Sexual Medicine Update - Archive

Surgical skills course – September 2008

VENOUS SURGERY

Cavernosal veno-occlusive erectile dysfunction may occur due to congenital factors and trauma in young men, and acquired factors such as Peyronie’s disease, diabetes and late-onset hypogonadism in older men.

Treatment options for penile venous leakage in men with erectile dysfunction initially includes phosphodiesterase- 5 (PDE-5) inhibitors as a first line treatment, transurethral alprostadil, vacuum constriction device or intracavernous injection, as a second line treatment(1). Penile venous surgery may be an option for young patients who do not respond or are not satisfied with the less invasive treatments(2). Diagnosis of penile venous leakage and surgical treatment with crural ligation are discussed in this review.

Diagnosis of penile venous leakage:

• A detailed history,
• Partial erection or a rigid erection with early detumescence during nocturnal erections, masturbation or intracavernosal injection test,
• Normal peak flow velocity (greater than 30 cm/second) with an end-diastolic pressure of >5 cm/sec on penile color duplex ultrasound.
• One or several abnormal venous channels including from ectopic, superficial and deep dorsal veins, cavernosal vein and large crural veins on pharmacological cavernosography.
• The accepted criteria for penile venous surgery include:
• Age < 40 years,
• No response to one of PDE-5 inhibitors (at least 4-6 times) or negative intracavernosal injection test,
• No systemic diseases including cardiovascular diseases and diabetes,
• Normal arterial system,
• Cavernosal veno-occlusive dysfunction.

SURGICAL TECHNIQUE:
Congenital penile venous leakage may be due to large, ectopic, superficial and deep dorsal veins or large crural veins(3,4). Previous surgical methods for venous leakage included ligation of superficial and deep dorsal veins. Recently, Tom Lue, MD, Professor of Urology, from the University of California at San Francisco, CA, USA has popularized crural ligation resulting in high success rate (5,6).

Penile venous surgery with crural ligation:

• Right inguinal-scrotal incision,
• Dissection to the base of the penis and incision of fundiform and suspensory ligaments,
• Resection of superficial and deep dorsal vein,
• Ligation of cavernosal vein and 2 crura proximal to the entrance of the cavernosal artery with umblical tapes,
• Preservation of the dorsal artery and nerve on both sides,
• Re-attachment of the penis to the periosteum of the pubic bone.

SURGICAL RESULTS:
A technique of crural ligation has been described via the perineal approach or inguinoscrotal approach (5,7,8). The perineal approach is useful if leakage is from the tip of the crus. However, leakage generally involves a long segment of the crus and ligation of the tip may be inadequate(6). In addition, the neurovascular bundle may be damaged via the perineal approach when the cruras are ligated close to the hilum of the penis. Neurovascular bundles and cavernosal arteries may be clearly identified and protected with the inguino-scrotal approach, as described by Lue(5). Penile venous leakage surgery may result in complications including postoperative penile shortening, curvature, penile numbness, curvature, lymphoedema and a misligation of the penile artery (2,5,6,8,10).

I routinely re-attach the tunica albuginea to the periosteum of pubis, suture the subcutaneous fat tissue over the base of the penis, as described by Lue, to prevent postoperative penile shortening. Careful dissection of the both neurovascular bundles prevents penile artery and nerves to avoid misligation of the dorsal artery and penile numbness, respectively. Rahman et al reported 11 patients with primary erectile dysfunction who underwent crural ligation surgery for congenital venous leakage, and marked improvement in erectile function was noted in 9 (81.8%) of 11 patients, and 2 (18.2%) patients had postoperative recurrence, requiring re-operation, in their series(6). I reported long term results of 26 cases who underwent penile venous leakage surgery with crural ligation (10). In our study population, mean IIEF- 5 score significantly increased from 6.7±3.61 to 16.3±6.4, postoperatively. Postoperative erectile functions improved completely in 11 men (42.3%), partially in 8 (30.8%) and remained unchanged in 7 (26.9%).

Of the patients who had no improvement in erectile functions, 2 had limited arterial blood flow, and 2 were diabetic, and 3 had recurrence, ranging one to five years after the surgery. Penile venous surgery may also increase the response to oral PDE-5 inhibitors. In our institute, 46% of the patients maintained satisfactory erection with the use of PDE-5 inhibitors which were not working preoperatively. Patient satisfaction with no any additional treatment or with the use of PDE-5 inhibitors was complete in 57.7%, partial in 30.7%, and 11.6% of the patients were not satisfied with the surgery(10).

CONCLUSIONS
Penile venous surgery with ligation of the crura for venous leakage has excellent long term results and patient satisfaction, and therefore should be offered in young men with primary cavernosal erectile dysfunction. Young patients with normal penile arterial system and no risk factors such as diabetes have the best chance to improveof postoperative success.

REFERENCES
1 1. McMahon CG. Nonsurgical treatment of cavernosal venous leakage. Urology 1997;49:97-100. 2. Wespes E, Schulman CC. Venous leakage: surgical treatment of a curable cause of impotence. J Urol 1985;133:796-8. 3. Ebbehoj J, Wagner G. Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology 1979;13:507-10. 4. Stief CG, Gall H, Scherb W, Bahren M. Erectile dysfunction due to ectopic penile vein. Urology 1988;31:300- 3. 5. Lue TF. Surgery for crural venous leakage. Urology 1999;54:739-41. 6. Rahman NU, Dean RC, Carrion R, Bochinski D, Lue TF. Crural ligation for primary erectile dysfunction: a case series. J Urol 2005;173:2064-6. 7. Puech-Leao P, Reis JM, Glina S, Reichelt AC. Leakage through the crural edge of corpus cavernosum. Diagnosis and treatment. Eur Urol 1987;13:163-5. 8. Mulhall JP, Martin D, Ergin E, Kim F. Crural ligation surgery for the young male with venogenic erectile dysfunction: technique. Tech Urol 2001;7:290-3. 9. Da Ros CT, Teloken C, Antonini CC, Sogari PR, Souto CA. Long-term results of penile vein ligation for erectile dysfunction due to cavernous disease. Tech Urol 2000;6:172-4. 10. Çayan S. Long term results of primary penile venous leakage surgerywith crural ligation in men with erectile dysfunction at a single university hospital. J Urol, in press.