Are Surgeries to Fix Erectile Dysfunction Effective?

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madman

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Abstract: Penile erection implicates arterial inflow, sinusoidal relaxation, and corporoveno-occlusive function. By far the most widely recognized vascular etiologies responsible for organic erectile dysfunction can be divided into arterial insufficiency, corporoveno-occlusive dysfunction, or mixed type, with corporoveno-occlusive dysfunction representing the most common finding. In arteriogenic erectile dysfunction, corpora cavernosa shows lower oxygen tension, leading to a diminished volume of cavernosal smooth muscle and consequential corporoveno-occlusive dysfunction. Current studies support the contention that corporoveno-occlusive dysfunction is an effect rather than the cause of erectile dysfunction. Surgical interventions have consisted primarily of penile revascularization surgery for arterial insufficiency and penile venous surgery for corporoveno-occlusive dysfunction, whatever the mechanism. However, the surgical effectiveness remained debatable and unproven, mostly owing to the lack of consistent hemodynamic assessment, standardized select patient and validated outcome measures, as well as various surgical procedures. Penile vascular surgery has been disclaimed to be the treatment of choice based on the currently available guidelines. However, reports on penile revascularization surgery support its utility in treating arterial insufficiency in otherwise healthy patients aged <55 years with erectile dysfunction of late attributable to the arterial occlusive disease. Furthermore, it is noteworthy that penile venous surgery might be beneficial for selected patients with corporoveno-occlusive dysfunction, especially with a better understanding of the innovative venous anatomy of the penis. Penile vascular surgery might remain a viable alternative for the treatment of erectile dysfunction and could have found its niche in the possibility of obtaining spontaneous, unaided, and natural erection.


Critical guideline issued In 2015, the panel in the fourth Paris International Consultation on Sexual Medicine concluded that venous surgery or embolization is not recommended for the treatment of CVOD; regardless, the procedures can be carried out under the circumstances of clinical research with informed consent, standardized methods of diagnosis and surgical treatment. Standardized questionnaires (IIEF) and long-term (a minimum of 24 months) follow up are also required (LOE = 4; strength of recommendation = C; option).33 In 2018, the American Urological Association Guidelines Panel proclaimed that penile venous surgery is not recommended for patients with ED (moderate recommendation; evidence level: grade C).91 The European Association of Urology guidelines on ED, premature ejaculation, penile curvature, and priapism also disclaimed penile venous surgery to be an option for management of ED.92

Conclusions

Nowadays, there is no convincing evidence available to draw conclusions that supplant these guidelines recommended by the panels on ED. Numerous physicians query whether or not penile vascular surgery addresses the underlying pathology. Sarcastically, the same concern should apply to current options recommended in the guidelines. Integration or combination of vascular surgery into goal-approached therapies, which include psychological counseling, medical (e.g. phosphodiesterase type 5 inhibitor and intracavernosal injection), non-surgical (e.g. vacuum device and low-intensity shock wave therapy), and alternative surgical intervention (e.g. penile prosthesis), would optimize patient-centered management strategies. It is noteworthy that penile venous surgery might be beneficial to selected patients with CVOD, especially with a better understanding of the innovative venous anatomy of the penis. To afford opportunities for the improvement of ED, penile vascular surgery remains a viable option and has found its niche in the possibility of obtaining spontaneous, unaided, and natural erection.
 

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madman

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Fig. 1 A transverse section in the midportion of the penis. Tunica albuginea, a bi-layered structure with a complete inner circular layer and an incomplete outer longitudinal layer, encircles the corpora cavernosa. Intracavernous pillars radiate from the inner circular layer, acting as struts. The fibro-skeleton collaborating with erection-related vasculatures provided full erection while elicited.
 

madman

Super Moderator
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Fig. 2 The blood supply of the superficial structure of the penis depends on branches from the femoral artery, which provide primary vascularization of the skin and subcutaneous tissues.
 

madman

Super Moderator
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Fig. 3 The vascular supply of the deep structure of the penis arises from the internal pudendal artery. The common penile artery, one branch of the internal pudendal artery, further ramifies into the dorsal penile, bulbourethral, and cavernosal arteries.
 

madman

Super Moderator
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Fig. 4 Schematic illustration of the innovative venous anatomy in the human penis. Lateral view. The DDV lies in the median grove, receiving blood from the glans penis, corpus spongiosum, and corpora cavernosa by way of emissary and circumflex veins. A pair of cavernosal veins and two pairs of PAVs are located in between Buck’s fascia and tunica albuginea. PAVs sandwich each corresponding DPA, coursing along the full length of the penis bilaterally. The innovated venous anatomy of the penis has served as a blueprint for penile venous stripping, and ligation sites (mark “X”) is resorted to on the tunical level.
 

madman

Super Moderator
(LEFT) Fig. 5 The anastomosis of the IEA to dorsal penile arteries in an end-to-side fashion (Michal II procedure, true revascularization).
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(RIGHT) Fig. 6 Anastomosis of the IEA to the DDV with additional proximal and/or distal vein ligation (venous arterializations, Furlow and Fisher procedure). The marks “X” indicate the sites for ligation.
 

madman

Super Moderator
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Fig. 7 The anastomosis of the IEA to the DDV and DPA (triple anastomosis with an arterial-venous shunt, Hauri’s procedure).
 

Nelson Vergel

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