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Experience in diagnosis and treatment of impotence caused by cavernosal leak syndrome
Experience in diagnosis and treatment of impotence caused by cavernosal leak syndrome R a l p h G. DePalma, MD, Frederick Schwab, M D , E d w a r d M. Druy, MD, Harry C. Miller, MD, Helene A. Emsellem, MD, Cherie M. Edwards, BS, and D e a n e Bergsrud, P A - C ,
Washington, D.C~
TO delineate neural, arterial, and venous components contributing to impotence, we used a previously described noninvasive screening sequence combined with stimulation o f artificial erection with papaverine injection, selective pudendal arteriography (SPA), and dynamic cavernosography (DC). Among 572 men with impotence, age range 17 to 78 years (average age 54.8 years), 26 men with potential cavernosal leaks in absence of other factors were identified; 16 underwent DC; among these five had normal cavernosal venous drainage. Eight men with abnormal cavernosal venous drainage required cavernous infusion flow rates higher than 120 ml/min to obtain erection and higher than 40 ml/min to maintain erection. Radiographic studies showed cavernosal leakage in all eight patients. Eight men, ages 39 to 61 years, underwent surgical ablation o f abnormal cavernosal venous drainage. Among these, five men have had excellent results for up to 3 years. One failure was related to unrecognized penile arterial disease later shown by SPA. In two men small doses o f papaverine now induce erection. We now recommend SPA before DC to nile out an arterial abnormality. Accurate identification o f factors contributing to erectile failure is critical for successful treatment; in this experience candidates for correction o f cavernosal leak syndrome were uncommon. (J VASe SURG 1989;9:117-21.)
Delineation of neural, arterial, and venous components contributing to penile erectile failure is critical for proper patient selection for surgical intervention. This report describes experience with venous leakage in men who were initially seen for diagnosis and possible treatment ofvasculogenic impotence. METHODS Screening sequence
The screening sequence, described in a previous article, I was used in 572 men to delineate neural, arterial, and venous components possibly contributing to penile erectile failure. The sequence included noninvasive estimates of penile perfusion, pulse volume recording (PVR), and measurements of penile brachial pressure indices (PBPI),2 somatosensory evoked potentials from the dorsal penile nerve and posterior tibia] nerve stimulation, and bulbocaverFrom the Departments of Surgery, Neurology, Radiology,and Urology, GeorgeWashington UniversityMedicalCenter. Presented at the SecondAnnual Meeting of the Eastern Vascular Society, Washington, D.C., May 21-22, 1988. Reprint requests: Ralph G. DePalma, MD, Department of Surgery, George Washington University Medical Center, 2150 PennsylvaniaAve., N.W., Washington, DC 20037.
nosus reflex timeJ Intracorporal papaverine injection, selective pudendal arteriography, and dynamic cavernosography (DC) were finally used to stimulate artificial erection and thereby select surgical candidates. The screening sequence included intracorporal papaverine injection, 4 which was used in all cases to determine candidacy for angiographic study. Candidates for DC were selected by the following criteria: (1) normal ncurologic studies; (2) absence of hormonal or arterial risk factors such as low testosterone, elevated prolactin, uremia, diabetes, or hypertension, which would predispose to cavernosal dysfunction; (3) normal pulse volume recordings and PBPI; (4) normal results of neural screening; (5) failure to obtain or maintain erection after intracorporal injection of papaverine in doses up to 60 mg; and (6) a willingness to undergo DC and cavernosometry and possible surgery for cavernosal leak syndrome. C a v e r n o s o m e t r y and c a v e m o s o g r a p h y
Venous leakage was documented by inducing passive erections by means of controlled perfusion of the corpora cavernosa, with continuous pressure monitoring modified from that procedure described 117
Journal of VASCULAR SURGERY
118 DePalma et al.
m/~50-4
80mmHg full erection (passive)
,--=/
i
•
withpapaverineoftensystolic
~
}~f-~Warmheparinized saline
Rollerpump calibrated40ml/min Fig. 1. Technique of dynamic cavernosography. Pump calibrated to deliver 40 ml/min increments through a 19-gauge needle. Pressure monitoring with usual pressure range shown; with papaverine injections pressure may be systolic or greater. by Wespes and Schulman. s A diagram of the method used is shown in Fig. 1. Cavernosometry was accomplished by perfusing the corpora cavernosa with warm heparinized saline solution under standard flow rates varying from 40 to 250 ml/min. Pressure within the cavernous bodies was monitored continually as passive erection occurred. At full erection or maximum tumescence the flow rate delivered by the roller pump was reduced to measure a flow rate needed to maintain erection. In patients in whom erection could not be produced by high flow rates, 30 mg ofpapaverine was given intracorporally. Flow rates then producing and maintaining erection were measured. At a flow rate sufficient to Obtain or maintain erection or maximum tumescence, a hand injection of nonionic radiopaque contrast medium was made. Serial radiographs were exposed under fluoroscopic guidance to show the sites of venous leakage from the cavernous bodies. Before standardization of the roller pump method, cavernosometric measurements were obtained manually and films exposed in a similar manner in two patients. In three patients pudendal arteriography was also performed to assure that arterial anatomy was normal before venous ablation. RESULTS Screening sequence During the interval from September 1983 to Febmary 1988, a total of 572 men ranging in age from 17 to 78 years were referred for screening for impotence. The mean age of these men was 54.8 years at the time of the complaint. By use of the previously
described values for PBPI and PVR, 2 normal penile arterial perfusion was discovered in 317 men and abnormal arterial penile perfusion was discovered in 255 men. Patients who were candidates for possible venous intervention were selected from the former group of 317 men who had normal arterial penile perfusion revealed noninvasively. Their number was further reduced to 200 by excluding patients with neurologie abnormalities that possibly contributed to erectile failure, and reduced further to 102 by excluding those with hormonal disorders, uremia, diabetes, or hypertension that required treatrncnt with antihypertensive drugs. Most of these men had the latter two problems; only four men in the series had low testosterone values. Twenty-six patients were further identified by~ failure to respond to papaverine injection, leaving 26 potential candidates for DC after screening. The number of patients finally accepting DC was 16. Table I summarizes the sharp reduction in number of men considered to exhibit cavernosal leak as a result of these selection criteria.
Results o f cavernosometry and cavernosography Thirteen men underwent successful DC by means of the roller pump method described, in two men a manual method was used~ and in one the corpora could not be infused because of fibrosis. Table II shows flow rates delivered by cavernosometry roller pump that were needed to obtain and maintain passive erection among 13 men. In the one patient in whom it was not possible to obtain unimpeded saline flow into the corpus cavernosum, there was a h i s t o ~
Volume 10 Number 2 August 1989
Treatment of impotence caused by cavernosal leak syndrome
Table II. Results of cavernosometry show
Table I. Sequence results for cavernosal leak syndrome Screening sequence Screened for impotence Normal arterial perfusion Normal neurostatus Negative diabetes or high blood pressure therapy Papaverine failure Dynamic cavernosography Operations cavernosal leak syndrome
119
No. screened 572 317 200 102 26 16 8
of prolonged priapism after cavernosography performed elsewhere. This caused fibrosis of both cavernous bodies. Normal dynamic and radiographic studies showing venous closure were obtained in five patients at flow rates ranging from 80 to 140 ml/min to obtain erection and 40 to 80 ml/min to maintain full erection. In eight patients with clearly abnormal cavemosal venous drainage, flow rates generally in excess of 140 ml/min were required to obtain erection, and flow rates of 80 to 160 ml/min were required to maintain erection even after 30 mg of papaverine was injected intracorporally. These data are summarized in Table II. Pressure monitoring revealed resting pressures of approximately 12 to 15 mm Hg in the corpus cavernosum, which increased to 80 to 100 mm Hg during full passive erection. With full erectile rigidity, intracavernous pressures ranging from 80 mm H g to 160 mm H g were measured after papaverine injection. At the time of maximum erection, discomfort was noted by some patients; it was found to be dinically important to visually monitor the status of penile tumescence during cavemosometry so that flow _ates could be adjusted properly to minimize discomfort and possible extravasation. Unequivocal venous leakage was shown in eight patients. Among these, leakage was detected along the dorsal veins in seven patients, and leaks into the prostatic plexus were found in four patients. The ultimate sites of venous leakage included both the right and left internal pudendal veins and the obturator and internal iliac veins. Whereas abnormal leakage occurred mainly into internal iliac veins, occasionally there was drainage into the common femoral veins.
Results of operation Among the eight men with abnormal study resuits shown in Table II, six were selected for operation. Two men in whom manual cavernosometry ~nd cavernosography was abnormal were also se-
observed flow rates in ml/min sufficient to obtain/maintain erection Normal range
Abnormal range
140/80 80/40 80/40 (P)
>250; 150/--(P) * >250; 140/80 (P) 200/160 200/120 >250; 160/80 (P) 160/80 140/80 >250
80/4o (P) 80/40 (P)
*P, 30 mg papaverine injection intracorporally.
lected. Therefore eight men of the original 572 with impotence became surgical candidates for venous ablation. These men ranged in age from 32 to 63 years with an average age of 51.3 years. The technique used was resection of the dorsal vein from the base of the penis to the glans and resection of all accessible circumflex veins. There were no complications or morbidity; seven of the eight procedures were done as same-day surgery. Patients have been reassesscd at intervals from 2 to 44 months. At each visit erectile function and intromission were reported. When dysfunction was reported, erection was tested by intracorporal papaverine injection; a threshold dosage at which erection could be produced in the clinic was noted, and this was then compared with preoperative papaverine injection. Five operations were immediately successful in restoring normal erectile function; four of these men have now maintained erectile capabilities for periods of 20 to 44 months. One among this initially successful group experienced hypertension and was treated with antihypertensive agents 18 months postoperatively. This caused recurrence of impotence, which was relieved when the drugs were discontinued. Control of hypertension by diet and weight reduction was undertaken. Two men reported that they were incapable of intromission; both were able to achieve erections in the clinic after intracorporal injection of small doses of papaverine of 7 to 15 mg. These men are still under observation but have had no further improvement. One patient achieved a dramatic increase in erectile function for 2 weeks and then experienced a recurrence of absolute erectile failure. This subject also failed to have erections with papaverine injections postoperatively in dosages up to 80 mg. Repeat review of his noninvasive findings and clinical history indicated that this $9-year-old subject showed com-
120 DePalma et al.
Fig. 2. A, Cavcrnosogram shows large venous leak of contrast meditun from corpora cavernosa into internal iliac vein (upper arrow) via obturator vein (lower arrowhead). B, Later phase shows continued washout of contrast medium from left side of corpus into pelvicveins. This leakage was corrected surgically.Patient has normal erectilefunction at 14 months.
plete absence of arterial and hormonal risk factors. Apart from slight flattening of penile PVR, no other ilbnormality was noted. However, selective pudendal arteriography was recommended. This single absolute failure related to an unrecognized penile arterial hypoplasia documented by arteriographic results. Ultimately this man was treated successfullywith a prosthesis. None of the remaining men have required prostheses or requested this procedure. In current case selection, to resolve questions about arterial abnormalities, we now recommend selective pudendal arteriography before DC. Venous abnormalities do occur in combination with arterial insufficiency; such patients can be considered candidates for deep dorsal vein arterialization. DISCUSSION Since initial description of impotence caused by abnormal venous drainage from corpus cavernosum,6 there has been increasing interest in documenting venous leakage. 7This type ofvasculogenic impotence is now called cavernosal leak syndrome. Ideally, objective measurements with quantifiable methods allow the most refined case selection. In the current series
Journal of VASCULAR SURGERY
the technique of DC originally described by Wespes and Schulman5 was modified and used in patients selected by our screening sequence. ~ Rates of flow in excess of 140 ml/min rather than 120 ml/min to obtain erection and higher than 80 ml/min to maintain erection were found to be abnormal. This is slightly higher than the 120 ml/min flow rate to obtain erection originally reported, s Fig. 2 shows radiographic evidence of a massive venous leak at high flow rate that was corrected surgically by techniques similar to those recently described by others .8,9 Two instances in which the leakage occurred primarily into the prostatic plexus at the base of the penis were identified. These men were not selected for operation. In such cases a secondary procedure has been reported, s'l° which involves combining resection of the deep dorsal vein with ligation of the crural edges of the perineal portion of the corpora'-' cavernosa. Relapses after dorsal vein resection might result from secondary leak through the cavernous veins. Therefore systematic combination of crural ligation and dorsal vein resection might make the success of venous ablation procedures more effective. However, few patients so treated have been described in the literature. We have neither used this operation nor recommended surgery when leakage through the prostatic plexus was found to be the major anatomic abnormality. The present experience shows that correction of radiographically proven penile deep dorsal vein leakage into the obturator, pudendal, and internal iliac veins is promising when this is the sole source of leakage. When selecting this option, it is important to be certain that arterial inflow is normal, since excision of the dorsal vein removes the possibility o f arterial revascularization, which might correct bot:,3 venous leakage and arterial insufficiency. The most notable finding in this experience was the sharp funneling effect of the screening sequence. Ultimately, only 16 patients received DC after 572 men were screened. It is possible that the criteria imposed by the screening sequence were too strict; however, a conservative approach has been deliberately adopted until factors contributing specifically to the function of the venous system in human erection can be better elucidated. Recent research~ suggests that cavernosal filling during erection compresses subalbugineous venules, substantially reducing venous outflow during normal erection. Circumflex veins contain structurally redundant complex valves, and whereas these venous valves function to prevent reflux of blood in the usual fashion, they may also prevent efflux of blood w h e ~
Volume l0 Number 2 August 1989
Treatment of impotence caused by cavernosalleak syndrome 121
the veins contract or are compressed during erection. With clearly documented abnormalities of this mechanism, dorsal vein resection and resection of the circumflex veins appear to be anatomically and physiologically sound. The durability of operations for cavernosal leak syndrome will require further longterm observation. REFERENCES 1. DePalrna RG, Emsellem HA, Edwards CM, et al. A screening sequence for vasculogenic impotence. J VASCSURG 1987; 5:228-36. 2. Stauffer D, DePalma RG. A comparison of penile-brachial index (PBI) and penile pulse volume recordings (PVR) for diagnosis of vasculogenic impotence. Bruit 1983;7:29-32. 3. Haldeman S, Bradley WE, Bhatia NN, Johnson BK. Pudendal evoked responses. Arch Neurol 1982;39:280-3. 4. Virag R, Virag H. L'epreuve a la papaverine intracaverneuse dans Petude de l'impuissance. J Mid Vasc 1983;8:293-5.
5. Wespes E, Schulman CC. Venous leakage: surgical treatment of a curable cause of impotence. J Urol 1985;133:796-8. 6. Ebbehoj J, Wagner G. Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology 1979; 13:507-10. 7. Virag R. Syndrome d'erection instable par insuffisance veineuse. J Mal Vasc 1981;6:121-4. 8. Wespes E, Schulman CC. Caverno-venous leakage: retrograde opacification and resection of the deep dorsal vein completed by ligation of the crural edges of the corpora. Arch Ital Urol Nefrol Androl 1987;59:140-54. 9. Lewis R, Puyan F, Bell D. Another surgical approach for vasculogenic impotence. J Urol 1986;136:1210-2. 10. Puech-Leao P, Reis JMSM, Glina S, Reichelt AC. Leakage through the crural edge of the corpus cavemosum: diagnosis and treatment. Eur Urol 1987;13:163-7. 11. Goldstein AMB, Slavin BG, Buckley PA. Occluding structures in circumflex veins of the penis. Ital Arch Urol Nefrol Androl 1987;59:127-31.
B O U N D VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of the JOUgZqALOF VASCULARSURGERY for 1989 are available to subscribers only. They may be purchased from the publisher at a cost of $52.00 ($66.00 international) for Vol. 9 (January to June) and Vol. 10 (July to December). Price includes shipping charges. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Circulation Fulfillment, The C,V. Mosby Company, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA. In the United States call toll free: (800)325-4177, ext. 351. In Missouri call collect: (314)872-8370, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
Washington, D.C~
TO delineate neural, arterial, and venous components contributing to impotence, we used a previously described noninvasive screening sequence combined with stimulation o f artificial erection with papaverine injection, selective pudendal arteriography (SPA), and dynamic cavernosography (DC). Among 572 men with impotence, age range 17 to 78 years (average age 54.8 years), 26 men with potential cavernosal leaks in absence of other factors were identified; 16 underwent DC; among these five had normal cavernosal venous drainage. Eight men with abnormal cavernosal venous drainage required cavernous infusion flow rates higher than 120 ml/min to obtain erection and higher than 40 ml/min to maintain erection. Radiographic studies showed cavernosal leakage in all eight patients. Eight men, ages 39 to 61 years, underwent surgical ablation o f abnormal cavernosal venous drainage. Among these, five men have had excellent results for up to 3 years. One failure was related to unrecognized penile arterial disease later shown by SPA. In two men small doses o f papaverine now induce erection. We now recommend SPA before DC to nile out an arterial abnormality. Accurate identification o f factors contributing to erectile failure is critical for successful treatment; in this experience candidates for correction o f cavernosal leak syndrome were uncommon. (J VASe SURG 1989;9:117-21.)
Delineation of neural, arterial, and venous components contributing to penile erectile failure is critical for proper patient selection for surgical intervention. This report describes experience with venous leakage in men who were initially seen for diagnosis and possible treatment ofvasculogenic impotence. METHODS Screening sequence
The screening sequence, described in a previous article, I was used in 572 men to delineate neural, arterial, and venous components possibly contributing to penile erectile failure. The sequence included noninvasive estimates of penile perfusion, pulse volume recording (PVR), and measurements of penile brachial pressure indices (PBPI),2 somatosensory evoked potentials from the dorsal penile nerve and posterior tibia] nerve stimulation, and bulbocaverFrom the Departments of Surgery, Neurology, Radiology,and Urology, GeorgeWashington UniversityMedicalCenter. Presented at the SecondAnnual Meeting of the Eastern Vascular Society, Washington, D.C., May 21-22, 1988. Reprint requests: Ralph G. DePalma, MD, Department of Surgery, George Washington University Medical Center, 2150 PennsylvaniaAve., N.W., Washington, DC 20037.
nosus reflex timeJ Intracorporal papaverine injection, selective pudendal arteriography, and dynamic cavernosography (DC) were finally used to stimulate artificial erection and thereby select surgical candidates. The screening sequence included intracorporal papaverine injection, 4 which was used in all cases to determine candidacy for angiographic study. Candidates for DC were selected by the following criteria: (1) normal ncurologic studies; (2) absence of hormonal or arterial risk factors such as low testosterone, elevated prolactin, uremia, diabetes, or hypertension, which would predispose to cavernosal dysfunction; (3) normal pulse volume recordings and PBPI; (4) normal results of neural screening; (5) failure to obtain or maintain erection after intracorporal injection of papaverine in doses up to 60 mg; and (6) a willingness to undergo DC and cavernosometry and possible surgery for cavernosal leak syndrome. C a v e r n o s o m e t r y and c a v e m o s o g r a p h y
Venous leakage was documented by inducing passive erections by means of controlled perfusion of the corpora cavernosa, with continuous pressure monitoring modified from that procedure described 117
Journal of VASCULAR SURGERY
118 DePalma et al.
m/~50-4
80mmHg full erection (passive)
,--=/
i
•
withpapaverineoftensystolic
~
}~f-~Warmheparinized saline
Rollerpump calibrated40ml/min Fig. 1. Technique of dynamic cavernosography. Pump calibrated to deliver 40 ml/min increments through a 19-gauge needle. Pressure monitoring with usual pressure range shown; with papaverine injections pressure may be systolic or greater. by Wespes and Schulman. s A diagram of the method used is shown in Fig. 1. Cavernosometry was accomplished by perfusing the corpora cavernosa with warm heparinized saline solution under standard flow rates varying from 40 to 250 ml/min. Pressure within the cavernous bodies was monitored continually as passive erection occurred. At full erection or maximum tumescence the flow rate delivered by the roller pump was reduced to measure a flow rate needed to maintain erection. In patients in whom erection could not be produced by high flow rates, 30 mg ofpapaverine was given intracorporally. Flow rates then producing and maintaining erection were measured. At a flow rate sufficient to Obtain or maintain erection or maximum tumescence, a hand injection of nonionic radiopaque contrast medium was made. Serial radiographs were exposed under fluoroscopic guidance to show the sites of venous leakage from the cavernous bodies. Before standardization of the roller pump method, cavernosometric measurements were obtained manually and films exposed in a similar manner in two patients. In three patients pudendal arteriography was also performed to assure that arterial anatomy was normal before venous ablation. RESULTS Screening sequence During the interval from September 1983 to Febmary 1988, a total of 572 men ranging in age from 17 to 78 years were referred for screening for impotence. The mean age of these men was 54.8 years at the time of the complaint. By use of the previously
described values for PBPI and PVR, 2 normal penile arterial perfusion was discovered in 317 men and abnormal arterial penile perfusion was discovered in 255 men. Patients who were candidates for possible venous intervention were selected from the former group of 317 men who had normal arterial penile perfusion revealed noninvasively. Their number was further reduced to 200 by excluding patients with neurologie abnormalities that possibly contributed to erectile failure, and reduced further to 102 by excluding those with hormonal disorders, uremia, diabetes, or hypertension that required treatrncnt with antihypertensive drugs. Most of these men had the latter two problems; only four men in the series had low testosterone values. Twenty-six patients were further identified by~ failure to respond to papaverine injection, leaving 26 potential candidates for DC after screening. The number of patients finally accepting DC was 16. Table I summarizes the sharp reduction in number of men considered to exhibit cavernosal leak as a result of these selection criteria.
Results o f cavernosometry and cavernosography Thirteen men underwent successful DC by means of the roller pump method described, in two men a manual method was used~ and in one the corpora could not be infused because of fibrosis. Table II shows flow rates delivered by cavernosometry roller pump that were needed to obtain and maintain passive erection among 13 men. In the one patient in whom it was not possible to obtain unimpeded saline flow into the corpus cavernosum, there was a h i s t o ~
Volume 10 Number 2 August 1989
Treatment of impotence caused by cavernosal leak syndrome
Table II. Results of cavernosometry show
Table I. Sequence results for cavernosal leak syndrome Screening sequence Screened for impotence Normal arterial perfusion Normal neurostatus Negative diabetes or high blood pressure therapy Papaverine failure Dynamic cavernosography Operations cavernosal leak syndrome
119
No. screened 572 317 200 102 26 16 8
of prolonged priapism after cavernosography performed elsewhere. This caused fibrosis of both cavernous bodies. Normal dynamic and radiographic studies showing venous closure were obtained in five patients at flow rates ranging from 80 to 140 ml/min to obtain erection and 40 to 80 ml/min to maintain full erection. In eight patients with clearly abnormal cavemosal venous drainage, flow rates generally in excess of 140 ml/min were required to obtain erection, and flow rates of 80 to 160 ml/min were required to maintain erection even after 30 mg of papaverine was injected intracorporally. These data are summarized in Table II. Pressure monitoring revealed resting pressures of approximately 12 to 15 mm Hg in the corpus cavernosum, which increased to 80 to 100 mm Hg during full passive erection. With full erectile rigidity, intracavernous pressures ranging from 80 mm H g to 160 mm H g were measured after papaverine injection. At the time of maximum erection, discomfort was noted by some patients; it was found to be dinically important to visually monitor the status of penile tumescence during cavemosometry so that flow _ates could be adjusted properly to minimize discomfort and possible extravasation. Unequivocal venous leakage was shown in eight patients. Among these, leakage was detected along the dorsal veins in seven patients, and leaks into the prostatic plexus were found in four patients. The ultimate sites of venous leakage included both the right and left internal pudendal veins and the obturator and internal iliac veins. Whereas abnormal leakage occurred mainly into internal iliac veins, occasionally there was drainage into the common femoral veins.
Results of operation Among the eight men with abnormal study resuits shown in Table II, six were selected for operation. Two men in whom manual cavernosometry ~nd cavernosography was abnormal were also se-
observed flow rates in ml/min sufficient to obtain/maintain erection Normal range
Abnormal range
140/80 80/40 80/40 (P)
>250; 150/--(P) * >250; 140/80 (P) 200/160 200/120 >250; 160/80 (P) 160/80 140/80 >250
80/4o (P) 80/40 (P)
*P, 30 mg papaverine injection intracorporally.
lected. Therefore eight men of the original 572 with impotence became surgical candidates for venous ablation. These men ranged in age from 32 to 63 years with an average age of 51.3 years. The technique used was resection of the dorsal vein from the base of the penis to the glans and resection of all accessible circumflex veins. There were no complications or morbidity; seven of the eight procedures were done as same-day surgery. Patients have been reassesscd at intervals from 2 to 44 months. At each visit erectile function and intromission were reported. When dysfunction was reported, erection was tested by intracorporal papaverine injection; a threshold dosage at which erection could be produced in the clinic was noted, and this was then compared with preoperative papaverine injection. Five operations were immediately successful in restoring normal erectile function; four of these men have now maintained erectile capabilities for periods of 20 to 44 months. One among this initially successful group experienced hypertension and was treated with antihypertensive agents 18 months postoperatively. This caused recurrence of impotence, which was relieved when the drugs were discontinued. Control of hypertension by diet and weight reduction was undertaken. Two men reported that they were incapable of intromission; both were able to achieve erections in the clinic after intracorporal injection of small doses of papaverine of 7 to 15 mg. These men are still under observation but have had no further improvement. One patient achieved a dramatic increase in erectile function for 2 weeks and then experienced a recurrence of absolute erectile failure. This subject also failed to have erections with papaverine injections postoperatively in dosages up to 80 mg. Repeat review of his noninvasive findings and clinical history indicated that this $9-year-old subject showed com-
120 DePalma et al.
Fig. 2. A, Cavcrnosogram shows large venous leak of contrast meditun from corpora cavernosa into internal iliac vein (upper arrow) via obturator vein (lower arrowhead). B, Later phase shows continued washout of contrast medium from left side of corpus into pelvicveins. This leakage was corrected surgically.Patient has normal erectilefunction at 14 months.
plete absence of arterial and hormonal risk factors. Apart from slight flattening of penile PVR, no other ilbnormality was noted. However, selective pudendal arteriography was recommended. This single absolute failure related to an unrecognized penile arterial hypoplasia documented by arteriographic results. Ultimately this man was treated successfullywith a prosthesis. None of the remaining men have required prostheses or requested this procedure. In current case selection, to resolve questions about arterial abnormalities, we now recommend selective pudendal arteriography before DC. Venous abnormalities do occur in combination with arterial insufficiency; such patients can be considered candidates for deep dorsal vein arterialization. DISCUSSION Since initial description of impotence caused by abnormal venous drainage from corpus cavernosum,6 there has been increasing interest in documenting venous leakage. 7This type ofvasculogenic impotence is now called cavernosal leak syndrome. Ideally, objective measurements with quantifiable methods allow the most refined case selection. In the current series
Journal of VASCULAR SURGERY
the technique of DC originally described by Wespes and Schulman5 was modified and used in patients selected by our screening sequence. ~ Rates of flow in excess of 140 ml/min rather than 120 ml/min to obtain erection and higher than 80 ml/min to maintain erection were found to be abnormal. This is slightly higher than the 120 ml/min flow rate to obtain erection originally reported, s Fig. 2 shows radiographic evidence of a massive venous leak at high flow rate that was corrected surgically by techniques similar to those recently described by others .8,9 Two instances in which the leakage occurred primarily into the prostatic plexus at the base of the penis were identified. These men were not selected for operation. In such cases a secondary procedure has been reported, s'l° which involves combining resection of the deep dorsal vein with ligation of the crural edges of the perineal portion of the corpora'-' cavernosa. Relapses after dorsal vein resection might result from secondary leak through the cavernous veins. Therefore systematic combination of crural ligation and dorsal vein resection might make the success of venous ablation procedures more effective. However, few patients so treated have been described in the literature. We have neither used this operation nor recommended surgery when leakage through the prostatic plexus was found to be the major anatomic abnormality. The present experience shows that correction of radiographically proven penile deep dorsal vein leakage into the obturator, pudendal, and internal iliac veins is promising when this is the sole source of leakage. When selecting this option, it is important to be certain that arterial inflow is normal, since excision of the dorsal vein removes the possibility o f arterial revascularization, which might correct bot:,3 venous leakage and arterial insufficiency. The most notable finding in this experience was the sharp funneling effect of the screening sequence. Ultimately, only 16 patients received DC after 572 men were screened. It is possible that the criteria imposed by the screening sequence were too strict; however, a conservative approach has been deliberately adopted until factors contributing specifically to the function of the venous system in human erection can be better elucidated. Recent research~ suggests that cavernosal filling during erection compresses subalbugineous venules, substantially reducing venous outflow during normal erection. Circumflex veins contain structurally redundant complex valves, and whereas these venous valves function to prevent reflux of blood in the usual fashion, they may also prevent efflux of blood w h e ~
Volume l0 Number 2 August 1989
Treatment of impotence caused by cavernosalleak syndrome 121
the veins contract or are compressed during erection. With clearly documented abnormalities of this mechanism, dorsal vein resection and resection of the circumflex veins appear to be anatomically and physiologically sound. The durability of operations for cavernosal leak syndrome will require further longterm observation. REFERENCES 1. DePalrna RG, Emsellem HA, Edwards CM, et al. A screening sequence for vasculogenic impotence. J VASCSURG 1987; 5:228-36. 2. Stauffer D, DePalma RG. A comparison of penile-brachial index (PBI) and penile pulse volume recordings (PVR) for diagnosis of vasculogenic impotence. Bruit 1983;7:29-32. 3. Haldeman S, Bradley WE, Bhatia NN, Johnson BK. Pudendal evoked responses. Arch Neurol 1982;39:280-3. 4. Virag R, Virag H. L'epreuve a la papaverine intracaverneuse dans Petude de l'impuissance. J Mid Vasc 1983;8:293-5.
5. Wespes E, Schulman CC. Venous leakage: surgical treatment of a curable cause of impotence. J Urol 1985;133:796-8. 6. Ebbehoj J, Wagner G. Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology 1979; 13:507-10. 7. Virag R. Syndrome d'erection instable par insuffisance veineuse. J Mal Vasc 1981;6:121-4. 8. Wespes E, Schulman CC. Caverno-venous leakage: retrograde opacification and resection of the deep dorsal vein completed by ligation of the crural edges of the corpora. Arch Ital Urol Nefrol Androl 1987;59:140-54. 9. Lewis R, Puyan F, Bell D. Another surgical approach for vasculogenic impotence. J Urol 1986;136:1210-2. 10. Puech-Leao P, Reis JMSM, Glina S, Reichelt AC. Leakage through the crural edge of the corpus cavemosum: diagnosis and treatment. Eur Urol 1987;13:163-7. 11. Goldstein AMB, Slavin BG, Buckley PA. Occluding structures in circumflex veins of the penis. Ital Arch Urol Nefrol Androl 1987;59:127-31.
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