Penile revascularization--contemporary update

Abstract

Contemporary therapies for erectile dysfunction are generally targeted towards older men and universally engage pharmacological and/or device related treatment options. Penile revascularization, using microvascular arterial bypass surgical techniques, is a non-pharmacological, non-device-related, and reconstructive surgical strategy for men with erectile dysfunction that was first described by Dr Vaclav Michal in 1973. Contemporary penile revascularization attempts to 'cure' pure arteriogenic erectile dysfunction in young men with arterial occlusive pathology in the distal internal pudendal, common penile or proximal cavernosal artery secondary to focal endothelial injury from blunt pelvic, perineal or penile trauma. A microvascular anastomosis is fashioned between the donor inferior epigastric and recipient dorsal penile artery. Increased perfusion pressure is theoretically communicated to the cavernosal artery via perforating branches from the dorsal artery. This article will review the history, indications and pathophysiology of blunt trauma-induced focal arterial occlusive disease in young men with erectile dysfunction, current surgical techniques utilized and results of surgery. Contemporary use of penile revascularization is a logical and wanted therapeutic option to attempt to reverse erectile dysfunction in young men who have sustained blunt pelvic, perineal or penile trauma.

Figure 1

Microvascular arterial bypass penile revascularization surgery. (a) Oblique, inguinal scrotal incision on side of scrotum opposite of donor inferior epigastric harvest. (b) Preservation of fundiform ligament with Scott retractor hooks provides excellent exposure of dorsal neurovascular bundle. Careful initial dissection of recipient dorsal penile artery is fashioned. (c) Transverse abdominal incision is fashioned to harvest the donor inferior epigastric artery. The donor inferior epigastric artery has been transected around the level of the umbilicus and is ready for transfer to the base of the penis. (d) The donor inferior epigastric artery has been transferred through the internal ring, through the inguinal canal and out the external ring underneath the fundiform ligament to lie at the base of the penis at the dorsal neurovascular bundle. (e) The microvascular arterial anastomosis between the donor inferior epigastric artery and the recipient dorsal penile artery using interrupted 10-0 nylon sutures has been completed. (f) The postoperative compressive dressing over the scrotum is in place. The On-Q catheters are in place for pain control—they are placed above and below the rectus muscle and stay in place for 3 days postoperation. The Foley catheter is in place and is removed the following morning. The hands are tucked in at the sides to prevent ulnar nerve injury.

Figure 2

Surgical results. (a) Selective internal pudendal arteriogram showing trauma-related (bicycle accident) arterial occlusive pathology at the proximal cavernosal artery in a 21-year male with erectile dysfunction. (b) Selective infusion of contrast in the donor inferior epigastric artery reveals excellent length, excellent luminal diameter and freedom from arterial occlusive disease.

Figure 3

Postoperative selective inferior epigastric arteriogram revealing intact microvascular arterial anastomosis. (a) Early film. (b) delayed film.