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Vascular interventions

Lessons learned

for impotence:

R a l p h G. D e P a l m a , M D , M i c h a e l O l d i n g , M D , G e o r g e W . Yu, M D , F r e d e r i c k J. S c h w a b , M D , E d w a r d M. D r u y , M D , H a r r y C. Miller, M D , and E l i z a b e t h M a s s a r i n , BA, R T , Washington, D.C.

Purpose: The purpose of this study was to analyze the results of vascular interventions for impotence in men with this complaint.

Methods: Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age 54.5 years) were screened by use o f penile plethysmography and penile brachial indexes: 635 were considered to have normal flow, and 459 were considered to have abnormal arterial flow, 12.2% of whom were found to have aortoiliac disease. Based on negative neural screening results, absence o f erectile responses on increasing doses o f intracavernously injected papaverine or prostaglandin E 1 (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriography. Operations for men discovered to have aortoiliac disease were based on conventional indications including aneurysm size or limb ischemia. None of the subjects had diabetes. Only those patients without diabetes and those not requiring blood pressure medications were selected for microvascular proce- dures. We report our experience and surgical outcomes at average follow-ups of 33 to 48 months. Four types o f operations were performed on 67 men (age 18 to 79 years). These included 17 aortoiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal vein arterializations, and 27 venous interruptions. Follow-up data were obtained by direct examination and noninvasive Doppler examinations; repeat arteriography (4 of 11); repeat D I C C after venous ablation procedures (18 of 27) and postoperative I C I response. Mail questionnaires completed postoperative surveillance.

Results: Among 17 men undergoing aortoiliac intervention for aneurysms in eight and occlusive disease in nine, 58% functioned spontaneously after operation and 18% used I C I or vacuum constrictor devices at an average follow-up time of 38 months. Among 11 men with dorsal penile artery bypasses, 27% fimctioned spontaneously and 45% used I C I at an average follow-up time of 34.5 months. Among 12 men with dorsal vein arterialization, 33% fianctioned spontaneously, and 47% used I C I at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 44% used ICI. In seven of eight aneurysms o f 4.5 to 6.0 cm in size, impotence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative D I C C results when flow to maintain erection was 40 ml or less. Apart from two cases of glans hyperemia, no surgical complications occurred in the microvascular procedures. There was one episode of bleeding caused by D I C C after aortic reconstruction. There were no deaths.

Conclusions: With prospective screening criteria, 6% to 7% of impotent men became candidates for vascular intervention. Including those functioning with I C I or vacuum constriction devices, about 70% of these men were fimctional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) o f spontaneous function as compared with those undergoing microvascular procedures. (J VAsc SURG 1995;21:576-85.)

From the Departments of Surgery, Urology and Radiology, George Washington University, Washington.

Presented at the Eighth Annual Meeting of the Eastern Vascular Society, Montrdal, Qudbec, Canada, May 12-15, 1994. Reprint requests: Ralph G. DePalma, MD, 1000 Locust St.,

Reno, NV 89520.

Copyright © 1995 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North Ameri- can Chapter.

0741-5214/95/$3.00 + 0 24/6/62359

T h e diagnosis and treatment o f vasculogenic impotence have advanced considerably since the late 1970s. Beginning with an emphasis on arteriogenic impotence and corpus cavernosal revascularization, 1 recognition o f the cavernosal leakage syndrome 2'3 and penile s m o o t h muscl e dysfunction 4's occurred in the 1980s. The need for penile revascularization 576

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Volume 21, Number 4 DePalma et aL 5 7 7

diminished considerably as a result of medical and intracavernous injection 68 therapy. However, there remains a subset of men in whom nonoperative treatment is unsuccessful; for this group, vascular interventions offer one means of restored function. We have used noninvasive and invasive sequences of comprehensive testing for vasculogenic impotence

since 1983. 9'1° This report describes experience with operative interventions among 67 men admitted with the chief complaint of impotence. These men were selected after sequential neurovascular screening and based on the failure of erection after a trial of medical treatment and intracavernous injections. The results of four types of interventions for vasculogenic impotence were analyzed. These included aortoiliac interventions for aneurysmal or obstructive disease; dorsal penile artery revascularization of distal or pudendal artery obstruction; deep dorsal vein arteri- alization for diffuse penile arterial disease or mixed arterial and venous impotence; and venous interrup- tion for cavernosal leak syndrome.

MATERIAL A N D M E T H O D S

Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age of 54.5 years) were screened noninvasively with use of penile plethysmography and penile brachial indexes9; 635 were considered to have normal arterial flow, and 459 were considered to have abnormal arterial flow. Before an office visit these men also underwent neural testing by use of pudendal and posterior tibial s0matosensory evoked potentials and measurement of bulbocavernosus reflex time11 as aids to gauge initial dosage of intracavernous vasoactive agent. Laboratory studies for diabetes mellitus, testosterone deficiency, or prolactin excess or general medical illness were also performed.

After complete history and physical examination, failure of erectile responses with increasing doses of intracavernous injection (ICI) of papaverine (up to 60 mg) 6 or prostaglandin E 1 (up to 30 ~g.)8 was used to select men for further study. All options including prosthetic insertion and vacuum constrictor devices (VCD), as well as the risks and benefits of a vascular procedure, were discussed. When small-vessel disease or cavernosal leakage syndrome appeared clinically likely, potential surgical candidates were referred for a dynamic infusion cavernosography and cavernos- ometry (DICC) and later for routine pudendal arteriography.12 This choice was based on absence of large-vessel disease, failure to respond to increasing doses ofintracavernous injection, and abnormal pulse volume recordings in small-vessel arterial disease.

With only one exception, men without diabetes and those not requiring continuous blood pressure medi- cations were selected for microvascular impotence interventions.

Men with the chief complaint of impotence and demonstrating aortoiliac, aneurysmal, or occlusive disease by history and physical and noninvasive examination underwent conventional imaging stud- ies, including ultrasound examination and computed tomography. Abdominal and pelvic arteriography with views of the origins of the internal iliac arteries were obtained as indicated when operative or percu- taneous intervention was considered. Indications for aneurysmectomy were those related to aneurysm size or extent; in men with occlusive disease the presence of significant lower extremity symptoms or ischemia with ankle brachial indexes less than 0.6 comprised indications to correct both limb symptoms and erectile function.

Four types of interventions were performed on 67 men (age 18 to 79 years). These were based on patterns of vascular involvement including the following: (1) aortoiliac interventions for aneurysm or occlusive disease in 17 men: eight for aneurysms ranging in size from 4.5 to 6.0 cm and nine for occlusive iliac disease, including two transluminal angioplasties, five femorofemoral bypasses, and two internal iliac endarterectomies; (2) dorsal penile artery bypass for pudendal or penile artery occlusion in 11; (3) deep dorsal vein arterialization for diffuse penile disease in 12 men; and (4) venous interruption for cavernosal leak syndrome in 27 men. Patients were observed for a minimum of 12 months with a maximum follow-up time of 108 months. Average follow-up times ranged from 33.4 to 48 months among the groups.

Follow-up data were obtained by history and office examination and by use of repeated Doppler ultrasound examinations and penile plethysmogra- phy as indicated, and ICI with papaverine or prostaglandin E 1 to assess erectile function objec- tively. Prostaglandin E 1 for ICI was used from 1989 onward.8 Repeat DICC to measure flow to maintain erection as previously described 13 was carried out after venous ablation procedures in 16 of 27 patients along with cavernosography and embolization for recurrent leakage. Flow to maintain erection in excess of 40 ml/min or pressure d r o p o f greater than 1 mm Hg/sec was considered abnormal. All men received mail questionnaires with the following inquiries: (1) Are you currently functional sexually? H o w often? (2) Since surgery, do you feel that your erections are better, same or worse? and (3) Are you currently

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Table I. Overall results

Aortoiliac No. of Average age Follow-up time average intervention patients (range) (mos.) (range)

Erectile function

Spontaneous ICI or VCD None Prosthesis

Total 17 61 (48-79) 38 (12-72)

Aneurysm 8 68 (54-79)

Occlusive 9 55.5 (48-65)

Dorsal penile artery 11 44.5 (21-64) 33.4 (12-48) bypass

Dorsal vein arteriati- 12 40.3 (18-61) 34.5 (12-84) zation Venous interruption 27 47.5 (31-69) 48 (12-106) Totals 67 10 (58%) 3 (18%) 4 5 2 1 -- 6 1 1 -- 3 (27%) 5 (45%) 3 2 4 (33%) 5 (47%) 3 2 9 (33%) 12 (44%) 6* 1 26 (38%) 25 (37%) 16 (25%) 5

*One late death as a result o f h u m a n immunovirus.

using any medication or intracavernous penile injec- tions? These data were used to ascertain subjective reporting o f potency. Further follow-up data were obtained by contacting patients or referring physi- cians by telephone. Seven patients were lost to follow-up at intervals from 12 to 48 months; one was reported to have acquired immune deficiency syn- drome 60 months after operation and has been lost to follow-up.

R E S U L T S

After exclusion for diabetes, long-term use o f antihypertensive medications, systemic illness, and failure to respond to intracavernous injections, 50 men, or about 5% o f those screened, became candidates for microvascular reconstruction or venous ligation. 3,~416 A total o f 67 men underwent operations, including 17 men requiring aortoiliac interventions where the chief complaint o f impotence had called attention to an aneurysm or occlusive disease. This constitutes about 6% o f this population. It is important to note that in seven o f the eight men with aneurysms, the complaint o f impotence led to the discovery o f these aneurysms between 1983 and 1993 and ultimately a recommendation for aortic reconstruction. None o f the men with aortoiliac disease were lost to follow-up. None of the 11 men with penile artery bypass, monitored 12 to 60 months, were lost to follow-up. Two o f the 12 men undergoing deep dorsal vein arterializations were lost to follow-up, whereas 5 o f the 27 patients with venous interruption procedures were lost to follow-up after 12 months. One patient in the venous interruption group was subsequently found to have diffuse penile arterial disease by arteriography and later was reported to have human immunodeficiency virus infection and is believed to be dead. This was the only such case among this series to date.

Table I summarizes overall results among patients in each group. The patients undergoing operation for aortoiliac diseases, particularly the patients with aneurysms (48 to 79 years), fall into an older age group with an average age of 61 years (48 to 70 years), in contrast to the men selected for microvas- cular operations in w h o m average ages range from 40.3 to 47.3 years. This age difference was statisti- cally significant by analysis o f variance atp < 0.001. These older men mainly had atherosclerosis in contrast to the small-vessel disease seen in those undergoing penile bypass, deep dorsal vein arterial- izafion, or venous ligation. However, by chi-squared analysis, there was observed a statistically significant difference (p < 0.05) and expected frequencies o f spontaneous erection between those with aortoiliac reconstruction and the group undergoing microvas- cular procedures.

The reporting o f spontaneous erectile function and its long-term documentation was consistently higher in the patients undergoing aortoiliac reconstruction: 58% reported spontaneous erections after operation, in contrast to 27% o f the men with dorsal penile artery bypass, 33% o f men with dorsal vein arterialization, and 33% o f men with venous interruption. However, when ICI or VCD were added as aids to function, these results were compa- rable among the groups in that 76% o f the men undergoing aortoiliac interventions were functional as compared with 72% o f men with dorsal penile artery bypass, 75% o f men with dorsal vein arterial- ization, and 77% o f men after venous interruption procedures. With passing time, men who had under- gone microvascular procedures or venous interrup- tion increasingly required ICI therapy to maintain function. This requirement was regarded by most o f them as favorable, because these men had all been previously unresponsive to ICI.

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Characteristics of function/failure

Aortoiliac intervention. Among 15 of 17 men

with aortoiliac reconstructions, penile pulse volumes correlated with reported erectile function or failure. These were essentially normal in patients with spontaneous erectile function, whereas those needing ICI or VCD exhibited penile-brachial pulse indexes less than 0.5 or abnormal pulse wave recordings characterized by delayed upstroke or flattened wave- forms. In all instances, preoperative neural testing results, including pudendal evoked potentials and bulbocavernosus reflex time were unchanged after these aortoiliac procedures. The operative procedures used previously described 17,~s methods to spare autonomic genital nerves and to perfuse or reperfuse internal iliac arteries. Femorofemoral bypasses were performed for occlusive disease in five men, internal iliac endarterectomy in two, and successful angio- plasty in two.

Fig. 1 illustrates aortoiliac disease in a 4.5 cm aortic aneurysm, which probably led to repeated embolization of one internal iliac artery. Here iliac aneurysmal involvement containing atheromatous debris extended to the origin of the right internal iliac artery. This appeared to correlate with absent right penile pulses and a penile-brachial index of 0. After initial subjective improvement after reconstruction with reported spontaneous function for several months, this patient eventually required a VCD. There was no change in the absent Doppler signals on the right, whereas plethysmographic waveforms im- proved slightly in amplitude but not in form. The patient functions well at 48 months and is satisfied with this result. Possible prevention of further embolization of aneurysmal material has prevented further deterioration of function. In two other instances with postoperative improvement of func- tion, aneurysmal involvement in the distal common iliac artery was similar. However, in these cases penile signals obtained by Doppler scanning were audible on the ipsilateral side before and after operation.

In men undergoing procedures for aortoiliac occlusive disease, all had abnormal penile-brachial pulse indexes and pulse volume recordings that returned to normal. However, two of these men did not have development of normal erectile function. One was severely depressed and required large doses of lithium after femorofemoral bypass. The other patient, after hemodynamically successful external transluminal iliac dilation continued to require pro- pranolol, which he took for control of tremor. There were no deaths; one aneurysm required reexploration in the immediate postoperative period for coagulop-

J

I L~ ~

.,.5_ sca°,,c,o,

Small aneurysm ~ ~:

with athero- ~ /

sclerotic d e b r i s ~ ~2,1 S~x~.

Penile Brachial

(¢ IJ

Penile Brachial Index: Right = 0 ~ Index: Left = 1.0

P V R ~ ~

Fig. 1. Aortoiliac aneurysm and associated penile pulse

volume recordings and penile brachial indexes. Aneurysm in 60-year-old man complaining of abrupt onset of impotence. Aortic aneurysm diagnosed 8 months before with abdominal component measured at 3.6 cm compared with suprarenal aortic diameter of 3 cm. Enlargement to 4.5 cm prompted operation. Small aneurysm at bifurcation of right common iliac artery appeared to relate to absent penile Doppler signals and penile brachial index of 0 on right. Penile pulse volume waves with delayed upstroke and sine waveform before and after operation suggest ipsilateral embolism.

athy with a leak at the right ifiac anastomosis. His recovery was uneventful after this episode, and this 70-year-old man functions with weekly intercourse at 36 months after operation.

Dorsal penile artery revascularization

Penile artery bypass was performed in 11 men with pure arteriogenic impotence and normal DICC as previously described 19 with use of 10-0 nylon on a BV75u or BV50u needle (Ethicon, Inc., Johnson and Johnson Co., Somerville, N.J.). End-to-side anastomoses were used in eight, and end-to-end anastomoses were used in the remainder with stan- dard microvaseular technique. The inferior epigastric artery was used routinely as an inflow source. Differing types of reconstructions are shown in Fig. 2. These variants were chosen on the basis of the arteriographic appearances of the penile arteries with selective pudendal arteriography, as well as findings at operation. The bifid type shown in Fig. 2, D might offer an advantage by providing both proximal and distal perfusion of the dorsal artery. It is believed that microvascniar end-to-end anastomoses would be

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580 D e P a l m a et al. April 1995

A

B

c D

Fig. 2. Technical variations used in microvascular reconstruction of dorsal penile artery with inferior epigastric artery used as inflow source.19 Choice is based on arteriographic and operative findings.

advantageous. No surgical complications occurred in this group. Postoperative Doppler recordings were effective for detecting closure in three cases; each was confirmed by arteriography. Two of these men selected prostheses within 2 months after failure of the vascular procedure.

Deep dorsal vein arterialization

This procedure, a modification of the Furlow- Fisher technique 2° (Fig. 3) was selected for 12 men exhibiting diffuse penile artery disease or mixed arterial and venous leakage impotence. This proce- dure uses interior epigastric artery-to-deep dorsal vein anastomoses with proximal and distal venous ligation and ablation of local valves. There were two complications that were due to glans hyperperfusion. In both cases the complication had its onset 5 to 7 weeks after deep dorsal vein arterialization. Its onset was signaled by spraying of urine as a result of swelling at the urethral orifice followed by superficial erosions of the glans penis. In one man, priapism accompanied this picture. Both of these complica- tions were reversed after distal venous interruption as shown in Fig. 3. One has continued to function by verbal report at 36 months; the other reported function, but this has not been confirmed by repeat ICI because this man was lost to follow-up. Three men described sudden loss of erections during prolonged intercourse; in these instances the epigas- tric artery revascularization had occluded as docu- mented by Doppler examination followed by angio- graphic study. Two of these men later had develop- ment of function again with ICI; one is now functioning spontaneously at 4 years. The use of serial penile Doppler examinations and plethysmog- raphy 9,1° correlated well with reported function and

graft patency. Waveforms characteristic of successful deep dorsal vein arterialization are shown in Fig. 4. Venous interruption

A pattern of vigorous spontaneous function in the first several months with rapid fall-offin spontaneous function during the first 36 months characterized this group. At 36 months overall, 33% functioned spontaneously, whereas 44% used ICI effectively. We have previously described the use of postoperative DICC as compared with preoperative findings as an objective measure of venous interruption for impo- tence. 16 Flow to maintain erection (FME) during DICC in 16 men reporting postoperative function or effective ICI at 3 months fell from 80 to 180 ml to less than 40 ml/min to maintain intercavernous pressure of 80 to 120 mm Hg. In two of the patients with immediate treatment failures undergoing venous ligation for diffuse cavernosal leakage, FME decreased only to 60 to 80 ml/min. Both of these men fail to function either spontaneously or with ICI. In this study, deep dorsal vein leakage, as shown in Fig. 5, was most favorable for successful function after resection. Diff-use patterns with large areas of caver- nosal leakage, as shown in Fig. 6, failed to respond to multiple attempts at embolization and dorsal vein resection, including a suprapubic approach.

Overall potency

Cumulative potency tables are presented for each of the procedures in Fig. 7, A through D. Both the use of previously ineffective ICI and resumption of function after a period of latency after graft closure are included in the functional assessment. It can be seen that the results were roughly comparable among the groups. Overall, about 70% to 75% of these men,

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J O U R N A L OF V A S C U L A R S U R G E R Y

Volume 21, Number 4 DePalma et aL 581

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in shall . . . . ..-s"

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Dorsal vein

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for glans hyperemia

Fig. 3. Technique of deep dorsal vein arterialization with use of Furlow-Fisher 2° technique. Note blood flow in emissary vein these drain mainly into spongiosum.

---,=::-t::~:V:: ... = :xh::'=]+, ::~': ~ :F:~:., ~: ::,i~i:~ !:: !-~q!iLl t!iix . . . :~:V.i ::i-4.i:7 [!!~-{:::ili!~. -~-~ !--i~!:- - 4 .. . . . ~:i! : X> : . i ~ Zz2!22[]IL z:il.27~',Z; 2LTd;;2(L;:[I~] Z2 X!;L72,27~ 771,2L2 Z_!l:2Lt-7+z-i LX12-7[1.:2+7 : 1224.:£1271 22~.2 2 i Z, '{ =:- ~= = . :{:~-~::-,: ,a ~ <,-~:---- = : : x l =- .=. m : = :-= ::Ji: >: w:~ =~]~4::

Fig. 4. Plethysmographic pulse wave recordings. A, Before operation in 42-year-old man with diffuse penile arterial disease. B, After deep dorsal vein arterialization. Note absence of waveforms before operation with normal wave forms 9,1° after operation.

exclusive o f five receiving prostheses, were fimctional at about 36 months. Some long-term follow-ups with functional results after excision o f the deep dorsal vein, have been observed at 62 to 108 months. D I S C U S S I O N

We have described four subsets o f impotent men w h o exhibit differing types o f disease. Aortoiliac disease is an u n c o m m o n cause o f impotence in our

population. About 1 in 100 men were f o u n d to have a n occult aortic aneurysm during their workup. Although the conditions in some patients improved after aortoiliac reconstruction, the important point is that impotence signalled this potentially lethal lesion. M t h o u g h we were able to see a potential relationship in at least three men between aneurysms and possible embolization, the finding o f a 1% prevalence o f aneurysms in men in the sixth to seventh decades o f

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582 D e P a l m a et al. April 1995

Fig. 5. Cavernosogram shows deep dorsal vein leakage. Preoperative flow to maintain erection was 1 l0 ml/min in 48-year-old man. Patient reports spontaneous function 4 years after dorsal venous ligation and excision.

life is not unexpected. Clearly more work is needed to define this relationship. In men with occlusive disease, impotence was the chief complaint; however, all exhibited extremity ischemia, requiring interven- tion. All o f these men underwent successful revascu- larization. Although penile hemodynamics appeared to improve by noninvasive testing, two failed to regain satisfactory erectile function related to contin- ued postoperative drug usage. One exception to our rule o f not operating on patients exhibiting neural defects was a 52-year-old man with paraplegia complaining o f impotence and an insensate but ischemic toe because o f unilateral common iliac artery occlusion. This man had a gratifying result after femorofemoral bypass, with regard to both spontaneous erectile function and reversal of extrem- ity ischemia at 36 months. Thus neural disorders might not contraindicate large vessel intervention, but more data are needed to select such patients.

In the men with microvascular penile artery bypass, there were two technical failures early in the series that were detected promptly by noninvasive examination. A m o n g the patients in this experience and similar to that o f Krane e t al. 21 the best responders to penile artery revascularization were younger men with either isolated pudendal disease or history ofperineal trauma. It is important to note that

Fig. 6. Diffuse cavernosal leakage in S8-year-old man who had never achieved normal erection, in spite of two attempts at embolization, dorsal vein excision, and supra- pubic excision and ligation of veins. FME of 180 ml/minute before operation fell to only 80 ml/minute after operation. Patient remains nonfunctional; pudendal arte- riogram is normal.

23% o f men with apparent cavernosal leak and normal noninvasive study results were found to have occult concurrent pudendal artery disease when selective arteriography was used routinely) 2 It is probable that at least one subject with arterial insufficiency was included in our early experience with venous ligations. Therefore, before any type o f penile operation, we now require both D I C C and highly selective pudendal arteriography.

Based on a previous analysis o f noninvasive and invasive study results, we recognized that penile- brachial pulse indexes and peripheral vascular resis- tance were 85% sensitive and 70% specific for arterial occlusive lesions. 1° Therefore noninvasive studies alone are inadequate in determining surgical choices for microvascular procedures. This is particularly important in analyzing poor results o f surgery for cavernosal leak syndrome where venous interruption has been practiced with arterial insufficiency unrec- ognized without routine pudendal arteriography. Diffuse cavemosal leakage, or mixed arterial and venous impotence are not suitable for venous inter-

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100 90 80 • 70 60 50 40 30 20 10 I

Aorto lilac Procedure n=17

72%

I

I

Dorsal Penile Artery Bypass n=11 60% 100 90 80 70 60 50 40 30 20 10

I

I

Deep Dorsal Vein Arterialization n=12 74%

I

I

Venous Interruption n=27 ] 66% I I I I I ~ F I 6 12 24 36 48 6 12 24 36 48 Months Months

Fig. 7. Cumulative erectile function rate by life-table representation, including men using ICI or VCD. A, Aortoilac disease. B, Dorsal penile artery bypass. C, Deep dorsal vein arterialization. D, Venous interruption.

ruption or direct arterial revascularization when penile arterial disease is diffuse.

The preferred operation for these conditions is deep dorsal vein arterialization. This is needed because no suitable arteries exist for reliable direct anastomoses. Excision o f the dorsal vein precludes this option, emphasizing the need for complete studies before microvascular procedures. Deep dorsal vein arterialization has the disadvantage o f glans hyperemia as a complication. In addition, the direc- tion o f flow appears to be mainly into the spongio- sum as observed by us 19 and Sohn et al. 22 The physiologic mechanisms by which the procedure causes erection is not understood. Nonetheless, our results with this procedure are similar to those reported by others. 23 In recent reports with follow- ups longer than 12 months, about half o f these men report firm erections spontaneously, and 70% achieve effective erections with ICI, which was previously ineffective. Furlow et al.20 reported a series o f 156 men with 68 functioning normally after deep dorsal vein arterialization with the technique de- scribed here.

With regard to venous ligation, this review

confirms our previous report that postoperative FME is an important physiologic measure, i3 The FME before operation in these men was 80 ml/min or greater; after operation FME decreased to 40 ml o r less in those men who were potent. The two men who did not achieve an FME o f 40 ml/min or less after venous interruption did not have potency after operation and did not erect with injection. These data are critical in illustrating the need for correlating results with physiologic postoperative measurements in evolving procedures such as these. These data again confirm that venous interruption does have a physi- ologic effect that can be correlated with function. Once again the results o f venous ligation are also similar to those reported by others. 3 There is an initial falloff in spontaneous function over 36 months, but 70% to 80% can function overall with ICI, which previously failed. Our prior cavernosography stud- ies 13 show that sequential leakage from other venous sources probably accounts for this falloff in function after operation. As complete an interruption as possible remains a desirable goal o f the initial procedure.

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7% o f m e n with the chief c o m p l a i n t o f i m p o t e n c e b e c o m e candidates for vascular interventions. These are also a h e t e r o g e n e o u s g r o u p , however, and require different procedures. I n the g r o u p w i t h aortoiliac disease, s p o n t a n e o u s function after o p e r a t i o n is m o r e c o m m o n . Overall, including those f u n c t i o n i n g with I C I , a b o u t 7 0 % o f m e n u n d e r g o i n g these vascular interventions will be functional after operation. T h e results o f o u r microvascular experiences are quite similar to o t h e r recent series. 24 Whereas o u t c o m e s , c o m p a r e d with o t h e r forms o f vascular surgery are n o t as u n i f o r m l y successful, vascular interventions are preferred before prosthetics in m a n y men. Five in this g r o u p ultimately chose a prosthesis w h e n the vascular p r o c e d u r e failed. Whereas the subsequent implanta- tion o f a prosthesis remains an o p t i o n after vascular surgery, the reverse sequence is usually n o t possible. H o w e v e r , with rare exception, all were satisfied w i t h their t r e a t m e n t and were grateful to be able to function albeit w i t h the aid o f intracavernous injec- tion. W i t h better selection criteria based o n quanti- tative diagnostic m e t h o d s , and m o r e precise surgical techniques, these results will p r o b a b l y improve. Overall, vascular interventions in a defined p r o p o r - tion o f m e n c o m p l a i n i n g o f i m p o t e n c e appeared to be rewarding.

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4. Saenz de Tejada I, Goldstein I, Azadzoi K, et al. Impaired neurogenic and endothelium-mediated relaxation of smooth muscle from diabetic men with impotence. N Engl J Med 1989;320:1025-30.

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6. Virag R. Intracavernous injection of papaverine for erectile failure. Lancet 1982;2:938.

7. Brindley GS. Cavernosal alpha-blockade: a new technique for investigating and treating erectile impotence. Br J Psychiatry 1983;143:332-7.

8. Stackl W, Hasun R0 Marbuger M. Intracavernous injections of prostaglandin E 1 in impotent men. J Urol 1988;140:66-8.

9. DePalma RG, Emsellem HA, Edwards CA, et al. A screening sequence for vasculogenic impotence. J VASE SURG 1987;5: 228-36.

10. DePalma RG, Schwab FJ, Emsellem HA, et al. Noninvasive assessment of impotence. Surg Clin N Am 1990;70:119-32. 11. Emsellem HA, Bergsrud DW, DePalma RG, et al. Pudendal- evoked potentials in the evaluation of impotence. J Clin Neurophysiol 1988;5:349.

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13. Yu GW, Schwab FJ, Melograna JFS, DePalma RG, et al. Preoperative and postoperative dynamic cavernosography and cavernosometry: objective assessment of venous ligation for impotence. J Urol 1992;147:618-22.

14. Lue TF, Tanagho EA. Treatment of venogenic impotence: medical and surgical management of male erectile dysfunc- tion. In: Tanago EA, Luet F, McLure R, eds. Contemporary management of impotence and infertifity. Baltimore: Wil- liams and Wilkins, 1988:175-7.

15. DePalma RD, Schwab FJ, Druy EM, et al. Experience in the diagnosis and treatment of impotence caused by cavernosal leak syndrome. J VAsc SURG 1989;10:117-21.

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in aortoiliac disease. In: Bergan JJ, Yao JST, eds. Arterial surgery: new diagnostic and operative techniques. Orlando: Grune and Stratton, 1988:337-48.

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Submitted May 31, 1994; accepted Nov. 23, 1994.

D I S C U S S I O N

Dr. Luis A. Queral (Baltimore, Md.). This is an extraordinarily detailed study of men with sexual impo- tence. The results of the authors' thorough evaluation

highlight the complex nature of male sexual dysfunction. Attention was given to hemodynamic, neurogenic, psy- chogenic, and hormonal factors; we see these all have to be

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optimal for achieving a good erection. I noticed that of the 1094 patients that he screened, only 17 had aortoiliac ancurysmal or occlusive disease. I am assuming that the other small-vessel reconstructions and venous leaks were done by urologic colleagues.

In your standard vascular surgical practice, what percent of patients have sexual dysfunction? Can you help these people? Should we document penile hemodynamics in all patients, particularly if they have either aneurysmal or occlusive disease involving the aortoiliac segment? Last, should our goal as vascular surgeons be to do our best to revascularize all three legs?

I notice also that you excluded from your surgical therapy patients with diabetes and those taking medica- tions for hypertension. Why were these people excluded? Also, what about tobacco use? Does excessive use of tobacco cause impotence, and if so what is the mechanism of action and is the damage caused by nicotine in anyway reversible?

Dr. Ralph G. DePalma. I too was disappointed to discover only 17 cases of aortic disease out of this series. Remember these are men with impotence only. In answer to your second question, about 40% of men with aortoiliac aneurysmal disease will have impotence as an ancillary complaint, provided you take a careful history. It is not common for this group, however, to complain primarily of impotence. If the patient and his parmer are interested in sexual function, we must get his history before we perform aortic reconstruction. Although you can do much to maintain function. About 4% or 5% of these patients can still be made impotent by aortic surgery.

We treated all of these cases. The average operating time for these operations is about 4 to 41/2 hours. Vascular surgeons who are doing distal bypasses into pedal vessels could manage them. Because the workup has fallen into the hands of the urologists, our urologic colleagues are naturally seeing more of these men. We were able to consult on almost all these cases at George Washington University, thanks to Dr. Harry Miller.

When sexual function is an issue we should document penile flow in aortic cases before and after operation. I believe that penile brachial indexes (PBI) and penile pythesmography are good ways to do this. The PBI was described by Dr. Queral et al. (Surgery 1979;86: 799-809) in an early report. It is a convenient, rough-and-ready test. Noninvasive screening is, however, only 85% specific and 70% sensitive. You cannot rely on good pulse waves and good PBIs to plan a venous interruption: you must obtain

a selective arteriogram. We have published data on the sensitivity and specificity of these tests.

I think you should try to revascularize all three extremities including the genitalia. Internal iliac revascu- larization is also good for the spinal cord. Finally, we excluded patients with diabetes and hypertension because we were doing a new procedure. I did not feel justified in including these complex problems. Cigarette smoking is very important; if you can get the patient to stop smoking, many of them get better. Eighty percent of these patients were treated effectively with medicine or injections; these men overall are among the most grateful patients that we have. Surgery is reserved for those in whom injection therapy fails.

Dr. Syde A. Taheri (Buffalo, N.Y.). We have evalu- ated 100 patients for impotency. Among these 100 patients, 13 patients had corpus cavernosa and calf muscle biopsy. Twelve of these patients had also venous insuffi- ciency. Among these 13 patients ,echo had muscle corpus cavernosa biopsy, eight of them had a sclerosing type of tissue that did not appear to be suitable for any type of surgical procedure. Three of these patients who had venous leak had a coil placed in the operative vein. One patient was lost to follow-up. The condition of one patient improved for one month and the condition in the other did not improve at all. Should we perform biopsy on the corpus cavernosa before somebody wants to do any type of surgery on this patient?

Dr. DePaima. In a relatively young patient you can consider that the corpora are normal. There is some consideration that fibrosis of the corpora in the aging patient is one of the mechanisms of impotence. It might be justified to subject older men to corporal biopsy before microrevascularization. We have considered this but have not done it. For the microvascular procedures we have confined our operations to men below 60 to 61 years of age. You can also get an idea by careful palpation after injection and also by color-flow dnplex scanning. You can both palpate and observe areas of fibrosis after injection. I have not mentioned that specialized aspect of the workup. For vascular disease we prefer the quick and simple way of measuring PBI and penile plethysmography in the flaccid penis. Certainly in a case of Peyronie's disease or where suspicion of fibrosis exists, we perform an injection and then duplex scanning. You can then see areas of scarring and fibrosis. Peyronie's disease is an important cause of impotence often uncovered by these examinations.

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