Standard Operating Procedures for Vascular Surgery in Erectile Dysfunction: Revascularization and Venous Procedures

Abstract

Introduction The impact of penile blood supply on erectile function was recognized some 500 years ago. At the turn of the 20th century first results of penile venous ligation were published and in 1973 the first surgical attempts to restore penile arterial inflow were undertaken. Numerous techniques were published in the meantime, but inclusion criteria, patient selection, and success evaluation differed extremely between study groups. Aim To develop evidence-based standard operating procedures (SOPs) for vascular surgery in erectile dysfunction, based on recent state of the art consensus reports and recently published articles in peer-reviewed journals. Methods Based on the recent publication of the consensus process during the 2009 International Consultation on Sexual Medicine in Paris, recommendations are derived for diagnosis and surgical treatment of vascular erectile dysfunction. In addition several recent publications in this field not mentioned in the consensus statements are included in the discussion. Main Outcome Measure The Oxford system of evidence-based review was systematically applied. Due to the generally low level of evidence in this field expert opinions were accepted, if published after a well-defined consensus process in peer-reviewed journals. Results Referring to penile revascularization it may be concluded, that in the face of missing randomized trials, only recommendations grade D may be given: this kind of surgery may be offered to men less than 55 years, who are nonsmokers, nondiabetic, and demonstrate isolated arterial stenoses in the absence of generalized vascular disease. The evidence level for recommendations concerning penile venous ligations may be even lower. Too many unsolved controversies exist and universal diagnostic criteria for patient selection as well as operative technique selection have not been unequivocally established. This kind of surgery is still considered investigational but may be offered in special situations on an individualized basis in an investigational or research setting after obtaining written consent, using both pre- and postoperatively validated measuring instruments of success evaluation. Conclusions SOPs for penile revascularization procedures can be developed, concerning a highly selected patient group with isolated arterial stenoses. Based on the available data it is not yet possible to define SOPs for surgical treatment of corporal veno-occlusive dysfunction.

Erectile dysfunction in urethral stricture and pelvic fracture urethral injury patients: diagnosis, treatment, and outcomes

“…In such cases, the patients with arteriogenic ED who have failed pharmacologic intervention have imaging that documents an isolated occlusion of the internal pudendal artery and no evidence of venous leak (Sohn et al, 2013). Surgical vascular repair is optimal in patients who are less than 55 years of age, non-diabetic, and non-smokers (Sohn et al, 2013). PFUI is often associated with arterial injury and occlusion of the distal internal pudendal artery and its branches (Zuckerman et al, 2012;Sohn et al, 2013).…”

“…Surgical vascular repair is optimal in patients who are less than 55 years of age, non-diabetic, and non-smokers (Sohn et al, 2013). PFUI is often associated with arterial injury and occlusion of the distal internal pudendal artery and its branches (Zuckerman et al, 2012;Sohn et al, 2013). Fortunately, most of these PFUI patients are young and have few comorbidities and are therefore ideal candidates for arterial PR (Zuckerman et al, 2012).…”

“…However, there was a high failure rate. Currently, arterial PR is performed mostly in specialized centers by using one of three techniques: anastomosis of the inferior epigastric artery (IEA) to dorsal penile arteries (end-to-end or end-to-side); anastomosis of the IEA to the deep dorsal vein with additional 446 Andrology, 2015, 3, 443-449 proximal and/or distal vein ligation (venous arterialization); or anastomosis of the IEA to the deep dorsal vein and artery (arterial-venous shunt) (Sohn et al, 2013). The diagnosis of an arterial occlusion needs to be defined by both PDDU and pelvic arterial angiography prior to surgery.…”

Current Diagnosis and Management of Erectile Dysfunction

“…Neither of these approaches, however, has a substantial evidence base, with only grade D recommendations offered in the absence of prospective, randomized studies (reviewed in [130]). However, the consensus at this time is that penile revascularization can be offered to nonsmoking, nondiabetic men <55 years old with isolated arterial stenoses without generalized vascular disease.…”

“…In the absence of prospective studies to evaluate the efficacy of penile revascularization procedures, several retrospective studies have evaluated both arterial revascularization and venous ligation procedures, with mixed results. Overall, arterial procedures appear to be more consistently successful than venous ligation procedures [130]. While the current data support intervention in select individuals, a definitive evidence base remains lacking, limiting the ability to identify and appropriately treat patients via revascularization.…”