U rollnt 1992:49:29-32

Department of Vascular Surgery, University of Sao Paulo School of Medicine, and Instituto H. Ellis. Sao Paulo. Brazil

Venous Surgery in Erectile Dysfunction



Impotence Penis Erection Corpus cavernosum

According to the physiopathological process beyond it, veno-occlusive dys­ function (VOD) may be classified in organic or functional VOD. The former is caused by lack of control of smooth muscle relaxation, while the later is related with morphological alterations of the corporeal tissue. The differential diagno­ sis of those two types is fundamental when venous surgery is to be discussed. Functional VOD may be treated with sex therapy, while in organic VOD, sur­ gical treatment may be considered. The experience with venous surgery for impotence at the H. Ellis Institute was not encouraging. Although a few patients were cured, the long-term follow-up showed that only 9 out of 57 patients were able to have a normal sexual life. New diagnostic tools, as well as a better understanding of the erectile mechanism, may lead to a better selec­ tion of cases with an improvement of the results in the future. Today, venous surgery remains as an option to patients with organic VOD. who are willing to accept a 45% probability of improvement for a few months, having been informed about all the other options in the treatment of erectile disorders.

Definition of 'Venous Leakage'

Erection demands entrapment of blood in the corpora cavernosa, by means of a veno-occlusive mechanism [1], Venous leakage may be defined as the loss of pressure in the corpora cavernosa caused by drainage of the entrap­ ped blood through the veins. Venous leakage is often a physiological phenomenon: every time a man completes a sexual intercourse, venous leakage occurs to promote dctumcscencc. It may also occur physiologically even before the intercourse is com­ pleted and orgasm is reached, when any change in the

environment requires a break in the intercourse, such as in life-threatening situations. When the corpora cavernosa are unable to retain blood in any situation, or when venous leakage occurs during intercourse, most of the times the patient has a nonphysiological venous leakage. Since this represents a primary failure or a inopportune reversion of the veno-occlusive mechanism, the term veno-occlusive dysfunction (VOD), introduced by a group of researchers at Boston Universi­ ty, seems more appropriate. There are basically two types of VOD: functional and organic VOD. The former is caused either by lack of

Pedro Pucch-l efio. M D . P hD Rúa Hcitor de Moracs 61 01237 Sao Paulo ( Brasil)

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Pedro Puech-Leao

Diagnosis of VOD and Patient Selection for Venous Surgery

The methods of diagnosis used in the H. Ellis Institute for detecting VOD have varied along the last years. Hav­ ing started with standard cavernosometry-cavernosography [4], we passed through pharmacocavernosomctry [5] and came to what is described hereafter. The First step in the diagnosis is pharmacoerection. The test is performed according to several guidelines which, in our experience, may decrease the number of false positives for vasculogenic impotence. (1) The dose of smooth muscle relaxant shall be effec­ tive. The complication of a high dose of drugs in the cor­ pora cavernosa is a prolonged erection which can be effi­ ciently managed in virtually every case by an experienced physician. But the complication of a low dose may be a false diagnosis that may lead to an unnecessary surgical operation. At present, we use 70 mg of papaverine plus 1 mg of phentolamine. (2) Adrenergic discharges during the test must be avoided as much as possible. We give the patient 7.5 mg of midazolam 30 min before the test and leave him alone after the injection. He is assured that nobody will disturb him during the next 20 min. and visual sexual stimulation by means of a videotape is started. Twenty minutes after the injection, the patient is eval­ uated. If a rigid erection is achieved, there is no VOD. If not, the diagnosis of VOD is considered. Next, gravity cavernosometry is performed, according to the technique described in another publication [6],



If the intracavernous pressure achieved with gravity perfusion is above 110 cm HyO. the elasticity and com­ pliance of the corpora cavernosa are considered adequate, and the possibility of venous surgery is discussed with the patient. If he accepts the possibility to undergo venous ligation, we propose a series of 5 trials with self-injections before the operation is recommended. The reason for this trial is the fact that, despite all care in avoiding stress dur­ ing laboratory pharmacoerection tests, we have seen a number of patients with psychogenic impotence who failed to achieve erection in such circumstances. In these cases, after self-injection in an erotic environment, they have rigid erections. When that occurs, the diagnosis of VOD has to be eliminated, since the lack of erection in the laboratory was the result of functional VOD at that moment. The possibility of venous surgery is not consid­ ered. because the experience with psychotherapy associ­ ated with a self-injection program has given us encourag­ ing results in these situations. We strongly believe that, in organic VOD, erection shall not be possible with pharmacoinjection in any circumstance. If the patient fails in achieving erection after five attempts with self-injection of PGE|. in progressively increasing doses up to 30 mg. the operation is considered. If he is diabetic or has had a history of alcoholism during a long period, a neurological evaluation including bulbo­ cavernous reflex latency and penile sensory-evoked po­ tentials is performed to rule out peripheral neuropathy. If the cavernous artery occlusion pressure is above 90 mm Hg and no signs of artcriopathy arc present, venous liga­ tion is proposed. The rate of success to be expected is carefully explained to the patient, as well as the advan­ tages and disadvantages of all kinds of penile implants. Cavernosography is noi performed in the work-up for the selection of patients for venous surgery. We believe that it docs not add any information to those obtained in cavernosometry in that phase. If the operation is decided, cavernosography is performed prior to the surgical proce­ dure to localize the veins and as a guide to venous liga­ tions. At present, we prefer to perform it in the operating room, under fluoroscopy, just after anesthesia is com­ pleted. It is repeated after the operation. From December 1985 to November 1990. 1,338 pa­ tients were interviewed at the H. Ellis Institute with the chief complaint of impotence. Only 1,097 of those agreed to undergo a complete work-up. From these 1.097, 296 were diagnosed as having pure VOD. Venous surgery and penile implants were discussed as possibilities with the 296 patients. Out of 296. 57 ac­ cepted to undergo venous surgery and/or crural ligation.

Venous Surgery in Erectile Dysfunction

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relaxation or by inopportune contraction of the corporal smooth muscle, which promotes reversion of the venoocclusive mechanism: it occurs in all cases of psychogenic impotence whenever performance anxiety is present. The latter is caused by structural alterations of the trabeculae which prevent distension of the cavernous tissue despite relaxation of the smooth muscle cells: it is a result of lack of elasticity in the sinusoids, caused by degenerative pro­ cesses [2], or by local damage like in Pevronie’s disease [3]. The differential diagnosis of the two kinds of VOD is of utmost importance. Functional VOD can, most of the times, be treated by psychological counseling, while or­ ganic VOD can only be treated by surgery. Unfortunately, the differential diagnosis is always difficult, and is a result of a careful and complete work-up, rather than the result of a single laboratory or radiological test.

The others either opted for a primary penile implant or decided not to undergo any surgical treatment for the erectile dysfunction.

T a b le 1.

Technique of Venous Ligation


Complications included postoperative pain in 12 of the patients submitted to crural ligation, shortening of the penis in 3 cases submitted to Lue’s operation, focal skin necrosis in 3 cases and postoperative priapism in 2 cases. The pain was controlled with analgesics and subsided spontaneously after 4-20 days; the 2 cases of postopera­ tive priapism were submitted to crural plus venous liga­ tion; both were treated with aspiration of blood and epi­ nephrine infusion with remission of the priapism, but in both cases, a permanent erectile incapacity lasted, requir­ ing indication of an implant.

Postoperative Evaluation and Management

Only 6 patients agreed to undergo a postoperative pharmacoerection test and cavernosometry. In 2 cases, the tests were turned to positive after the operation; 1 of these patients claimed to have good erections and the other was still impotent. In the other 4 cases, the result of the tests was similar to the preoperative data, although 1 of them claimed to have rigid erections after the proce­ dure. No reoperations were performed. In all unsuccessful cases, a penile implant was recommended.

Number of Procedure patients

Good results 1 year

2 years

23 23 11

13/23 9/23 4/11

3/23 4/20' 2/11


CL = Crural ligation; VL = venous liga­ tion. 1 3 patients were lost to follow-up.


Although venous ligations do not approach the basic pathophysiology of VOD, it may theoretically create a venous stasis that may compensate the inability to store blood in the corpora cavernosa. The occurrence of 2 cases of postoperative priapism in our series showed that ve­ nous surgery may indeed promote a decrease in venous drainage from the corpora cavernosa. Long-term results, however, were not encouraging in our experience. Since complications may occur, the indication should be very carefully discussed with the patient together with all pos­ sibilities and alternatives before reaching a decision. An analysis of the causes of failure is difficult. Ethical reasons prevent us from performing postoperative inva­ sive tests with academic purposes, unless the patient vol­ unteers after having been informed on what kind of bene­ fits he may personally get from these tests, which are not many. Persistence of veins not detected during surgery as well as compensatory dilatation of small veins in the months subsequent to the operation certainly play a role in the causes of failure. However, if we consider the fact that a precise diagnosis of impotence caused by structural im­ pairment of the veno-occlusive mechanism is still a goal to be reached, we can conclude that the major cause of failure is probably inadequate selection of cases. The appearance of more recent diagnostic tools, such as analysis of the electrical activity of the corpora caver­ nosa [9] and needle biopsies of the cavernous tissue [10], is followed with great expectancy by all those who treat impotent patients. Only after an improvement in the diagnostic methods will the place for venous surgery be determined in the treatment of erectile disorders.


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Twenty-three patients were submitted to crural liga­ tion alone according to the technique previously de­ scribed [7], 23 patients were submitted to venous ligation according to the technique described by Lue [8], and 11 patients were submitted to venous plus crural ligation. The results and length of the follow-up are shown in table 1. We consider as good result the return to normal sexual life with rigid erections. Since this is what the patient may get from the alternative treatment (penile implant), any result other than that is considered as fail­ ure.

Results of venous surgery for


R e fe re n c e s


4 Wespes E. Delcour C. Struyven J. Schulman CC: Cavernometry-cavcrnography: Its role in organic impotence. Eur Urol 1984:10:229232. 5 Wespes E. Delcour C. Struyven J. Schulman CC: Pharmacocavernometry-cavernography in impotence. Br J Urol 1986:58:429-433. 6 Puech-Lcao P. Chao S. Glina S. Rcichelt AC: Gravity cavernosomctry - A simple diagnostic test for cavernosal incompetence. Br J Urol 1990:65:391-394. 7 Puech-Leao P. Reis JMSM. Glina S. Reichelt AC: Leakage through the crural edge of the cor­ pora cavernosa - Diagnosis and treatment. Eur Urol 1987:13:163-165.


8 Lue TF: Penile venous surgery. Urol Clin North Am 1989:16:607-611. 9 Wagner G. Gerstenbcrg T: Human in vivo studies of electrical activity of corpus cavernosum .J Urol 1988:139:327A. 10 Wespes E. Depicrreux M. Schulman CC: Use of biopsy gun for cavernous biopsy. Int J Impo­ tence Res I990:2(suppl 2):228—229.

Venous Surgery in Erectile Dysfunction

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1 Fournier GR Jr. Juenemann KP. Lue TF. et al: Mechanism of venous occlusion during canine penile erection - An anatomic demonstration. J Urol 1987:137:163-166. 2 Azadzoi K, Saenz de Tejada I. Goldstein I. Krane RJ: Atherosclerosis and high cholesterol diet induce corporal veno-occlusive dysfunc­ tion. Proc Third Biennial Meet Impotence. Boston. Boston University. 1988. p 17. 3 Gasior B. Levine F. Goldstein I. et al: Cavernosomctric and cavernosographic findings in patients with idiopathic Peyronie disease: Plaque-associated corporal veno-occlusive dys­ function. Int J Impotence Res 1990:2(suppl 2): 111- 112.

Venous surgery in erectile dysfunction.

According to the physiopathological process beyond it, veno-occlusive dysfunction (VOD) may be classified in organic or functional VOD. The former is ...
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