Vascular Surgery - Erectile Dysfunction
What is vascular surgery?
Vascular surgery attempts to restore penile blood flow that has been reduced by correcting a blockage or leakage in blood flow to the penis in order to improve a man's ability to get and maintain a natural erection.
Vascular surgeries can include:
- Repairing leaking veins that prevent a man from keeping an erection
- Bypass operations to re-route blood past blocked arteries to the penis
- Blocking off veins that allow blood to leave penile tissue.
What is artery bypass surgery used for ED?
Artery bypass surgery, also known as penile revascularization, is a treatment for ED that is designed to bypass blocked arteries that limit blood flow to the penis thus causing ED. In this surgery, an artery is transferred from another area of the body (usually the abdomen), to a penile artery in an effort to create a new path for blood flow to the penis that bypasses the blocked or injured vessel. Therefore, the specific objective of artery bypass surgery is to increase artery blood flow to the erection tissue of the penis.
This procedure is most commonly used in men who have experienced a penile vessel injury caused by events such as trauma, pelvic facture or surgery.
Artery bypass surgery is a treatment that has the potential to permanently cure patients of ED, allowing men to spontaneously develop erections without the need for any ED medications or internal/external devices.
Who are candidates for penile revascularization?
Young men who have ED secondary to traumatic occlusion of the erectile artery(ies) and who have no other vascular risk factors (eg. diabetes, hypertension, hypercholesterolemia, or significant cigarette smoking) represent the ideal patient population for penile vascular surgery. The investigation and preoperative evaluation of these patients are aimed at ensuring 1) normal hormonal status, 2) normal neurologic function, and 3) the documentation of poor blood flow and the absence venous leak. All young patients with a history suggestive of trauma-associated ED (particularly patients who have experienced pelvic fracture or perineal trauma) can be considered candidates for penile vascular surgery.
What form of patient evaluation is required?
All patients considered candidates for penile revascularization should have a routine hormone evaluation to ensure adequate circulating levels of testosterone. In addition, a nocturnal penile tumescence and rigidity analysis (NPTR) should be performed to rule out neurogenic and psychogenic erectile dysfunction. Finally, a blood flow assessment with duplex Doppler penile ultrasonography or dynamic infusion cavernosometry/cavernosography (DICC) is required. Following testing, if the patient has a diagnosis of pure arterial insufficiency, an arteriogram is performed to show the arterial anatomy and confirm the location of the blockage. The arteriogram should demonstrate several findings to ensure optimal results from penile revasularization. These findings include: 1) a blockage of the common penile or cavernosal artery at a point that is amenable to bypass 2) at least one donor (inferior epigastric) artery of sufficient length and caliber to reach the top surface of the penis and the recipient artery 3) communicating branches passing from the dorsal artery into the erection chamber (corpus cavernosum) on at least one side, preferably the side of the occlusion.
What does the surgery involve?
There are many variations of this procedure, which is beyond the scope of this section. The operation takes approximately 4-6 hours. The patient is asleep under general anesthesia. In the most commonly and probably most successful approach to penile revascularization, the donor artery is harvested for the abdomen. The inferior epigastric artery is a blood vessel that supplies blood to one of the abdominal muscles. Removing this artery has no effect on the health of this muscle. This blood vessel harvesting requires an incision on the belly. The artery is detached from its upper attachment and swung down onto the top surface of the penis by tunneling it through the hernia ring. There is a second incision on the scrotum or penis. Once on the top of the penis the inferior epigastric artery is attached to the recipient artery the surface artery of the penis (dorsal artery). Patients routinely stay in hospital a single night, miss one week from work and need to avoid physical exertion including sexual activity for several weeks after surgery.
How successful is penile revascularization?
The medical literature indicates that there are some men who are cured of their ED by this operation. The success is based on how appropriate a candidate the patient is for the surgery and the experience and training of the surgery. There are few centers in the world that would be considered centers of excellence for this operation. This is not an operation that should be routinely performed by a urologist or surgeon who has not received special training in this form of microsurgery. Most medical papers published suggest that approximately 50% of men will be cured at 2-5 years after surgery. Besides this group there are men who are improved but who still require the use of erection medicines after surgery.
What is vein ligation surgery for ED?
Sometimes veins in the penis can leak, preventing it from staying erect. Venous ligation surgery attempts to correct this problem by blocking off veins (ligation) that normally allow blood to leave the penis. By creating an intentional blockage in blood flow out of the penis, this reduction in the leakage of blood is aimed at increasing the rigidity of the penis during an erection. Leakage of blood from the penis is the result of damage to the structure of the erection tissue. Thus, this form of surgery does not address the underlying cause but more the symptoms of leakage. To date, there is no evidence that vein ligation surgery has success in the long-term cure of ED due to venous leak. Thus, most authorities currently do not advocate venous ligation surgery. There is one group of men in whom there is renewed interest in such surgery. Preliminary evidence suggests that young men who have a specific form of leak (isolate crural venous leak) may benefit from a specific form of surgery (crural ligation/exclusion surgery). Patients are candidates for this surgery if they have this special form of leak proven usually requiring a test called cavernosography. At this time, very few centers in the USA have experience in this procedure.