Results of deep dorsal vein ligation for venogenic impotence]

We treated seventy venogenic impotence with ligation of the deep dorsal vein of the penis. Their corporal veno-occlusive function was evaluated by dynamic infusion cavernosometry and cavernosography (DICC). Under local anesthesia, we made a longitudinal skin incision at the base of the penis. The deep dorsal vein was ligated and also a portion of this vein of 1.5 cm long was resected together with branches surrounding the vein. After the operation, the infusion rate determined by DICC was confirmed to be decreased in almost all patients. Thirty nine out of seventy cases had their erectile capability restored and reported that they could achieve sexual intercourse. Sixty one of the seventy cases showed full erection together with an intracavernous papaverine injection. However fifty percent of the sixty one patients who became capable of obtaining erection with the treatment had lost their erectile capability again within one year of the operation, however the other fifty percent were shown to maintain their erectile capability for up to three years. As four years after the treatment only thirty percent of those who had achieved the initial erectile capability still remained potent. This operation is easy to perform without any major complications, and its outcome is as good as that achieved by other more invasive venous ligation in the treatment of patients with venogenic impotence. We therefore conclude that penile deep dorsal vein ligation and partial resection of the vein one of the most useful treatments currently available for venogenic impotence and should be the treatment of choice.     

Electron microscopic findings of penile tissues in veno-occlusive dysfunction: Is penile biopsy necessary?

In this study, we examined the biopsy patterns of penile tissues taken during operation from patients subjected to surgical treatment for veno-occlusive dysfunction, and evaluated the importance of penile biopsy. We evaluated the findings from 17 patients with venous impotence. Fourteen of them underwent total vein ligation and the rest penile prosthesis implantation. Tissue speciments taken from superficial and deep dorsal veins, tunica albuginea and corpus cavernosum during operation were examined under electron microscope. Tissue specimens taken from 3 cadavers were used as the control group. Although the deep and superficial vein specimens of all patients did not show significant differences, oedema and increase of fibroblasts in collagen fibres of the corpus cavernosum and tunica albuginea were demonstrated. We concluded that penile biopsy as an invasive method does not give enough information about the choice of treatment for erectile dysfunction.     

Surgical therapy of erectile impotence of vascular venous origin

We report about 32 men, who suffered from erectile impotence due to venous leakage. Three methods of penile surgery are described, the ligature of plexus santorini, the ligature of deep dorsal vein and the ligature of ectopic veins of the penis. By these operations 72% of the patients achieved potency again.     

Treatment of impotence due to venous leakage by resection of the deep dorsal vein of the penis.

Ligation and resection of the deep dorsal vein of the penis is a surgical approach to restore potency in venogenic impotence. Between December 1989 and December 1990, we treated 25 men with venogenic impotence by this technique. Additionally, the Nesbit operation was performed in 3 cases due to penile curvature and in 1 case a penile plaque was excised. The patients were asked to come for control 1, 3, 6 and 12 months after surgery. In 14 patients the rigidity and duration of erections were improved 3 months after surgery but, in 21 of the 25 men, erectile dysfunction recurred 6-15 months (average 9.4 months) following surgery and penile prostheses were implanted in 7 cases. The complications were orchiepididymitis in 1 case, penile edema and hyperemia which lasted for 1 week in 1 patient and numbness near the incision site in 10 cases. We conclude that, in patients who had erectile impotence due to venous leakage, resection of the deep dorsal vein of the penis could provide a transient satisfactory result, but should not be considered as a long-term treatment modality.     

Venous leaks: anatomical and physiological observations

A total of 50 patients with impotence underwent cavernosometry and cavernosography with intracavernous injection of vasoactive drugs. Several hemodynamic parameters were analyzed, including the pressure response curve after injection of vasoactive drugs and infusion of saline, the volume required to achieve erection, venous outflow resistance, erection maintenance infusion rate, rate of pressure decrease after discontinuation of infusion and post-infusion steady state pressure. On the basis of cavernosometric findings, venous leakage was ruled out in 4 patients. In the remaining 46 patients leak sites visualized during cavernosography included superficial dorsal vein in 1 (2.2%), deep dorsal vein in all 46 (100%), cavernous veins in 32 (69.6%), glans in 19 (41.3%) and corpus spongiosum in 14 (30.4%). Aberrant veins were documented in 7 patients (15.2%) communicating with the saphenous vein in 4 (8.9%), scrotal veins in 2 (4.4%) and femoral veins in 1 (2.2%). Eight patients (17.4%) had leakage through the deep dorsal vein as the only venous site, 17 (36.9%) had leakage through 2 venous sites, 14 (30.4%) had leakage through 3 venous sites and 7 (15.2%) had leakage through 4 venous sites. Correlations among hemodynamic and radiographic observations allowed the identification of 4 different types of cavernosometric findings. While type I represented normal penile vascular findings, types III and IV represented venous leakage. Type II could represent no leak, a mild leak or an undetected arterial problem. Accuracy of interpretation of a study may be improved by taking more than 1 parameter into consideration, including erection maintenance infusion rate, intracavernous pressure decrease within the first 5 seconds after discontinuation of infusion and the final steady state intracavernous pressure. The majority of patients have more than 1 leak site (82.6%). The most commonly combined sites of leakage are the deep dorsal and cavernous veins.     

Treatment of impotence caused by veno-occlusive dysfunction with detachable balloons and coils in combination with resection of the deep dorsal vein: comparison with resection of the deep dorsal vein only

Summary A total of 21 patients presenting with impotence due to venous leakage were treated with occlusion of the proximal part of the deep dorsal penile vein and the distal part of the prostatic plexus by way of a radiological intervention technique, i.e. occlusion with detachable balloons and coils. The distal part of the deep dorsal vein was also resected. The follow-up period ranged from 1 to 27 months (mean, 15.3 months). The results of this treatment were compared with the results of resection of the deep dorsal vein alone in 29 patients. Better results were obtained in the balloon-occlusion group, although the differences between the two groups did not reach statistical significance. When the results obtained in the two groups were considered in relation to the amount of leakage, we found no statistically significant difference. The long-term results of venous surgery for veno-occlusive dysfunction are not encouraging, even when more extensive procedures for the prevention of venous outflow are used.     

Penile venous ligation surgery for the management of cavernosal venous leakage.

Forty-one patients underwent penile venous ligation surgery for pure cavernosal venous leakage diagnosed by infusion cavernosometry and cavernosography. Before surgery, arterial integrity was assessed by pelvic angiography, and all patients were found to have a normal penile arterial system. The patients were divided into two groups on the basis of the type of venous operation performed. The overall complete-potency success rate was 46% (19 of 41 patients). Postoperative complications were minimal. Our experience shows that penile venous surgery remains an acceptable option for treatment of carefully selected patients with documented pure cavernosal venous leakage of a mild degree who have no evidence of arterial insufficiency and who do not prefer, or are not suitable for, other medical or surgical treatment options. Patients who had more severe degrees of cavernosal venous leakage had a poor result from this procedure. For patients with moderate to severe venous leakage, we now perform a combined surgical procedure, deep dorsal vein arterialization and venous ligation.     

Treatment of erectile dysfunction in cases of venous and corporovenous insufficiency of phallus

A total of 230 patients of different age with impaired venous drainage of penis cavernous bodies were examined. Test with intracavernous injection of papaverin, dopplerography of the vessels and cavernosometry were employed. To treat venous and corporovenous insufficiency, it is suggested to make a resection of the deep dorsal vein, ligation of the superficial and circular veins with suturing tunica albuginea. In negative result of the surgery viagra in a done 50 (100) mg is recommended or penile implants.     

Diagnosis and surgical treatment of pathological venous drainage from the cavernous bodies of the penis

In examination of 50 patients with impotence, pathological venous drainage (PVD) was revealed in 11 of them. Perfusion graded cavernosometry/cavernosography is the only method by which PVD can be detected and studied thoroughly. Analysis of the cavernosograms revealed a sphincter of the deep dorsal vein of the penis, the dysfunction of which in 10 of the 11 patients was the cause of PVD; in 5 of these patients the dysfunction was combined with excessive development of the subcutaneous veins of the penis. In one patient PVD was caused by a large venous trunk which emptied into the ostium of the left major subcutaneous vein. The 11 patients underwent operation after which they returned to a normal sex life.     

Penile venous drainage in erectile dysfunction. Anatomical, radiological and functional considerations

To elucidate further the penile venous anatomy and its role in the haemodynamics of erection, we performed pharmacological cavernometry and cavernography in 95 patients with venogenic impotence and in 12 patients with psychogenic impotence. The findings were correlated with those of dissection in 10 adult male cadavers. Cavernography confirmed that the main venous drainage of the corpora cavernosa is via the cavernous veins, with additional drainage through the crural, circumflex and deep dorsal veins and demonstrated that, in patients with venogenic impotence, the cavernous veins are the common site of leakage. Cavernometry provided valuable parameters for the quantification of the degree of venous leakage. Detailed knowledge of the penile venous system and cavernometry and cavernography are essential for the proper diagnosis and treatment of patients with venogenic impotence.     

对几种治疗阳萎方法的评价

目的：评价几种治疗阳萎方法的效果。方法：对采用阴茎海绵体内药物注射、真空缩窄环、阻断阴茎背深静脉瘘，阴茎动脉重建和假体植主的４８６例阳萎患者的临床资料进行性分析。结果：满意率阴茎海绵体内药物注射组为３０．１％，真空缩窄环组为１４．３％，静脉瘘结扎组为１３．３％，且为３２．２％，阴茎动脉重建组为５０．０％，假体植入组为９５．４％。结论：使用海绵体内药支物注射和真空缩装置虽为简便、安全和有效的方法，但     

Microsurgical arterialization for vascular impotence

Of 400 patients with erectile lesions Doppler flowmetry in combination with nitroglycerin stimulation showed a decreased penile arterial blood flow in 42 males. Dynamic cavernosography and cavernosometry showed a concomitant increase of venous drainage in 38 of them. Phallo-arteriography in 22 males demonstrated occlusion of the internal pudendal artery in 21 of them. In 15 patients penile arterialization was done by interposition of a saphenous vein graft between the iliac artery and deep dorsal penile vein. In 4 of these patients an additional venous leak was treated during the same operation by ligation of the internal iliac veins. Two years postoperatively two thirds of the patients are doing well. Failures in 5 of them included 4 diabetic neurovascular lesions and 1 postoperative priapism.     

静脉性勃起功能障碍中阴茎静脉漏的彩色多普勒超声观察

目的 探讨静脉性勃起功能障碍(ED)患者阴茎静脉的血液动力学变化. 方法 静脉性ED患者32例,年龄26～63岁,平均41岁.病程6个月～10年,平均2.5年.采用前列腺素E1试验后行常规阴茎彩色多普勒超声检查,观察阴茎背深静脉、海绵体静脉、球静脉的超声表现,分析其与海绵体动脉阻力指数(RI)的相关性. 结果 32例患者诱发勃起前静脉内径(0.06±0.15)mm,血流速度(4.30+1.36)cm/s,诱发勃起5 min后阴茎静脉管径(1.23±0.30)mm,血液回流增多,血流速度(11.50+4.02)cm/s.阴茎背深静脉、海绵体静脉、球静脉流量与海绵体动脉RI的相关系数r分别为-0.55,-0.53,-0.24(P＜0.05).考虑存在混合性静脉漏因素的前提下,阴茎静脉流量与海绵体动脉RI的r为-0.88(P＜0.001). 结论 高频超声能清楚显示阴茎静脉漏部位,可初步判断静脉性ED患者的静脉漏部位及其程度.     

Improved results with intracavernous vasoactive drug infusion following new surgical techniques for vasculogenic impotence

Summary A large percentage of patients suffering from organic impotence will exhibit arterial insufficiency and/or compromise of the venous closure mechanism. In our institution, patients with organic impotence undergo penile Doppler studies, dynamic cavernosometry and cavenosography and when indicated, penile angiography. At present, patients with arterial insufficiency undergo either a single end-to-end anastomosis between the inferior epigastric artery and the distal segment of the dorsal artery of the penis or double end-to-end anastomosis utilizing both epigastric arteries to both the proximal and distal ends of the dorsal artery. In addition, patients receive post-operative cavenosal infusion of vasoactive agents. We have been able to increase our potency rate from 42% to 82% utilizing newer surgical techniques in combination with post-operative cavernosal infusion. In addition, we report on 234 patients in whom selective ligation of incompetent veins has been performed with a nine-month 55% potency rate. In selected patients with milder vasculogenic syndromes, cyclic cavernosal infusion of papaverine and phentolamine has produced a 40% potency rate.     

美蓝染色法提高静脉性勃起功能障碍手术疗效观察

目的 :探讨美蓝染色法提高静脉性勃起功能障碍 (ED)手术疗效。　方法 :78例静脉性ED在美蓝染色标识下切除和结扎回漏静脉 ,采用国际勃起功能指数 5 (IIEF 5 )得分对手术效果进行评估。　结果 :阴茎背深静脉切除 +属支结扎 2 6例 ,有效 2 0例 ( 76.9% ) ;背深静脉切除 +阴茎脚静脉结扎 3 2例 ,有效 2 5例 ( 78.1% ) ;背深静脉切除 +尿道海绵体分离和阴茎头静脉结扎 13例 ,有效 5例 ( 3 8.5 % ) ;单纯脚静脉结扎 7例 ,有效 3例 ( 4 2 9% )。术后随访 1～ 12个月、13～ 2 4个月和 2 5～ 3 6个月的总有效率分别为 67 9%、4 1.0 %和 3 3 .3 %。IIEF 5得分从术前的 ( 4 .8± 0 .5 )分分别提高到 ( 19.5± 0 .5 )分、( 18.6± 0 .5 )分和 ( 18.6± 0 .6)分 ,P值均 <0 .0 0 1。　结论 :阴茎海绵体注射美蓝染色可以提高静脉性ED的手术疗效。     

Controlled trial of infusion cavernosometry in impotent and potent men

Infusion cavernosometry often is performed to diagnose venous leak impotence. However, normal values have seldom been established in proved potent men. We performed a prospective study of infusion cavernosometry on nocturnal penile tumescence confirmed potent male volunteers and impotent men. Of 20 potent male controls 19 had resistance values of greater than 5 (mm. Hg.minute)/ml. Of 38 impotent men 20 (53%) had resistance values of less than 5 (mm.Hg. minute)/ml. There was considerable overlap between resistance values and infusion rates in potent and impotent men. Impotent men with resistances of greater than 5 (mm.Hg.minute)/ml. more often had normal nocturnal penile tumescence results than men with lower resistance values. Venous leakage is a significant cause of impotence.     

The progression of the penile vein: could it be recurrent?

Our aim was to study retrospectively the destiny of the deep dorsal vein of the penis in the event of its stripping surgery or its simple ligation in patients diagnosed with venoocclusive dysfunction 17 years ago. From June 1986 to May 1987, a total of 31 men were seen for erectile dysfunction due to venous leakage resulting from priapism, aging, or congenital or idiopathic factors. Of these, 23 men underwent venous stripping of the deep dorsal vein and are referred to as the stripping group. The remaining 8 patients received a simple ligation of the deep dorsal vein and are classified as the ligation group. A total of 21 patients (16 of the 23 and 5 out of the 8) were available for follow-up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and cavernosograms. In the ligation group, the imaging demonstrates some compensatory veins that are commensurate with impotence postoperatively. In the stripping group, however, the follow-up cavernosograms disclosed no venous recurrence, but residual ones that were not crucial to the rigidity. The IIEF-5 scoring in the ligation group changed from a preoperative mean IIEF-5 score of 10.0 +/- 4.5 to 9.8 +/- 3.6 postoperatively. In the stripping group, however, the mean preoperative IIEF-5 score of 9.8 +/- 4.1 increased to a mean postoperative IIEF-5 score of 18.9 +/- 2.1. Although there was no significant difference between the 2 groups' preoperative IIEF-5 score, there was a statistically significant difference between treatments (P <.001). The penile venous vasculature bears no evidence of regeneration even as long as 17 years after their removal. This finding is in contrast to what is commonly believed, that erectile dysfunction will recur about 2 years after ligation of the deep dorsal vein. We therefore believe that the clinical recurrence may not be due to venous regeneration, and penile venous surgery, if properly performed, may be durable, although larger studies will be required.     

Penile pharmacocavernosography and cavernosometry in the evaluation of impotence

Within the past few years, veno-occlusion of the corpora cavernosa has become generally recognized as an essential prerequisite for adequate penile erection. Veno-occlusive incompetence is suspected to be a frequent cause of impotence. Our recent experience with cavernosography in two normal volunteers and 36 impotent patients indicates that angiography is reliable in evaluating the competence of the veno-occlusive mechanism only if both pharmacocavernosography (PCG) and pharmacocavernosometry (PCM) are applied. Twenty minutes after intracavernosal (IC) injection of a mixture of 60 mg. papaverine and one mg. phentolamine (regitine), 100 ml. of diluted radiographic contrast medium are infused at the rate of one or two ml./sec. while pressure is recorded, and radiographic films are exposed at the rate of one every eight to 15 seconds. PCM and PCG of the corpora cavernosa indicated the overall degree of competence of the cavernosal veno-occlusive mechanisms, and the sites of veno-occlusive incompetence; non-pharmacologic studies were unreliable in these regards. During non-pharmacologic infusion in normals, pressures rose to 40 to 45 mm. Hg, and free efflux could be visualized from multiple venous systems. After pharmacologic injection in normals, all venous channels closed, and pressures rapidly rose toward or above 200 mm. Hg, at which time the infusion was stopped. Veno-occlusive incompetence was defined angiographically when more than minimal efflux occurred during pharmacocavernosography from any venous system. The incompetence could involve the deep penile system, the deep dorsal system, or the spongiosal system, alone or in combination. Severe veno-occlusive incompetence was considered diagnostic of venogenic impotence, and was defined manometrically when IC pressures failed to exceed 100 mm. Hg during infusion of 100 ml. of fluid at 2 mm./second after IC papaverine and phentolamine injection. We believe these angiographic methods will improve the criteria against which other diagnostic and therapeutic methods can be assessed.     

Basic and clinical research of impotence--its present situation and problems involved

From detailed investigation of the vascular structure of the penis, it has been proposed that there exists a valvular structure, consisting of smooth muscle, located at a point immediately before the helicine artery, bifurcated from the deep artery, opens to the cavernous sinuses, an area where autonomic nerves are densely distributed, participating in opening and closing the valve. On the other hand, there is said to be no valvular structure in the vein outflowing from the cavernous sinuses, and blood flows into the dorsal penile vein by penetrating the albuginea obliquely or vertically after running parallel in the region immediately below the albuginea. It is considered that, when the valve of the helicine artery opens, blood flows into the cavernous sinuses, expanding them, and as a result the outflowing vein is compressed between the sinuses and the albuginea, or the albuginea itself, acting like a valve and therefore assuming an important function in maintaining erection by disturbing the reflux of blood flow. It is also presumed that the contracting of ishiocavernous muscle plays a part in developing the rigidity of the penis. It is considered, moreover, that the trabecula of the cavernous body consisting of smooth muscle also plays a part in the promotion and disappearance of erection. It is very important to run functional tests of erection when diagnosing impotence, and today many tests are available for differential diagnosis; including papaverine test, dynamic cavernosometry and cavernosography. As for therapy, treatments involving vasoactive agent infusion, such as papaverine or prostaglandin E1 into the cavernous body, have become common. For cases with venous impotence, ligation of the penile deep vein and crus of the penile cavernous body have come to be attempted. Furthermore, revascularization of penile artery can be performed to treat arterial impotence. For cases in whom these methods are not effective, implantation of various penile prostheses into the penis has been shown to be successful.     

Penile blunt trauma induced veno-occlusive erectile dysfunction

Blunt trauma to the pelvic or perineal region of the corpora cavernosa is a risk factor for the subsequent development of persistent erectile dysfunction. The hemodynamic investigation of the integrity of the veno-occlusive mechanism has been rare in cases of traumatic impotence. We present two young men with erectile dysfunction following blunt penile or perineal trauma. Combined intracavernous injection and stimulation test, color duplex ultrasonography, and pharmacologic cavernosometry and cavernosography revealed normal arterial velocity and pulsation without cavernosal arterial fistula, but severe venous occlusion and site-specific abnormal veins were noted in both patients. They received penile vein ligation procedure and resulted in near-completely normal erectile function after a four-year followup. Penile venous ligation, especially on the site-specific veins, is still the choice of treatment for the trauma-induced penile veno-occlusive erectile dysfunction, and the result is satisfactory.