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Penile Vein Ligation for Corporeal Incompetence: An Evaluation of Short-Term and Long-Term Results
0022-5347 /90/1443-0679$02.00/0
Vol.
THE JOURNAL OF UROLOGY
September
in U.S.A.
Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
PENILE VEIN LIGATION FOR CORPOREAL INCOMPETENCE: AN EVALUATION OF SHORT-TERM AND LONG-TERM RESULTS BARRY ROSSMAN, MARIA MIEZA AND ARNOLD MELMAN From the Department of Urology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx and Department of Radiology, Beth Israel Hospital, New York, New York
ABSTRACT
Dynamic cavernosometry and cavernosography can be used to identify patients with corporeal venous incompetence as a cause of erectile dysfunction. We reviewed our series of 16 patients with venous leakage who underwent surgical correction of the specific abnormality identified on cavernosography. Short-term and long-term results were obtained, and while at least temporary improvement was noted in 89.5% of the patients the long-term results tended to show a reversion to the preoperative status in the majority. (J. Ural., 144: 679-682, 1990) While dramatic advances in the evaluation and treatment of male erectile dysfunction have been made during the last several years, many unanswered questions remain. Penile venous incompetence as an etiological factor in impotence has recently become an area of increased intense investigation. However, despite the ability of many investigators to identify the presence and even location of apparent venous leakage from the corpora cavernosa, surgical repair has not achieved uniformly successful results. While some investigators do report improvement with venous ligation in as many as 80% of the patients, 1 · 2 others achieve success in only as few as 20% 3 and most represent limited followup. 1- 9 It should be noted that the concept of venous insufficiency as a cause of erectile dysfunction actually dates back to the turn of the twentieth century. Wooten in 1902 10 and Lydston in 190811 first suggested that ligation of the dorsal veins of the penis might be effective treatment for certain types of impotence. However, only with the advent of dynamic cavernosometry and cavernosography has our ability to diagnose accurately and treat these patients genuinely developed. By monitoring intracavernous pressure during the dynamic induction of an erection with pharmacological agents and rapid fluid flow, the presence of a venous leak can be diagnosed. The addition of dynamic cavernosography then enables the investigator to pinpoint the actual site of venous leakage. These can be manifested as shunts from the corpora cavernosa to the corporus spongiosum or glans, or alternatively as leakage directly into the dorsal, crural or pudenda! veins. Accordingly, several different surgical techniques have been advocated, each reporting varying degrees of success. i-s In an effort to investigate this issue further we reviewed the short-term and long-term outcome of our patients with corporeal incompetence who underwent penile vein ligation. The study was done in an attempt to identify any trends or factors that might allow us to predict better which patients would and would not fare well with an operation. MATERIALS AND METHODS
All patients referred for the evaluation of erectile dysfunction underwent a comprehensive evaluation. Initially, based on the findings of a careful history and physical examination, patients were selected who were suspected of having corporeal incompetence. Cavernous venous leakage was particularly suspected when the patient described lack of rigidity with a soft, transient erection that was inadequate for penetration. 8 Typically, the impotence was of gradual onset and there was generally an absence of other risk factors (for example diabetes, peripheral vascular disease, antihypertensive medications and so forth). More objective evidence then was sought to eliminate other Accepted for publication February 14, 1990. 679
etiologies. Rigiscan monitored nocturnal penile tumescence and visual sexual stimulation9 were obtained to evaluate for any psychogenic component. Doppler penile blood pressures and plethysmography, and/or a trial of intracavernous vasoactive drugs was used to study the adequacy of arterial inflow. Patients with venous insufficiency typically achieve only partial or short-lived erections with nocturnal penile tumescence or visual sexual stimulation, and generally demonstrate a poor response to intracavernous injection of pharmacological agents, specifically papaverine (30 mg.) with or without phentolamine (1 mg.). No response, only partial tumescence and a full but transient erection often associated with signs of systemic absorption, such as dizziness and facial flushing, are all suggestive of venous incompetence. Penile blood pressure measurements with calculation of the penile brachia! index (penile blood pressure/brachia! blood pressure) would be expected to be within the normal range in patients with isolated venous incompetence. Patients then suspected of having venous incompetence underwent dynamic cavernosometry. If the study suggested a venous leak they then underwent cavernosography performed by a variation of the technique used by several investigators, such as Wespes and associates, 12 • 13 Puyau and Lewis, 14• 15 and Bookstein and associates. 16 After appropriate skin preparation with an alcohol swab, 23 and 19 gauge butterfly needles were each placed into a corpus cavernosum. While simultaneously measuring intracavernous pressure with a Gould pressure transducer via the 23 gauge needle, warmed isotonic saline or lactated Ringer's solution was infused with a Sarns infusion pump into the penis via the 19 gauge needle. The fluid was instilled at 50 cc per minute initially and increased up to 200 50 cc per minute increments or until an cc per minute erection developed. Then, with the base of the penis transiently pinched between 2 fingers, papaverine hydrochloride (30 to 60 mg.) was injected via the existing 19 gauge needle directly into the corpora cavernosa. After waiting approximately 5 to 7 minutes for penile tumescence to develop, the infusion was repeated via the Sarns pump in the same manner and pressure measurements were recorded. Patients who never had a rigid erection with this technique (that is no erection with flow rates greater than 200 ml. per minute after injection of papaverine) were considered probably to have a venous leak. In addition, patients who required either more than 150 ml. per minute of fluid inflow to initiate or more than 50 ml. per minute to maintain an erection also were suspected of having venous incompetence. Patients who met these criteria for corporeal incompetence by dynamic cavernosometry then underwent dynamic caver-
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ROSSMAN, MIEZA AND MELMAN
nosography. While a pre-papaverine and post-papaverine study was routinely performed early in our series, later only the postpapaverine study was obtained. The pre-papaverine study was performed by placing a 23 gauge butterfly needle without use of local anesthesia directly into the corpora cavernosa. Dilute iothalamate meglumine 43 % contrast material then was infused via a Harvard pump at a set rate of 0.39 ml. per second (23.6 ml. per minute) under fluoroscopic visualization. A full rigid erection did not typically develop, and spot radiographs were obtained during early filling and at the 30-second interval (anteroposterior and oblique). The infusion was stopped after an average of 40 ml. contrast medium were given, and at this time 30 to 60 mg. papaverine were injected intracavernously and the study was repeated giving contrast medium via the Harvard pump again at a rate of 0.39 ml. per second. Spot films were similarly taken at early filling and at 30 seconds (anteroposterior and oblique). A delayed radiograph was taken at 10 minutes and all x-rays were critically and independently evaluated by a uroradiologist (M. M.). An operation was recommended to patients who met the criteria for corporeal incompetence (that is positive cavernosometry and cavernosography, and abnormal nocturnal penile tumescence). A total of 16 patients subsequently underwent penile vein ligation. The surgical technique used was directed at the site of leakage in each individual. We used either a perineal incision, an upside-down J infrapubic incision, a circumcising incision or a combination thereof to identify, isolate and ligate best the known areas of venous incompetence. Any large emissary or circumflex veins were initially identified under Buck's fascia as they coursed from the tunica albuginea to the superficial venous drainage system. These veins were traced and ligated as they exited the tunica with 3-zero chromic suture material. If shunts between the corpora cavernosa and corpus spongiosum or glans were seen on preoperative cavernosography, then these were divided by a modified version of the surgical technique described by Ebbeh~j and Wagner. 4 The deep and superficial dorsal veins then were isolated, ligated and divided as indicated by cavernosography. The deep dorsal vein was ligated as proximally as possible in the infrapubic area near the dorsum of the crus (the crural veins as suggested by Pusch-Leao and associates, 17 and Lue 18). Finally, if crural venous incompetence was identified preoperatively, then the crura were carefully exposed via either an extended infrapubic incision into the scrotal area or by a separate perineal incision. Crural vein ligation and division were performed by tying off all large exiting veins. Crural plication additionally was performed when indicated. RESULTS
A total of 16 patients with venous incompetence as the etiology of erectile dysfunction according to the aforementioned methods subsequently underwent an operation. Patient age ranged from 21 to 62 years, with a mean age of 46 years. The duration of impotence ranged from 4 months to 20 years. Four men (21, 22, 24 and 31 years old) stated that they never had experienced a normal erection. All patients underwent a detailed history and physical examination, and further evaluation was directed as indicated. Of the patients 12 underwent nocturnal penile tumescence testing and 7 underwent visual sexual stimulation testing to rule out more objectively a psychological etiology to the impotence. 19 There was no history of penile trauma or physical evidence of penile fibrosis in any patient in this group. All patients, who subsequently had corporeal incompetence, demonstrated either soft or no erections during these studies, except for 2 who had rigid but short-lived erections (less than 5 minutes in duration). Penile blood pressures were measured by Doppler ultrasound with calculation of penile brachial index in 14 of the 16 patients to confirm the absence of significant arterial inflow insufficiency. The majority of these patients had penile brachial indexes of more than 0.90, with only 2 having values of less than 0.90 (1 had a penile brachial index of 0.81 to 0.82, while 1
had an index of 0.79 to 0.78). Four patients were tested with a trial of 30 to 60 mg. papaverine without effect. Cavernosometry evaluation was then used primarily to screen patients for an operation who were suspected of having venous leakage by the aforementioned preliminary evaluation. Patients who fulfilled the previously mentioned cavernosometric criteria for leakage then underwent dynamic cavernosography. All patients thus studied by cavernosography had radiographically identifiable venous leaks and were encouraged to undergo venous ligation. A total of 16 patients agreed and they underwent 19 procedures (3 underwent 2 operations each after a failed initial procedure). Multiple different sites of leakage were noted, including cavernous-spongiosal or glandular shunts, drainage via the perforating and circumferential veins to the deep and superficial dorsal veins, and drainage via the crural veins to the pudendal plexus. The surgical plan was to ligate the veins in the area of drainage visualized on cavernosography. The operation was performed between June 1985 and March 1988. While 3 procedures (16%) were done via a perineal approach alone, in 2 patients (11%) a combined perineal and circumcising incision was used, while 1 (5%) underwent a combined perineal and infrapubic approach. Five patients (26%) underwent an isolated circumcision approach to the venous leaks and 8 (42%) underwent an independent infrapubic approach (fig. 1). Postoperatively, no significant complications were encoun-
circ & perinea! 11% 2 perinea! 16% 3
infrapub. & perinea! 5% 1
infrapubic 42% 8
FIG. 1. Approach used for penile vein ligation
16 PATIENTS
Initial Improvement
No
Improvement
2 PATIENTS [ 2 Procedures] ( 10.5%)
14 PATIENTS [ 17 Procedures] (89.5%)
Fm. 2. Penile vein ligation 14 PATIENTS
2 PATIENTS
2 PATIENTS
7 PATIENTS
2...E.I§.__
Maintained Improvement (spon. potent)
Deteriorated but still resp to PAP.
No signif. functional change
Penile Prosth
Fm. 3. Operative results after initial improvement
1 PT Worse
PENILE VEIN LIGATION FOR CORPOREAL INCOMPETENCE
681
FIG. 4. A, preoperative cavernosogram shows significant leakage of contrast medium into crural veins after injection of 30 mg. intracavernous papaverine in patient with erectile dysfunction. B, postoperative cavernosogram of same patient. Contrast material is seen flowing into deep dorsal system. Crural veins have been ligated with hemoclips.
tered, including no reports of wound infections, significant penile edema, penile anesthesia, penile shortening or significant hematoma. There also were no cases of priapism. Followup included an initial postoperative office visit and monthly to bimonthly visits thereafter. All but 2 patients reported at least transient improvement after each operation (fig. 2). The duration of improvement typically lasted from l to 4 months with a large percentage (70%) of the patients recalling only approximately 4 to 8 weeks of improvement. As far as the aspect of the erection that was improved, 80% of the patients reported increased firmness and 65 % reported duration of erection. Several patients reported the remarkable ease with which spontaneous erections developed with simple fantasizing or minimal stimulation. Unfortunately, the initial good results tended to be temporary. Of the 14 patients who reported initial improvement 2 remain spontaneously potent with the consistent ability to achieve an erection satisfactory for intercourse (fig. 3). These 2 patients currently are 9 and 15 months after ligation. While 2 patients are responsive to papaverine, which was not the case preoperatively, the majority of the patients reported return to their previous functional level within 1 month to 4 years. Nine patients report no great value of an operation, placement of a penile including 2 who subsequently prosthesis. Only 1 patient reports that he is worse postoperatively. He has resigned himself to the situation and refuses further evaluation or treatment. Finally, 5 of the patients who underwent an operation for venous incompetence and who did well transiently later deteriorated and underwent repeat dynamic cavernosography. Of note, while the sites of previous leakage seen on the preoperative cavernosograms were generally well ligated on the repeat studies, several of the patients subsequently had new radiographic sites of leakage (fig. 4). Of these 5 patients 3 elected to undergo repeat directed penile vein ligation, with each patient again describing only transient improvement that waned with time. DISCUSSION
While it recently has been suggested and reported by several investigators that malfunction of the veno-occlusive mechanism of the corpora cavernosa probably is the most common cause of vasculogenic impotence, 20 · 21 this process remains an enigma. The most current hypothesis of the erectile mechanism is that relaxation of the corporeal smooth muscle combined
with increased blood to the corporeal sinusoids allows the trabeculae to close the venous drainage of the subtunical venous plexus, that is a flap valve mechanism with resultant penile rigidity. Presumably, patients with corporeal incompetence have an as yet to be defined defect of this mechanism. With our increased understanding of the physiology and mechanism of erection 21 - 24 we have developed a multifaceted approach to the impotent patient 9 • 19 and this has led us to be better able to diagnose more accurately arterial and venous disorders that may be responsible for erectile failure. The penile brachia! index as a measure of arterial disease was begun in this study 5 years ago. To date either penile plethysmography or pulsed Doppler ultrasound would be used to analyze penile arterial competence. Nonetheless, our surgical correction of a seemingly obvious abnormality has not led to long-standing good results, and this finding suggests that the pathophysiological process leading to corporeal venous incompetence is more intricate than our current understanding. Our initial goal, to identify risk factors that were predictive of surgical outcome, was not realized. There was no correlation with the visible site of the leak, age of the patient, duration of disease, rate of initial or maintenance infusion, and successful outcome because nearly all of the patients eventually failedo While it certainly is possible that the poor results with venous ligation in our review might represent either an improper diagnosis, correction of only 1 aspect of a multifaceted problem (for example, arterial insufficiency not ruled out by Doppler blood pressure) or inadequate surgical technique, we believe that the high failure rate represents an inherent problem in these patients. There appears to be something intrinsically and fundamentally wrong with the active veno-occlusive mechanism in these patients, which does not allow them to trap the blood effectively in the corpora. At reoperation of patients who had failed an initial procedure there was a marked increase in the number of veins draining from the corpora, that is multiple new drainage channels formed. Perhaps atrophy or fibrosis of the underlying corporovenous occlusive mechanism is the pathological factor within the tunica. Until this defect is identified further and understood, it seems that this operation is unlikely to give good long-standing success. The only suggested alternative to vein ligation for this disease is with detachable balloons or coils. In a report of 31 treated patients 26 had resumed normal sexual life. 25 Followup in 14 patients was less then 6 months. That series will have to be substantiated by other groups using similar techniques. However, whether a vein is
682
ROSSMAN, MIEZA AND MELMAN
surgically ligated or occluded the obstruction created still is external to the tunica, outside the probable site of disease, and unlikely to result in long-term success. REFERENCES
1. Wespes, E. and Schulman, C. C.: Venous leakage: surgical treatment of a curable cause of impotence. J. Urol., 133: 796, 1985. 2. Gilbert, P. and Steif, C.: Spongiolysis: a new surgical treatment of impotence caused by distal venous leakage. J. Urol., 138: 784, 1987. 3. Buvat, J., Lemaire, A. and Dehaene, J. L.: Critical study of the organic basis of the "venous leakages" detected by the artificial erection test. In: Proceedings of the First World Meeting on Impotence. Edited by R. Virag and H. Virag-Lappas. Paris: Les Editions du CERI, pp. 179-184, 1984. 4. Ebbeh~j, J. and Wagner, G.: Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology, 13: 507, 1979. 5. Bar-Moshe, 0. and Vandendris, M.: Treatment of impotence due to perinea! venous leakage by ligation of crura penis. J. Urol., 139: 1217, 1988. 6. Lewis, R. W., Puyau, F. A. and Bell, D. P.: Another surgical approach for vasculogenic impotence. J. Urol., 136: 1210, 1986. 7. Bennett, A.H., Rivard, D. J., Blanc, R. P. and Moran, M.: Reconstructive surgery for vasculogenic impotence. J. Urol., 136: 599, 1986. 8. Lewis, R. W.: Venous surgery for impotence. Urol. Clin. N. Amer., 15: 115, 1988. 9. Melman, A.: The evaluation of erectile dysfunction. Urol. Rad., 10: 119, 1988. 10. Wooten, J. S.: Ligation of the dorsal vein of the penis as a cure for atonic impotence. Texas Med. J., 18: 325, 1902. 11. Lydston, G. F.: The surgical treatment of impotency. Amer. J. Clin. Med., 15: 1571, 1908. 12. Wespes, E., Delcour, C., Struyven, J. and Schulman, C. C.: Pharmacocavernometry-cavernography in impotence. Brit. J. Urol., 58: 429, 1986. 13. Wespes, E., Delcour, C., Struyven, J. and Schulman, C. C.: Cavernosometry-cavernosography: its role in organic impotence. Eur. Urol., 10: 229, 1984. 14. Puyau, F. A., Lewis, R. W., Balkin, P., Kaack, M. B. and Hirsch, A.: Dynamic corpus cavernosography: effect ofpapaverine injection. Radiology, 164: 179, 1987. 15. Puyau, F. A. and Lewis, R. W.: Corpus cavernosography. Pressure flow and radiography. Invest. Rad., 18: 517, 1983. 16. Bookstein, J. J., Valji, K., Parsons, L. and Kessler, W.: Penile pharmacocavernosography and cavernosometry in the evaluation of impotence. J. Urol., 137: 772, 1987. 17. Puech-Leao, P., Reis, J. M., Glina, S. and Reichelt, A. C.: Leakage through the crural edge of corpus cavernosum. Diagnosis and treatment. Eur. Urol., 13: 163, 1987. 18. Lue, T. F.: Proceedings of the sixth biennial international symposium for corpus cavernosium revascularization. Third Biennial World Meeting on Impotence. Boston, Massachusetts, October 6-9, 1988. 19. Melman, A., Tiefer, L. and Pedersen, P.: Evaluation of first 406 patients in urology department based Center for Male Sexual Dysfunction. Urology, 32: 6, 1988. 20. Bookstein, J. J.: Cavernosal venocclusive insufficiency in male impotence: evaluation of degree and location. Radiology, 164: 175, 1987. 21. Tudoriu, T. and Bourmer, H.: The hemodynamics of erection at the level of the penis and its local deterioration. J. Urol., 129: 741, 1983. 22. Newman, H.F. and Northrup, J. D.: Mechanism of human penile erection: an overview. Urology, 17: 399, 1981. 23. Fournier, G. R., Jr., Juenemann, K.-P., Lue, T. F. and Tanagho, E. A.: Mechanism of venous occlusion during canine penile erection: an anatomic demonstration. J. Urol., 137: 163, 1987. 24. Krane, R. J., Goldstein, I. and Saenz De Tejada, I.: Impotence. New Engl. J. Med., 321: 1648, 1989. 25. Courtheoux, P., Maiza, D., Henriet, J.-P., Vaislic, C. D., Evrard, C. and Theron, J .: Erectile dysfunction caused by venous leakage: treatment with detachable balloons and coils. Radiology, 161: 807, 1986.
after expansion of the relaxed trabecular walls against the tunica albuginea. In patients with corporeal veno-occlusive dysfunction the perfusion pressure and arterial inflow to the penis may be adequate but the outflow through the subtunical venules is excessive, thereby preventing adequate penile rigidity. Corporeal veno-occlusive dysfunction may be secondary to insufficient trabecular smooth muscle relaxation, such as may occur either with excessive adrenergic constrictor tone or with damaged parasympathetic dilator nerves. Corporeal venoocclusive dysfunction also may be secondary to a proposed structural alteration in the fibroelastic components of the trabeculae. Such compliance disturbances of the penile fibroelastic frame may be the result of aging and vascular risk factors, such as hypercholesterolemia. In both cases disturbances with collagen, such as cross-linking between fibers of collagen induced by nonenzymatic glycosylation or altered synthesis of collagens, are hypothesized to be the underlying abnormality (reference 24 in article). Although more studies are needed, our own research and the finding of these authors suggest that vein ligation for most cases of corporeal veno-occlusive dysfunction secondary to aging or vascular risk factorassociated compliance disturbances does not address the suspected primary pathophysiologic condition. Corporeal veno-occlusive dysfunction also may occur in young patients secondary to perinea! trauma when the suspected abnormal erectile tissue compliance appears by cavernosometry and cavernosography to be restricted to the crus of the penis. Such patients have had objective long-term success with cavernous vein ligation and crural plication. It is likely that the success in these patients is due to the normal compliance of the erectile tissue distal to the crus. Irwin Goldstein Department of Urology Boston University School of Medicine Boston, Massachusetts Is penile vein ligation a rediscovery of the wheel or a refined approach to the most common identifiable penile abnormality (venous leakage) in impotent patients? What is venous leakage? This misnomer actually refers to a failure to store blood normally within the sinusoids of the corpora cavernosa and this leakage into the penile veins prevents the attainment of high intracorporeal pressures. Although scientifically inconclusive, there is increasing evidence that the most likely culprit of this abnormality may actually be a dysfunction of the corporeal smooth muscle rather than the veins themselves. This would explain the observation of the authors, that is that stopping up the leaks via occlusion of the leaky veins, if successful, is only temporary until other veins become leaky. It may be argued that the authors did not surgically occlude all of the veins (particularly the cavernous veins) but the initial improvement postoperatively would suggest otherwise. The initial clinical improvement also could be due to a placebo effect of the operation and not related to anything physiologically. If one were to accept the concept of dysfunctional smooth muscle as an etiology of venous leakage it seems reasonable to assume from this study (late failure of the operation) that to cure the problem of venous leakage the dysfunction of the smooth muscle must be corrected. To accomplish this correction we must first comprehend how this unique smooth muscle works. Compared to other smooth muscle in the body, such as gastrointestinal or vascular smooth muscle, little effort has been expended in trying to unravel the normal physiology of corporeal smooth muscle. A ray of hope comes from initial evidence that the innervation of this muscle is via nonadrenergic noncholinergic nerves, thereby raising the possibility that the dysfunction of the muscle may actually reside in these nerves rather than the corporeal smooth muscle itself. Once we unravel the normal physiology of this smooth muscle it is possibl
Jacob Rajfer Division of Urology Harbor/UCLA Medical Center Torrence, California
EDITORIAL COMMENTS The authors present their experience with surgery for corporeal veno-occlusive dysfunction, primarily cavernosographically directed penile vein ligation, and have found that in the long term the majority of patients persist in having corporeal veno-occlusive dysfunction. Erection results after penile smooth muscle relaxation. Reduction of venous outflow, the corporeal veno-occlusive mechanism, appears to be the result of the mechanical compression of the subtunical venules
REPLY BY AUTHORS Doctors Goldstein and Rajfer are correct in that the defect of corporeal venous malfunction is within the tunica albuginea. The abnormality may be structural and/or neuromuscular. The ligation procedures are a holding pattern-a finger on a hole in the dike-until a more precise treatment becomes available.
Vol.
THE JOURNAL OF UROLOGY
September
in U.S.A.
Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
PENILE VEIN LIGATION FOR CORPOREAL INCOMPETENCE: AN EVALUATION OF SHORT-TERM AND LONG-TERM RESULTS BARRY ROSSMAN, MARIA MIEZA AND ARNOLD MELMAN From the Department of Urology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx and Department of Radiology, Beth Israel Hospital, New York, New York
ABSTRACT
Dynamic cavernosometry and cavernosography can be used to identify patients with corporeal venous incompetence as a cause of erectile dysfunction. We reviewed our series of 16 patients with venous leakage who underwent surgical correction of the specific abnormality identified on cavernosography. Short-term and long-term results were obtained, and while at least temporary improvement was noted in 89.5% of the patients the long-term results tended to show a reversion to the preoperative status in the majority. (J. Ural., 144: 679-682, 1990) While dramatic advances in the evaluation and treatment of male erectile dysfunction have been made during the last several years, many unanswered questions remain. Penile venous incompetence as an etiological factor in impotence has recently become an area of increased intense investigation. However, despite the ability of many investigators to identify the presence and even location of apparent venous leakage from the corpora cavernosa, surgical repair has not achieved uniformly successful results. While some investigators do report improvement with venous ligation in as many as 80% of the patients, 1 · 2 others achieve success in only as few as 20% 3 and most represent limited followup. 1- 9 It should be noted that the concept of venous insufficiency as a cause of erectile dysfunction actually dates back to the turn of the twentieth century. Wooten in 1902 10 and Lydston in 190811 first suggested that ligation of the dorsal veins of the penis might be effective treatment for certain types of impotence. However, only with the advent of dynamic cavernosometry and cavernosography has our ability to diagnose accurately and treat these patients genuinely developed. By monitoring intracavernous pressure during the dynamic induction of an erection with pharmacological agents and rapid fluid flow, the presence of a venous leak can be diagnosed. The addition of dynamic cavernosography then enables the investigator to pinpoint the actual site of venous leakage. These can be manifested as shunts from the corpora cavernosa to the corporus spongiosum or glans, or alternatively as leakage directly into the dorsal, crural or pudenda! veins. Accordingly, several different surgical techniques have been advocated, each reporting varying degrees of success. i-s In an effort to investigate this issue further we reviewed the short-term and long-term outcome of our patients with corporeal incompetence who underwent penile vein ligation. The study was done in an attempt to identify any trends or factors that might allow us to predict better which patients would and would not fare well with an operation. MATERIALS AND METHODS
All patients referred for the evaluation of erectile dysfunction underwent a comprehensive evaluation. Initially, based on the findings of a careful history and physical examination, patients were selected who were suspected of having corporeal incompetence. Cavernous venous leakage was particularly suspected when the patient described lack of rigidity with a soft, transient erection that was inadequate for penetration. 8 Typically, the impotence was of gradual onset and there was generally an absence of other risk factors (for example diabetes, peripheral vascular disease, antihypertensive medications and so forth). More objective evidence then was sought to eliminate other Accepted for publication February 14, 1990. 679
etiologies. Rigiscan monitored nocturnal penile tumescence and visual sexual stimulation9 were obtained to evaluate for any psychogenic component. Doppler penile blood pressures and plethysmography, and/or a trial of intracavernous vasoactive drugs was used to study the adequacy of arterial inflow. Patients with venous insufficiency typically achieve only partial or short-lived erections with nocturnal penile tumescence or visual sexual stimulation, and generally demonstrate a poor response to intracavernous injection of pharmacological agents, specifically papaverine (30 mg.) with or without phentolamine (1 mg.). No response, only partial tumescence and a full but transient erection often associated with signs of systemic absorption, such as dizziness and facial flushing, are all suggestive of venous incompetence. Penile blood pressure measurements with calculation of the penile brachia! index (penile blood pressure/brachia! blood pressure) would be expected to be within the normal range in patients with isolated venous incompetence. Patients then suspected of having venous incompetence underwent dynamic cavernosometry. If the study suggested a venous leak they then underwent cavernosography performed by a variation of the technique used by several investigators, such as Wespes and associates, 12 • 13 Puyau and Lewis, 14• 15 and Bookstein and associates. 16 After appropriate skin preparation with an alcohol swab, 23 and 19 gauge butterfly needles were each placed into a corpus cavernosum. While simultaneously measuring intracavernous pressure with a Gould pressure transducer via the 23 gauge needle, warmed isotonic saline or lactated Ringer's solution was infused with a Sarns infusion pump into the penis via the 19 gauge needle. The fluid was instilled at 50 cc per minute initially and increased up to 200 50 cc per minute increments or until an cc per minute erection developed. Then, with the base of the penis transiently pinched between 2 fingers, papaverine hydrochloride (30 to 60 mg.) was injected via the existing 19 gauge needle directly into the corpora cavernosa. After waiting approximately 5 to 7 minutes for penile tumescence to develop, the infusion was repeated via the Sarns pump in the same manner and pressure measurements were recorded. Patients who never had a rigid erection with this technique (that is no erection with flow rates greater than 200 ml. per minute after injection of papaverine) were considered probably to have a venous leak. In addition, patients who required either more than 150 ml. per minute of fluid inflow to initiate or more than 50 ml. per minute to maintain an erection also were suspected of having venous incompetence. Patients who met these criteria for corporeal incompetence by dynamic cavernosometry then underwent dynamic caver-
680
ROSSMAN, MIEZA AND MELMAN
nosography. While a pre-papaverine and post-papaverine study was routinely performed early in our series, later only the postpapaverine study was obtained. The pre-papaverine study was performed by placing a 23 gauge butterfly needle without use of local anesthesia directly into the corpora cavernosa. Dilute iothalamate meglumine 43 % contrast material then was infused via a Harvard pump at a set rate of 0.39 ml. per second (23.6 ml. per minute) under fluoroscopic visualization. A full rigid erection did not typically develop, and spot radiographs were obtained during early filling and at the 30-second interval (anteroposterior and oblique). The infusion was stopped after an average of 40 ml. contrast medium were given, and at this time 30 to 60 mg. papaverine were injected intracavernously and the study was repeated giving contrast medium via the Harvard pump again at a rate of 0.39 ml. per second. Spot films were similarly taken at early filling and at 30 seconds (anteroposterior and oblique). A delayed radiograph was taken at 10 minutes and all x-rays were critically and independently evaluated by a uroradiologist (M. M.). An operation was recommended to patients who met the criteria for corporeal incompetence (that is positive cavernosometry and cavernosography, and abnormal nocturnal penile tumescence). A total of 16 patients subsequently underwent penile vein ligation. The surgical technique used was directed at the site of leakage in each individual. We used either a perineal incision, an upside-down J infrapubic incision, a circumcising incision or a combination thereof to identify, isolate and ligate best the known areas of venous incompetence. Any large emissary or circumflex veins were initially identified under Buck's fascia as they coursed from the tunica albuginea to the superficial venous drainage system. These veins were traced and ligated as they exited the tunica with 3-zero chromic suture material. If shunts between the corpora cavernosa and corpus spongiosum or glans were seen on preoperative cavernosography, then these were divided by a modified version of the surgical technique described by Ebbeh~j and Wagner. 4 The deep and superficial dorsal veins then were isolated, ligated and divided as indicated by cavernosography. The deep dorsal vein was ligated as proximally as possible in the infrapubic area near the dorsum of the crus (the crural veins as suggested by Pusch-Leao and associates, 17 and Lue 18). Finally, if crural venous incompetence was identified preoperatively, then the crura were carefully exposed via either an extended infrapubic incision into the scrotal area or by a separate perineal incision. Crural vein ligation and division were performed by tying off all large exiting veins. Crural plication additionally was performed when indicated. RESULTS
A total of 16 patients with venous incompetence as the etiology of erectile dysfunction according to the aforementioned methods subsequently underwent an operation. Patient age ranged from 21 to 62 years, with a mean age of 46 years. The duration of impotence ranged from 4 months to 20 years. Four men (21, 22, 24 and 31 years old) stated that they never had experienced a normal erection. All patients underwent a detailed history and physical examination, and further evaluation was directed as indicated. Of the patients 12 underwent nocturnal penile tumescence testing and 7 underwent visual sexual stimulation testing to rule out more objectively a psychological etiology to the impotence. 19 There was no history of penile trauma or physical evidence of penile fibrosis in any patient in this group. All patients, who subsequently had corporeal incompetence, demonstrated either soft or no erections during these studies, except for 2 who had rigid but short-lived erections (less than 5 minutes in duration). Penile blood pressures were measured by Doppler ultrasound with calculation of penile brachial index in 14 of the 16 patients to confirm the absence of significant arterial inflow insufficiency. The majority of these patients had penile brachial indexes of more than 0.90, with only 2 having values of less than 0.90 (1 had a penile brachial index of 0.81 to 0.82, while 1
had an index of 0.79 to 0.78). Four patients were tested with a trial of 30 to 60 mg. papaverine without effect. Cavernosometry evaluation was then used primarily to screen patients for an operation who were suspected of having venous leakage by the aforementioned preliminary evaluation. Patients who fulfilled the previously mentioned cavernosometric criteria for leakage then underwent dynamic cavernosography. All patients thus studied by cavernosography had radiographically identifiable venous leaks and were encouraged to undergo venous ligation. A total of 16 patients agreed and they underwent 19 procedures (3 underwent 2 operations each after a failed initial procedure). Multiple different sites of leakage were noted, including cavernous-spongiosal or glandular shunts, drainage via the perforating and circumferential veins to the deep and superficial dorsal veins, and drainage via the crural veins to the pudendal plexus. The surgical plan was to ligate the veins in the area of drainage visualized on cavernosography. The operation was performed between June 1985 and March 1988. While 3 procedures (16%) were done via a perineal approach alone, in 2 patients (11%) a combined perineal and circumcising incision was used, while 1 (5%) underwent a combined perineal and infrapubic approach. Five patients (26%) underwent an isolated circumcision approach to the venous leaks and 8 (42%) underwent an independent infrapubic approach (fig. 1). Postoperatively, no significant complications were encoun-
circ & perinea! 11% 2 perinea! 16% 3
infrapub. & perinea! 5% 1
infrapubic 42% 8
FIG. 1. Approach used for penile vein ligation
16 PATIENTS
Initial Improvement
No
Improvement
2 PATIENTS [ 2 Procedures] ( 10.5%)
14 PATIENTS [ 17 Procedures] (89.5%)
Fm. 2. Penile vein ligation 14 PATIENTS
2 PATIENTS
2 PATIENTS
7 PATIENTS
2...E.I§.__
Maintained Improvement (spon. potent)
Deteriorated but still resp to PAP.
No signif. functional change
Penile Prosth
Fm. 3. Operative results after initial improvement
1 PT Worse
PENILE VEIN LIGATION FOR CORPOREAL INCOMPETENCE
681
FIG. 4. A, preoperative cavernosogram shows significant leakage of contrast medium into crural veins after injection of 30 mg. intracavernous papaverine in patient with erectile dysfunction. B, postoperative cavernosogram of same patient. Contrast material is seen flowing into deep dorsal system. Crural veins have been ligated with hemoclips.
tered, including no reports of wound infections, significant penile edema, penile anesthesia, penile shortening or significant hematoma. There also were no cases of priapism. Followup included an initial postoperative office visit and monthly to bimonthly visits thereafter. All but 2 patients reported at least transient improvement after each operation (fig. 2). The duration of improvement typically lasted from l to 4 months with a large percentage (70%) of the patients recalling only approximately 4 to 8 weeks of improvement. As far as the aspect of the erection that was improved, 80% of the patients reported increased firmness and 65 % reported duration of erection. Several patients reported the remarkable ease with which spontaneous erections developed with simple fantasizing or minimal stimulation. Unfortunately, the initial good results tended to be temporary. Of the 14 patients who reported initial improvement 2 remain spontaneously potent with the consistent ability to achieve an erection satisfactory for intercourse (fig. 3). These 2 patients currently are 9 and 15 months after ligation. While 2 patients are responsive to papaverine, which was not the case preoperatively, the majority of the patients reported return to their previous functional level within 1 month to 4 years. Nine patients report no great value of an operation, placement of a penile including 2 who subsequently prosthesis. Only 1 patient reports that he is worse postoperatively. He has resigned himself to the situation and refuses further evaluation or treatment. Finally, 5 of the patients who underwent an operation for venous incompetence and who did well transiently later deteriorated and underwent repeat dynamic cavernosography. Of note, while the sites of previous leakage seen on the preoperative cavernosograms were generally well ligated on the repeat studies, several of the patients subsequently had new radiographic sites of leakage (fig. 4). Of these 5 patients 3 elected to undergo repeat directed penile vein ligation, with each patient again describing only transient improvement that waned with time. DISCUSSION
While it recently has been suggested and reported by several investigators that malfunction of the veno-occlusive mechanism of the corpora cavernosa probably is the most common cause of vasculogenic impotence, 20 · 21 this process remains an enigma. The most current hypothesis of the erectile mechanism is that relaxation of the corporeal smooth muscle combined
with increased blood to the corporeal sinusoids allows the trabeculae to close the venous drainage of the subtunical venous plexus, that is a flap valve mechanism with resultant penile rigidity. Presumably, patients with corporeal incompetence have an as yet to be defined defect of this mechanism. With our increased understanding of the physiology and mechanism of erection 21 - 24 we have developed a multifaceted approach to the impotent patient 9 • 19 and this has led us to be better able to diagnose more accurately arterial and venous disorders that may be responsible for erectile failure. The penile brachia! index as a measure of arterial disease was begun in this study 5 years ago. To date either penile plethysmography or pulsed Doppler ultrasound would be used to analyze penile arterial competence. Nonetheless, our surgical correction of a seemingly obvious abnormality has not led to long-standing good results, and this finding suggests that the pathophysiological process leading to corporeal venous incompetence is more intricate than our current understanding. Our initial goal, to identify risk factors that were predictive of surgical outcome, was not realized. There was no correlation with the visible site of the leak, age of the patient, duration of disease, rate of initial or maintenance infusion, and successful outcome because nearly all of the patients eventually failedo While it certainly is possible that the poor results with venous ligation in our review might represent either an improper diagnosis, correction of only 1 aspect of a multifaceted problem (for example, arterial insufficiency not ruled out by Doppler blood pressure) or inadequate surgical technique, we believe that the high failure rate represents an inherent problem in these patients. There appears to be something intrinsically and fundamentally wrong with the active veno-occlusive mechanism in these patients, which does not allow them to trap the blood effectively in the corpora. At reoperation of patients who had failed an initial procedure there was a marked increase in the number of veins draining from the corpora, that is multiple new drainage channels formed. Perhaps atrophy or fibrosis of the underlying corporovenous occlusive mechanism is the pathological factor within the tunica. Until this defect is identified further and understood, it seems that this operation is unlikely to give good long-standing success. The only suggested alternative to vein ligation for this disease is with detachable balloons or coils. In a report of 31 treated patients 26 had resumed normal sexual life. 25 Followup in 14 patients was less then 6 months. That series will have to be substantiated by other groups using similar techniques. However, whether a vein is
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surgically ligated or occluded the obstruction created still is external to the tunica, outside the probable site of disease, and unlikely to result in long-term success. REFERENCES
1. Wespes, E. and Schulman, C. C.: Venous leakage: surgical treatment of a curable cause of impotence. J. Urol., 133: 796, 1985. 2. Gilbert, P. and Steif, C.: Spongiolysis: a new surgical treatment of impotence caused by distal venous leakage. J. Urol., 138: 784, 1987. 3. Buvat, J., Lemaire, A. and Dehaene, J. L.: Critical study of the organic basis of the "venous leakages" detected by the artificial erection test. In: Proceedings of the First World Meeting on Impotence. Edited by R. Virag and H. Virag-Lappas. Paris: Les Editions du CERI, pp. 179-184, 1984. 4. Ebbeh~j, J. and Wagner, G.: Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology, 13: 507, 1979. 5. Bar-Moshe, 0. and Vandendris, M.: Treatment of impotence due to perinea! venous leakage by ligation of crura penis. J. Urol., 139: 1217, 1988. 6. Lewis, R. W., Puyau, F. A. and Bell, D. P.: Another surgical approach for vasculogenic impotence. J. Urol., 136: 1210, 1986. 7. Bennett, A.H., Rivard, D. J., Blanc, R. P. and Moran, M.: Reconstructive surgery for vasculogenic impotence. J. Urol., 136: 599, 1986. 8. Lewis, R. W.: Venous surgery for impotence. Urol. Clin. N. Amer., 15: 115, 1988. 9. Melman, A.: The evaluation of erectile dysfunction. Urol. Rad., 10: 119, 1988. 10. Wooten, J. S.: Ligation of the dorsal vein of the penis as a cure for atonic impotence. Texas Med. J., 18: 325, 1902. 11. Lydston, G. F.: The surgical treatment of impotency. Amer. J. Clin. Med., 15: 1571, 1908. 12. Wespes, E., Delcour, C., Struyven, J. and Schulman, C. C.: Pharmacocavernometry-cavernography in impotence. Brit. J. Urol., 58: 429, 1986. 13. Wespes, E., Delcour, C., Struyven, J. and Schulman, C. C.: Cavernosometry-cavernosography: its role in organic impotence. Eur. Urol., 10: 229, 1984. 14. Puyau, F. A., Lewis, R. W., Balkin, P., Kaack, M. B. and Hirsch, A.: Dynamic corpus cavernosography: effect ofpapaverine injection. Radiology, 164: 179, 1987. 15. Puyau, F. A. and Lewis, R. W.: Corpus cavernosography. Pressure flow and radiography. Invest. Rad., 18: 517, 1983. 16. Bookstein, J. J., Valji, K., Parsons, L. and Kessler, W.: Penile pharmacocavernosography and cavernosometry in the evaluation of impotence. J. Urol., 137: 772, 1987. 17. Puech-Leao, P., Reis, J. M., Glina, S. and Reichelt, A. C.: Leakage through the crural edge of corpus cavernosum. Diagnosis and treatment. Eur. Urol., 13: 163, 1987. 18. Lue, T. F.: Proceedings of the sixth biennial international symposium for corpus cavernosium revascularization. Third Biennial World Meeting on Impotence. Boston, Massachusetts, October 6-9, 1988. 19. Melman, A., Tiefer, L. and Pedersen, P.: Evaluation of first 406 patients in urology department based Center for Male Sexual Dysfunction. Urology, 32: 6, 1988. 20. Bookstein, J. J.: Cavernosal venocclusive insufficiency in male impotence: evaluation of degree and location. Radiology, 164: 175, 1987. 21. Tudoriu, T. and Bourmer, H.: The hemodynamics of erection at the level of the penis and its local deterioration. J. Urol., 129: 741, 1983. 22. Newman, H.F. and Northrup, J. D.: Mechanism of human penile erection: an overview. Urology, 17: 399, 1981. 23. Fournier, G. R., Jr., Juenemann, K.-P., Lue, T. F. and Tanagho, E. A.: Mechanism of venous occlusion during canine penile erection: an anatomic demonstration. J. Urol., 137: 163, 1987. 24. Krane, R. J., Goldstein, I. and Saenz De Tejada, I.: Impotence. New Engl. J. Med., 321: 1648, 1989. 25. Courtheoux, P., Maiza, D., Henriet, J.-P., Vaislic, C. D., Evrard, C. and Theron, J .: Erectile dysfunction caused by venous leakage: treatment with detachable balloons and coils. Radiology, 161: 807, 1986.
after expansion of the relaxed trabecular walls against the tunica albuginea. In patients with corporeal veno-occlusive dysfunction the perfusion pressure and arterial inflow to the penis may be adequate but the outflow through the subtunical venules is excessive, thereby preventing adequate penile rigidity. Corporeal veno-occlusive dysfunction may be secondary to insufficient trabecular smooth muscle relaxation, such as may occur either with excessive adrenergic constrictor tone or with damaged parasympathetic dilator nerves. Corporeal venoocclusive dysfunction also may be secondary to a proposed structural alteration in the fibroelastic components of the trabeculae. Such compliance disturbances of the penile fibroelastic frame may be the result of aging and vascular risk factors, such as hypercholesterolemia. In both cases disturbances with collagen, such as cross-linking between fibers of collagen induced by nonenzymatic glycosylation or altered synthesis of collagens, are hypothesized to be the underlying abnormality (reference 24 in article). Although more studies are needed, our own research and the finding of these authors suggest that vein ligation for most cases of corporeal veno-occlusive dysfunction secondary to aging or vascular risk factorassociated compliance disturbances does not address the suspected primary pathophysiologic condition. Corporeal veno-occlusive dysfunction also may occur in young patients secondary to perinea! trauma when the suspected abnormal erectile tissue compliance appears by cavernosometry and cavernosography to be restricted to the crus of the penis. Such patients have had objective long-term success with cavernous vein ligation and crural plication. It is likely that the success in these patients is due to the normal compliance of the erectile tissue distal to the crus. Irwin Goldstein Department of Urology Boston University School of Medicine Boston, Massachusetts Is penile vein ligation a rediscovery of the wheel or a refined approach to the most common identifiable penile abnormality (venous leakage) in impotent patients? What is venous leakage? This misnomer actually refers to a failure to store blood normally within the sinusoids of the corpora cavernosa and this leakage into the penile veins prevents the attainment of high intracorporeal pressures. Although scientifically inconclusive, there is increasing evidence that the most likely culprit of this abnormality may actually be a dysfunction of the corporeal smooth muscle rather than the veins themselves. This would explain the observation of the authors, that is that stopping up the leaks via occlusion of the leaky veins, if successful, is only temporary until other veins become leaky. It may be argued that the authors did not surgically occlude all of the veins (particularly the cavernous veins) but the initial improvement postoperatively would suggest otherwise. The initial clinical improvement also could be due to a placebo effect of the operation and not related to anything physiologically. If one were to accept the concept of dysfunctional smooth muscle as an etiology of venous leakage it seems reasonable to assume from this study (late failure of the operation) that to cure the problem of venous leakage the dysfunction of the smooth muscle must be corrected. To accomplish this correction we must first comprehend how this unique smooth muscle works. Compared to other smooth muscle in the body, such as gastrointestinal or vascular smooth muscle, little effort has been expended in trying to unravel the normal physiology of corporeal smooth muscle. A ray of hope comes from initial evidence that the innervation of this muscle is via nonadrenergic noncholinergic nerves, thereby raising the possibility that the dysfunction of the muscle may actually reside in these nerves rather than the corporeal smooth muscle itself. Once we unravel the normal physiology of this smooth muscle it is possibl
Jacob Rajfer Division of Urology Harbor/UCLA Medical Center Torrence, California
EDITORIAL COMMENTS The authors present their experience with surgery for corporeal veno-occlusive dysfunction, primarily cavernosographically directed penile vein ligation, and have found that in the long term the majority of patients persist in having corporeal veno-occlusive dysfunction. Erection results after penile smooth muscle relaxation. Reduction of venous outflow, the corporeal veno-occlusive mechanism, appears to be the result of the mechanical compression of the subtunical venules
REPLY BY AUTHORS Doctors Goldstein and Rajfer are correct in that the defect of corporeal venous malfunction is within the tunica albuginea. The abnormality may be structural and/or neuromuscular. The ligation procedures are a holding pattern-a finger on a hole in the dike-until a more precise treatment becomes available.