable multicomponent models depends on the seriousness of the disease. If a certain erection response can be achieved, we prefer Subrini's implant (less expensive and more physiological). In the most serious cases the hydraulic, three-component prostheses are the treatment of choice.
Venous Surgical Procedures with Special Remarks concerning Crural Veins, Cavernosoglandular Global Venous Insufficiency, and Ectopic Veins
Since 1986 we have used the technique of progressive ligations of the main veins draining the corpora cavernosa (according to cavernosography). All procedures are carried out under general anaesthe sia which eliminates the risk of distress, making peropera tive cavernometry more valuable. The operation begins with the ligation of the main venous pathways shown by dynamic cavernography and continues with progressive ligations until OME figures decrease below 30 ml/min. Since 1988 we have also performed at the vein ligation stage the procedure we called corporopexy by means of 4-6 single stitches of non-absorbablc material which draw the corpora towards the pubic bone, so strengthen ing the suspensory ligament of the penis, and creating a proximal cavernous stricture. Peroperative cavernosome try allows us to check the correct presentation of the stric ture. In case o f‘deep’ cavernous leakage (according to caver nosography), we used plication of the cavernous crura. A mid-vertical incision of the perineum allows a good access to the bulbourethral and to the cavernous crura; we can perform the plication either in both the corpora or unilaterally, depending on the peroperative cavernosometric values. The technical experience we have obtained in penile surgery during the last 15 years has taught us that the care ful isolation of the glans and of the urethral tissue from the cavernous bodies (performed in, e.g., surgical treat-
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The second part of cavernosometry is performed 2 min after intracavernosal injection of 20 mg papaverine (1 cm3), and this time, the following figures can be consid ered pathological: (1) an OOE rate > 100 ml/min, an OME rate > 4 0 ml/min, a final steady-state intracavernous pressure < 1 0 0 mm Hg (5 sec after interrupting mechanical perfusion) and its continuous decrease during the subsequent 30 s > 50 mm Hg. Unfortunately, factors such as psychological inhibition and stress (which often occur when cavernosometry is performed on a conscious patient) cause the stimulation of a-adrenergic receptors, and so determine arterial and perisinuoidal smooth muscle contraction. We do not know if the intracavernous administration of papaverine and/or phentolamine can always balance these effects, making cavernometric response totally accurate [9], During routine evaluation of venous leakage, cavernosography occupies a less important place in our manage ment plan. Demonstration of the contrast medium in the penile draining system, fora certain percentage of healthy men, suggests that venous leakage as revealed by cavernosography must not be considered diagnostically valid for venogenic impotence. This, however, plays an impor tant role in preoperative evaluation of the most important drainage pathways of the corpora. We perform cavernosograms (anteroposterior and oblique film) at the end of cavernosometry only in those cases shown to be pathological (OME > 4 0 ml/min after intracavernous injection of paperverine, 20 mg).
Complications
Table 2 represents our experience of complications fol lowing venous surgery'.
Analysis of Failures: Persistent or Newly Formed Venous Channels, Arterial Factors, Psychology!?)
The aetiopathogenesis of venous leakage consists in an intrinsic dysfunction of the cavernous body [12, 13]. Venous ligation is unavoidably, a mere palliative, as not even corporopexy and crura plication which reduce the calibre of the cavernous bodies can cure these anatomical defects. The high rate of relapses found after all these proce dures is determined by the formation of new venous col lateral pathways. In our experience, the results of corporo pexy seem to be more satisfactory, and this might be contigent on the dual effect which this technique procures. It
Follow-Up
Table 1. General
We obtained the best immediate success rate (full sex ual intercourse) with the lowest figures at the peroperative cavernosometry in the patients who underwent spongio glandular lysis, but. unfortunately, they showed a high percentage (60%; 6 out of 10 patients checked) of recur rence (intermittent erection, no rigidity, OME > 3 5 ml/min) at 12 months of follow-up, with an OME average of 60 ml/min (range 55-75). The percentage of relapses was also significant among patients operated on by other techniques (table 3). Recurrence rates are shown in ta ble 4.
Table 2.
Complications
Number of patients DDV arterialization (Virag's technique until 1981) Simple DDV ligation (local anaesthesia) Intrapubic DDV plus colateral vein ligation Spongioglandular lysis DDV ligation plus crura plication DDV ligation plus corporopexy
39 135 53 11 37 80
Total
355
Procedure
Complications
n
%
DDV arterialization (n = 39)
hypervascularization of glans thrombosis of shunts inguinal hernia foreskin oedema glans pain foreskin oedema
39 20 4 18 58 30
100 51 10 13.3 43 56.6
glans paraesthesia widespread oedema of the penis reactive fascial fibrosis painful postoperative erection perineal pain priapism (due to an excessive decrease of cavernous outflow) iatrogenic ligation of one or both cavernous arteries localized cellulitis diastasis of the suture public pain (osteitis)
7 9 2 10 30
63.6 81.8 18.2 90.9 81.1
3
8.1
1 30 16 48
2.7 37.5 20 60
Simple DDV ligation (n = 135) DDV plus collateral vein ligation (n = 53) Spongioglandular lysis (n = 11)
DDV ligation plus crura plication (n = 37)
DDV ligation plus corporopexy (n = 80)
66
experience of venous surgery
Austoni/Colombo/Mantovani/Trinchieri
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
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mcnt of Peyronie’s disease) allows the reduetion of the cavernous outflow. We have consequently treated 11 patients suffering from venous leakage by this technique (spongioglandular lysis) [11]. The procedure leads to the interruption of all the communicating veins between the corpora and the urethroglandular structures. Table 1 sums up our experi ence of venous surgery.
improves rigidity, the erection angle of the penis (due to the strengthening of the suspensory ligament) and, at the same time, it reduces cavernous outflow, thus increasing rigidity. In our institution, the presence of arterial deficiency precludes that the patient can undergo venous surgery. Furthermore, Doppler sonography, performed after ve nous surgery relapses, never exhibited arterial insuffi ciency. Psychogenic factors, often described in impotent pa tients, must be carefully evaluated. In case this aspect assumes primary importance, the patient should be re ferred to a psychosexologist. When the psychogenic ele ment is secondary to organic disease patients seem to improve after venous surgery, more, it seems, because of autosuggestion rather than because of a specific organic response: is this a case of the placebo effect? Is improve ment of self-confidence due to the greater penile tumes cence to be considered?
crura plication. All but 3 of these patients achieved func tional improvement after the second surgical procedure. Of the 3 non-responders, 2 required prosthesis implant.
Supportive Therapy: Intracavernous Injection of Vasoactive Drugs, Reoperation, Prostheses
84% of the recurrence cases did show, however, an improved clinical response after an intracavernous papaverine injection (20 mg during VSS). and 73% of these reported satisfactory sexual inter course after a self-administered papaverine injection.
In our management plan, all patients operated on by venous surgery undergo postoperative training with intra cavernous injection of papaverine combined with phentolamine (10-40 mg papaverine; 0.5-2 mg phcntolamine). In our opinion, this has a dual effect: cavernous compliance recovery, and a-adrenergic tone balance (due to postoperative stress). Reoperation In our experience, 32 patients previously operated on by simple DDV ligation underwent reoperation: 21 of them were treated by collateral vein ligation and 11 by
Table 3.
Relapse rate up to 1 year
Procedure
n
%
OME, ml/min average range
DDV simple ligations DDV plus collateral vein ligation DDV plus crural ligation DDV ligation plus corporopexy Spongiosoglandular lysis
Table 4.
36/120 26/48 14/34 11/50 6/10
80 54 41 22 60
80 60 45 40 60
45--95 40--55 40--60 35--50 55--75
Recurrence rate up to 24 months Recurrence
Procedure
DDV plus collateral vein ligation (n = 48) DDV plus crura plication (n = 34) DDV plus corporopexy (n = 50)
Model
Subrini (n = 114) Small-Carrion (n = 40) AMS 700* (n = 12: three-component) Scott (n = 5) Finney (n = 7) Omniphase (n = 3)
n
%
30 16 13
62.5 47 26
Complications
Sexually active at 6 months, %
pain
extrusion
rare
normal frequent
5 22 66
2 5 41 20 -
86 65 50 40 71 -
11 30 9 40 29 -
-
14 -
3 5 41 20 -
*American Medical System.
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Table 5. Results after prosthesis implantation
Prosthesis When venous leakage is associated with arterial insuf ficiency, or the patient is over 65 years of age, intracaver nous prostheses is our treatment of choice. If a partial
erectile ability is preserved, we use the Subrini implant. The cavernous size reduction and the blood outflow hin drance provide intracavernous pressure increase, thus de termining physiological complementary erection (the low cost of Subrini prostheses is also a factor). A Subrini implant is effective if cavernous tissue is present. In these cases, postoperative CID treatment can be proposed for
vasoactive training. In case of severe erectile dysfunction (severe arterial insufficiency, local fibrosis), we use the three-component inflatable prosthesis (an intraperitoneal reservoir and a scrotal pump device). The latest model by AMS (Ultrex) assures a cavernous increase, also in longi tudinal size. Table 5 shows our results after prosthesis implantation.
References
68
6 Furlow WE. Fisher J. Knoll ED: Penile revas cularization experience with deep dorsal vein arterialization: The Furlow-Fischcr modifica tion with 27 patients. Proc 6th Biennial Int Symp for Corpus Cavcrnosum Revasculariza tion and 3rd Biennial World Meet on Impo tence. Boston. International Society for Impo tence Research. 1988, p 139. 7 Virag R: Intracavernous injection of papaver ine for erectile failure (letter). Lancet 1982;ii: 938. 8 Wespes E. Dclcour C. Struyvcn J, Shulman CC: Cavcrnomctry-cavernography: Its role in organic impotence. EurUrol 1984:10:229. 9 Lue TF. Tanagho EA: Physiology of erection and pharmacological management of impo tence. J Urol 1987;137:829-836.
Austoni/Colombo/Mantovani/Trinchieri
10 Bookstein JJ. Valji K. Parsons E, Kessler W: Pharmacoartcriographv in the evaluation of impotence. J Urol 1987;137:333-337. 11 Gilbert P. Steif C: Spongiolysis: A new surgical treatment of impotence caused by distal ve nous leakage. J Urol 1987;138:784-786. 12 Eue TF. Tanagho EA: Functional anatomy and mechanism of penile erection; in Tanagho EA. Luc TF. McClure RD (eds): Contemporary Management of Impotence and Infertility. Bal timore. Williams & Wilkins. 1988. pp 39-50. 13 Conti G: L'érection du penis humain et scs bases morphologico-vasculaires. Acta Anal 1952:14:217.
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
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1 Shirai M. Ishii N. Mitsukawa S. Malsuda S. Nakamura M: Hemodynamic mechanism of erection in the human penis. Arch Androl 1978;1:345. 2 Furchgott RF. Zawadski JV: The obligatory role o f endothelial cells in the relaxation of arterial smooth muscle to acetvcholine. Nature 1980:373-376. 3 Hcdlund II. Andersson KE: Contraction and relaxation induced by some prostanoids in iso lated human penile erectile tissue and caver nous artery. J Urol 1985:134:1245. 4 Michal V: Arterial disease as a cause of impo tence. J Clin Endocrinol Metab 1982; 11:725748. 5 Virag R: Revascularization of the penis: in Bennett AH (cd): Management of Male Impo tence. Baltimore, Williams & Wilkins, 1982. chap 17, pp 219-233.
Institute of Urology (Head: Prof. E. Pisani). University of Milan, Italy
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
Key Words
Abstract
Impotence Penile haemodynamics Venous surgery
The therapeutic rationale of venous surgery is to create an effective obstacle to the pathologically increased venous outflow, determined by an intrinsic pathology of the cavernous bodies. In the last 15 years, many techniques have been proposed, and our therapeutic approach has evolved with our knowledge of penile haemodynamics. Up to October 1990, we performed 316 operations for the relief of impotence. In a 2-year follow-up our recurrence rates were as follows: DDV plus corporpexy (n = 50): 26% (n = 13); DDV plus crura plica tion (n = 34): 47% (n = 16); DDV plus collateral vein ligation (n = 48): 62.5% (n = 30).
Definition of Venous Leakage and Number of Operations Performed
Erectile failure due to venous leakage can be described as the inability of the penile vascular system to trap blood within the corpora cavernosa and, therefore, as a failure to increase the intracorporeal pressure in excess of the systolic blood pressure. The venogcnic impotent patient cannot maintain a firm erection and achieve tumescence sufficient for intercourse. Numerous factors can contrib ute to determine excessive cavernous vein outflow: pathological changes of the cavernous smooth muscles, abnormal local venous drainage, insufficient neurotrans mitter release, or alteration of the cavernous endothelium [1-3]. Other elements which can interfere with the control mechanism of cavernosal venous outflow are certainly
neurological disorders and, in our experience, defects of the suspensory ligament of the penis. Moreover, there is a frequent association between penile arterial disease and veno-occlusive insufficiency of the corpora cavernosa. Some authors suggest that arterial insufficiency may be one of the causes of corporal ischaemic injury, thus pro ducing cavernosal veno-occlusive failure [4], The consequence of such aetiological uncertainty is the current surgical therapy, the so-called ‘venous surgery’. The therapeutic rationale behind this kind of surgery is to create an effective but mere hindrance to the pathologi cally increased venous outflow. During the last 15 years, many techniques have been proposed, and our thera peutic approach has evolved with our knowledge of penile haemodynamics. In the early 80s, we have performed 39 operations using Virag’s techniques [5] - arterialization of the deep
Prof. E. Austoni Istitutodi Urologia Via Commcnda. 15
© 1992 S. Karger AG. Basel 0042-1138/92/0491-0063 $2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/26/2018 12:32:47 AM
E. Austoni F. Colombo F. Mantovani A. Trinchieri
64
Procedure for Diagnostic Management: Role of Pharmacological Testing, Standards of Flow Rates, Value of Intracavernosal Pressure, Value of Cavernosography
The diagnostic management of patients suspected of venous leakage developed at the Institute of Urology of the University of Milan includes the following steps: (1) his tory (sexual intercourse, ability to obtain a firm erection, therapy with beta blockers, diuretic drugs, etc.); (2) physi cal examination (recurvatum, fibrosis, PP); (3) psychologi cal evaluation; (4) endocrine panel (testosterone, folliclestimulating hormone, luteinizing hormone prolactin, and estrogen); (5) nocturnal penile tumescence monitoring (Rigiscan, 3 consecutive nights); (6) intracavernous pa paverine injection test (20 mg, 1 cm3, after informed con sent has been obtained); (7) penile Doppler sonography, with the penis in the flaccid state and after intracavernous injection of 8 mg of papaverine; (8) cavernosometry after intracavernous injection of papaverine (Wicst-Cavomat, roller infusion pump), monitoring the infusion flow and intracavernous pressure; (9) cavernosography, in case of pathological response by cavernosometry, and (10) neuro logical evaluation (bulbocavernous reflex by electromyo graphy and/or evoked potential). When patients do not reach an effective erection fol lowing the papaverine test (20 mg. intracavernous injec tion) we have to discriminate between insufficient arterial inflow and excessive venous outflow (venous leakage) [7], For this purpose, we perform a dynamic infusion caver nosometry [8], Both corpora cavernosa and the glans are punctured through with 19-gauge butterfly needles after a local anaesthetic spray (lidocaine 15%) is applied. A saline infusion pump device is connected to one but terfly needle, while the other one is attached to a manom eter to allow continuous intracorporeal pressure monitor ing (Wiest-Cavomat roller pump device). The initial resting intracorporeal pressure of the nonerect penis is recorded. We begin the examination with the saline flow rate at 40 ml/min, increasing to 20 ml/min every 30 s until erection occurs or until the flow rate has reached 160 ml/min for more than 60 s. If no erection is obtained, we apply 90 s digital compres sion on the cavernous crura (perineum), noting the intraca vernous pressure increase; after 1 min we repeat the 90-sec ond digital compression, but this time on the infrapubic ar ea. In this way we obtain information about the main ve nous outflow pathways (V DP and collaterals or cavernous). We consider as normal values an erection flow < 140 ml/min and a maintaining erection flow < 7 0 ml/min.
Austoni/Colombo/Mantovani/Trinchicri
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/26/2018 12:32:47 AM
dorsal vein (DDV), with consequent venous blocking which gave us immediate positive results in 28% of oper ated cases, but we later abandoned these procedures because of frequent complications, such as thrombosis of the shunts and hypervascularization of the glans. The latest technological advances in the diagnostic field (cavernous biopsy, cavernoscopy) have made it pos sible to show anatomo-pathological factors affecting the corpora cavernosa (such as fibrosis and sclerosis of erec tile tissue) that seem to play a major role in erectile fail ure. Neurological processes, such as adrenergic hyperto nus (which constricts the sinusoidal and penile microarterial tissue) significantly contribute to complete the dysrcactivc erectile syndrome. For this reason DDV arterialization techniques have been reconsidered by some au thors (as well as by some of us) [6]. Some precautions, such as the preliminary ligations of the cavernous-glandular distal venous connections and the proximal DDV ligation, have to be respected to avoid the above-mentioned collateral effects (glans hyperacmia and erectile tissue fibrosis due to the high pressure caused by the anterograde arteriocavcrnous shunt). These techni cal measures render circumflex veins the only pathways of the arterial haematological increase. At the same time they absorb arterial systolic impulses (with a smaller risk of thrombosis or of cavernous fibrosis, which is typical of direct cavernous arterialization) and create such a light and continuous endocavernous hyperdistension that it opposes and counter-balances the adrenergic hypertonus. At our institution, our experience with these modified techniques is still at an early stage, but the first haemody namic data (peroperativc and short-time follow-up) looks encouraging, especially in patients who suffer from ve nous leakage. In earlier years, we performed 135 DDV simple liga tions. under local anaesthetics using a short longitudinal mid-incision on the dorsal face of the penis. Subsequent ly, we moved to the technique of progressive ligations of the veins with peroperative cavernometry. Using this technique, the following operations have been carried out: (1) DDV + collateral veins ligation (Kelamy access; n = 53); (2) spongiosoglandular lysis (n = 11), and (3) DDV ligation plus tightening of the cavernous crura (n = 37). During the last 3 years, we have also treated 80 venous leakage patients by DDV ligation fol lowed by proximal dorsal tightening of the cavernous bodies by means of 4-6 non-absorbable stitches, perform ing corporopubic suspension (corporopexy) at the same time. Up to October 1990 we performed such 316 opera tions.
Management of an Arterial (Co)factor in Diagnosis and Treatment
There is a frequent association between veno-occlusive insufficiency and penile arterial disease. Investigations performed on a canine model [10] showed a possible aetiologic relationship between acute, subacute, and chronic pudendal arterial obstruction and failure of the veno-occlusive mechanism. These authors suggested that the venous leakage may be secondary to some ischaemic injury. In our management, all patients undergo Doppler son ography, and, if pudendal arterial insufficiency has been shown, venous surgery is not performed. If the patient is under the age of 60 years, and the angiographic evaluation does not show diffused atherosclerosis, he can undergo arterial revascularization of the dorsal artery of the penis (we perform epigastrodorsal double anastomosis, orthoand backflow: 68 patients between 1986 and 1990).
On the contrary, if the patient is over 60, or arteriogra phy shows plaques of atheroma inside the main arteries (especially the internal iliac artery) we prefer to resort to prosthetic implant. In doubtful cases, these patients are treated with a weekly intracavernous injection of papav erine and phentolamine for a period of 6 months. Some patients improved their erection response following this treatment. In non-responder cases, we perform a pros thetic implant. The choice between Subrini’s prosthesis and inflatable multicomponent models depends on the seriousness of the disease. If a certain erection response can be achieved, we prefer Subrini's implant (less expensive and more physiological). In the most serious cases the hydraulic, three-component prostheses are the treatment of choice.
Venous Surgical Procedures with Special Remarks concerning Crural Veins, Cavernosoglandular Global Venous Insufficiency, and Ectopic Veins
Since 1986 we have used the technique of progressive ligations of the main veins draining the corpora cavernosa (according to cavernosography). All procedures are carried out under general anaesthe sia which eliminates the risk of distress, making peropera tive cavernometry more valuable. The operation begins with the ligation of the main venous pathways shown by dynamic cavernography and continues with progressive ligations until OME figures decrease below 30 ml/min. Since 1988 we have also performed at the vein ligation stage the procedure we called corporopexy by means of 4-6 single stitches of non-absorbablc material which draw the corpora towards the pubic bone, so strengthen ing the suspensory ligament of the penis, and creating a proximal cavernous stricture. Peroperative cavernosome try allows us to check the correct presentation of the stric ture. In case o f‘deep’ cavernous leakage (according to caver nosography), we used plication of the cavernous crura. A mid-vertical incision of the perineum allows a good access to the bulbourethral and to the cavernous crura; we can perform the plication either in both the corpora or unilaterally, depending on the peroperative cavernosometric values. The technical experience we have obtained in penile surgery during the last 15 years has taught us that the care ful isolation of the glans and of the urethral tissue from the cavernous bodies (performed in, e.g., surgical treat-
65
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The second part of cavernosometry is performed 2 min after intracavernosal injection of 20 mg papaverine (1 cm3), and this time, the following figures can be consid ered pathological: (1) an OOE rate > 100 ml/min, an OME rate > 4 0 ml/min, a final steady-state intracavernous pressure < 1 0 0 mm Hg (5 sec after interrupting mechanical perfusion) and its continuous decrease during the subsequent 30 s > 50 mm Hg. Unfortunately, factors such as psychological inhibition and stress (which often occur when cavernosometry is performed on a conscious patient) cause the stimulation of a-adrenergic receptors, and so determine arterial and perisinuoidal smooth muscle contraction. We do not know if the intracavernous administration of papaverine and/or phentolamine can always balance these effects, making cavernometric response totally accurate [9], During routine evaluation of venous leakage, cavernosography occupies a less important place in our manage ment plan. Demonstration of the contrast medium in the penile draining system, fora certain percentage of healthy men, suggests that venous leakage as revealed by cavernosography must not be considered diagnostically valid for venogenic impotence. This, however, plays an impor tant role in preoperative evaluation of the most important drainage pathways of the corpora. We perform cavernosograms (anteroposterior and oblique film) at the end of cavernosometry only in those cases shown to be pathological (OME > 4 0 ml/min after intracavernous injection of paperverine, 20 mg).
Complications
Table 2 represents our experience of complications fol lowing venous surgery'.
Analysis of Failures: Persistent or Newly Formed Venous Channels, Arterial Factors, Psychology!?)
The aetiopathogenesis of venous leakage consists in an intrinsic dysfunction of the cavernous body [12, 13]. Venous ligation is unavoidably, a mere palliative, as not even corporopexy and crura plication which reduce the calibre of the cavernous bodies can cure these anatomical defects. The high rate of relapses found after all these proce dures is determined by the formation of new venous col lateral pathways. In our experience, the results of corporo pexy seem to be more satisfactory, and this might be contigent on the dual effect which this technique procures. It
Follow-Up
Table 1. General
We obtained the best immediate success rate (full sex ual intercourse) with the lowest figures at the peroperative cavernosometry in the patients who underwent spongio glandular lysis, but. unfortunately, they showed a high percentage (60%; 6 out of 10 patients checked) of recur rence (intermittent erection, no rigidity, OME > 3 5 ml/min) at 12 months of follow-up, with an OME average of 60 ml/min (range 55-75). The percentage of relapses was also significant among patients operated on by other techniques (table 3). Recurrence rates are shown in ta ble 4.
Table 2.
Complications
Number of patients DDV arterialization (Virag's technique until 1981) Simple DDV ligation (local anaesthesia) Intrapubic DDV plus colateral vein ligation Spongioglandular lysis DDV ligation plus crura plication DDV ligation plus corporopexy
39 135 53 11 37 80
Total
355
Procedure
Complications
n
%
DDV arterialization (n = 39)
hypervascularization of glans thrombosis of shunts inguinal hernia foreskin oedema glans pain foreskin oedema
39 20 4 18 58 30
100 51 10 13.3 43 56.6
glans paraesthesia widespread oedema of the penis reactive fascial fibrosis painful postoperative erection perineal pain priapism (due to an excessive decrease of cavernous outflow) iatrogenic ligation of one or both cavernous arteries localized cellulitis diastasis of the suture public pain (osteitis)
7 9 2 10 30
63.6 81.8 18.2 90.9 81.1
3
8.1
1 30 16 48
2.7 37.5 20 60
Simple DDV ligation (n = 135) DDV plus collateral vein ligation (n = 53) Spongioglandular lysis (n = 11)
DDV ligation plus crura plication (n = 37)
DDV ligation plus corporopexy (n = 80)
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experience of venous surgery
Austoni/Colombo/Mantovani/Trinchieri
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
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mcnt of Peyronie’s disease) allows the reduetion of the cavernous outflow. We have consequently treated 11 patients suffering from venous leakage by this technique (spongioglandular lysis) [11]. The procedure leads to the interruption of all the communicating veins between the corpora and the urethroglandular structures. Table 1 sums up our experi ence of venous surgery.
improves rigidity, the erection angle of the penis (due to the strengthening of the suspensory ligament) and, at the same time, it reduces cavernous outflow, thus increasing rigidity. In our institution, the presence of arterial deficiency precludes that the patient can undergo venous surgery. Furthermore, Doppler sonography, performed after ve nous surgery relapses, never exhibited arterial insuffi ciency. Psychogenic factors, often described in impotent pa tients, must be carefully evaluated. In case this aspect assumes primary importance, the patient should be re ferred to a psychosexologist. When the psychogenic ele ment is secondary to organic disease patients seem to improve after venous surgery, more, it seems, because of autosuggestion rather than because of a specific organic response: is this a case of the placebo effect? Is improve ment of self-confidence due to the greater penile tumes cence to be considered?
crura plication. All but 3 of these patients achieved func tional improvement after the second surgical procedure. Of the 3 non-responders, 2 required prosthesis implant.
Supportive Therapy: Intracavernous Injection of Vasoactive Drugs, Reoperation, Prostheses
84% of the recurrence cases did show, however, an improved clinical response after an intracavernous papaverine injection (20 mg during VSS). and 73% of these reported satisfactory sexual inter course after a self-administered papaverine injection.
In our management plan, all patients operated on by venous surgery undergo postoperative training with intra cavernous injection of papaverine combined with phentolamine (10-40 mg papaverine; 0.5-2 mg phcntolamine). In our opinion, this has a dual effect: cavernous compliance recovery, and a-adrenergic tone balance (due to postoperative stress). Reoperation In our experience, 32 patients previously operated on by simple DDV ligation underwent reoperation: 21 of them were treated by collateral vein ligation and 11 by
Table 3.
Relapse rate up to 1 year
Procedure
n
%
OME, ml/min average range
DDV simple ligations DDV plus collateral vein ligation DDV plus crural ligation DDV ligation plus corporopexy Spongiosoglandular lysis
Table 4.
36/120 26/48 14/34 11/50 6/10
80 54 41 22 60
80 60 45 40 60
45--95 40--55 40--60 35--50 55--75
Recurrence rate up to 24 months Recurrence
Procedure
DDV plus collateral vein ligation (n = 48) DDV plus crura plication (n = 34) DDV plus corporopexy (n = 50)
Model
Subrini (n = 114) Small-Carrion (n = 40) AMS 700* (n = 12: three-component) Scott (n = 5) Finney (n = 7) Omniphase (n = 3)
n
%
30 16 13
62.5 47 26
Complications
Sexually active at 6 months, %
pain
extrusion
rare
normal frequent
5 22 66
2 5 41 20 -
86 65 50 40 71 -
11 30 9 40 29 -
-
14 -
3 5 41 20 -
*American Medical System.
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Table 5. Results after prosthesis implantation
Prosthesis When venous leakage is associated with arterial insuf ficiency, or the patient is over 65 years of age, intracaver nous prostheses is our treatment of choice. If a partial
erectile ability is preserved, we use the Subrini implant. The cavernous size reduction and the blood outflow hin drance provide intracavernous pressure increase, thus de termining physiological complementary erection (the low cost of Subrini prostheses is also a factor). A Subrini implant is effective if cavernous tissue is present. In these cases, postoperative CID treatment can be proposed for
vasoactive training. In case of severe erectile dysfunction (severe arterial insufficiency, local fibrosis), we use the three-component inflatable prosthesis (an intraperitoneal reservoir and a scrotal pump device). The latest model by AMS (Ultrex) assures a cavernous increase, also in longi tudinal size. Table 5 shows our results after prosthesis implantation.
References
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6 Furlow WE. Fisher J. Knoll ED: Penile revas cularization experience with deep dorsal vein arterialization: The Furlow-Fischcr modifica tion with 27 patients. Proc 6th Biennial Int Symp for Corpus Cavcrnosum Revasculariza tion and 3rd Biennial World Meet on Impo tence. Boston. International Society for Impo tence Research. 1988, p 139. 7 Virag R: Intracavernous injection of papaver ine for erectile failure (letter). Lancet 1982;ii: 938. 8 Wespes E. Dclcour C. Struyvcn J, Shulman CC: Cavcrnomctry-cavernography: Its role in organic impotence. EurUrol 1984:10:229. 9 Lue TF. Tanagho EA: Physiology of erection and pharmacological management of impo tence. J Urol 1987;137:829-836.
Austoni/Colombo/Mantovani/Trinchieri
10 Bookstein JJ. Valji K. Parsons E, Kessler W: Pharmacoartcriographv in the evaluation of impotence. J Urol 1987;137:333-337. 11 Gilbert P. Steif C: Spongiolysis: A new surgical treatment of impotence caused by distal ve nous leakage. J Urol 1987;138:784-786. 12 Eue TF. Tanagho EA: Functional anatomy and mechanism of penile erection; in Tanagho EA. Luc TF. McClure RD (eds): Contemporary Management of Impotence and Infertility. Bal timore. Williams & Wilkins. 1988. pp 39-50. 13 Conti G: L'érection du penis humain et scs bases morphologico-vasculaires. Acta Anal 1952:14:217.
Venous Surgery in Erectile Dysfunction: Therapeutic Strategy and Results
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1 Shirai M. Ishii N. Mitsukawa S. Malsuda S. Nakamura M: Hemodynamic mechanism of erection in the human penis. Arch Androl 1978;1:345. 2 Furchgott RF. Zawadski JV: The obligatory role o f endothelial cells in the relaxation of arterial smooth muscle to acetvcholine. Nature 1980:373-376. 3 Hcdlund II. Andersson KE: Contraction and relaxation induced by some prostanoids in iso lated human penile erectile tissue and caver nous artery. J Urol 1985:134:1245. 4 Michal V: Arterial disease as a cause of impo tence. J Clin Endocrinol Metab 1982; 11:725748. 5 Virag R: Revascularization of the penis: in Bennett AH (cd): Management of Male Impo tence. Baltimore, Williams & Wilkins, 1982. chap 17, pp 219-233.
