Over a period of seven years nine patients with vascular complications after lumber discectomy received medical care at the Clinic of Vascular Surgery, University of Graz Medical School. We report five acute bleeding complications occurring during the operation and four late manifestations of vascular lesions. Five patients presented with acute life-threatening iatrogenic haemorrhages from pelvic vessels. Three patients made a complete recovery, one patient died from acute haemorrhagic shock, one further patient died from sepsis due to an associated complication-an injury to the ureter. Over a period of two to ten years after primary surgery we corrected late complications such as 1 case of posttraumatic aneurysm of the aortic bifurcation found to have eroded the body of the fifth lumbar vertebra, and three cases of arteriovenous fistula between the common iliac artery and the common iliac vein. The four cases described below are an attempt to document the vascular surgical procedures involved and to provide typical findings. The risk of injuring the pelvic vessels intra-operatively can be explained by the close anatomical relation between the retroperitoneal vessels and the vertebral column and furthermore not only by the fact that pre-existent deficiencies but also injury to the anterior longitudinal ligament give access to the retroperitoneal space.
The Talent system revealed satisfactory early results which are comparable to competitive stent-graft systems. An advantage of this stent-graft device is the availability in a wide range of dimensions. A major disadvantage is the large introducer system (french size 22-27).
Introduction
Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals.
Objective
We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization.
Methods
An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers.
Results
The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline.
Conclusions
This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery.
Disclosure
No
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