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Laparoscopically Assisted Penile Revascularization for Vasculogenic Impotence
@322-5347/95/1536-1923$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 153, 1923-1926,June 1995 Printed in U.S.A.
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE GREG 0. LUND, HOWARD N. WINFIELD AND JAMES F. DONOVAN From the Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
ABSTRACT
Young patients with impotence a n d cavernous arterial insufficiency resulting from traumainduced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach w a s used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence. KEY WORDS:penile erection, impotence, laparoscopy, veins
Since the initial reports of penile revascularization by Michal in 1973, a multitude of procedures have been described for the treatment of vasculogenic erectile dysfunction.' These operations have been demonstrated to be effective in properly select patients.2 Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are considered ideal candidates for microvascular arterial bypass surgery.3 Most of these vascular reconstructions use the inferior epigastric artery, which is traditionally harvested through a long transverse, midline or paramedian abdominal incision. Laparoscopic surgery has gained a strong foothold in urology. Laparoscopic pelvic lymph node dissection is routinely performed as a staging technique for men with cancer of the prostate.4 Varix ligation by the laparoscopic approach has been a good option for correction of the clinically significant varicocele.5 During the last 18 months many of these laparoscopic procedures as well as others, such as bladder neck suspension, nephrectomy and inguinal herniorrhaphy have been performed by a preperitoneal or retroperitoneal approach.6-8 During intraperitoneal and preperitoneal laparoscopic procedures, the inferior epigastric vessels are easily identified emanating from the external iliac vessels, then coursing onto the posterior surface of each rectus abdominis muscle belly. For laparoscopic inguinal hernia repair these vessels serve as an important anatomical landmark in the dissection of the inguinal floor.9 Due to the ease of visualization of the inferior epigastric vessels, we proposed that they could be mobilized laparoscopically, then tunneled into the operative field at the base of the penis for subsequent microvascular anastomosis with the penile vessels. We report a case of trauma-induced arteriogenic impotence treated with laparoscopic-assisted mobilization of the inferior epigastric artery and microsurgical penile revascularization. CASE REPORT
A 27-year-old white man was involved in a motor vehicle accident in December 1992 and sustained multiple bony injuries, including pelvic, left acetabular, and bilateral superior and inferior pubic rami fractures. A partial urethral disruption was acutely treated with suprapubic catheter hainage and successful urethral catheter stenting. Followup wethrography revealed no evidence of stricture and he denied voiding dificulties. However, since the accident he comPlained of erectile dysfunction with moderate, sustained tumescence but of inadequate rigidity for penetration during mtercourse. Ejaculatory function was normal. There were no Accepted for publication December 2, 1994.
symptoms or findings to suggest endocrinopathy or psychogenic impotence. Arteriovenous penile color Doppler ultrasound revealed pre-injection right and left cavernous artery maximum systolic velocities of 7 and 10 cm. per second, respectively. Following intracavernous injection of 0.15 ml. of a 3-drug solution of 4.4 mg. papaverine, 0.15 mg. phentolamine and 1.5 yg. prostaglandin E l in 0.25 ml. saline there was an increase in the maximum systolic velocities to 53 and 55 cm. per second on the right and left sides, respectively, and reversal of flow was demonstrated. The right and left cavernous arteries measured 2 mm. and 1.2 m. in diameter, respectively. The left dorsal penile artery was patent at 1 mm. in diameter, while the right dorsal artery demonstrated only a trickle of flow and a marked decrease in caliber. The patient reported minimal improvement in the rigidity of erection with intracorporeal pharmacological injections. Selective internal iliac arteriography revealed truncation of the internal pudendal arteries proximally near the inferior pubic rami fractures, with diminutive branches distally and no filling of the penile arteries (fig. 1).ARer intra-arterial injection of 25 mg. tolazoline hydrochloride there was a vascular blush at the base of the penis with some retrograde filling of right collateral vessels. The dorsal penile and deep cavernous arteries were not visualized. Despite the high maximum systolic velocities aRer intracorporeal injection of vasodilators, the arteriographic findings suggested that erectile dysfunction was due to arterial insufficiency secondary to occlusion of the internal pudendal arteries within Alcock's canal. Various options, including vacuum erection devices, insertion of a penile prosthesis, and penile revascularization, were discussed and the patient elected primary revascularization with dissection and mobilization of the inferior epigastric vessels by a laparoscopic approach. With the patient under general anesthesia, a 4 cm. infraumbilical incision was made through the linea alba. A preperitoneal plane was developed with blunt finger dissection. Because the patient had previously undergone surgery in the space of Retzius at the initial injury, attempts to create an adeauate laparoscopic extraperitoneal working space were unHuccessf&. Therefore, transperitoneal accesswas secured with a 10/11 mm. Hasson type cannula. Then, 3 additional 10 mm. ports were placed on the right side of the abdomen at sites further lateral than typically used for laparoscopic pelvic procedures. This placement allowed for greater angulation of the laparoscopic instruments to reach the anterior abdominal wall and gain access to the inferior epigastric vessels (fig. 2). Dissection was initiated on the left inferior epigastric ves-
1923
1924
LAPAROSCOPIC PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE
feet
head FIG. 1. Selective right internal iliac arteriogram demonstrates truncation of internal pudendal artery.
FIG.2. Patient positioning to afford access to left inferior epigastric vessels (transverse lower abdominal view).
sels below the level of the arcuate line. Gentle downward traction was used on the inferior epigastric bundle to pull the vessels away from the rectus muscle, and perforating branches were clip ligated and divided. The vessels were dissected cephalad to a bifurcation point of the inferior epigastric artery above the level of the umbilicus and caudad close to their point of origin from the external iliac vessels. The inferior epigastric vessel bundle was clip ligated and transected at the cephalad margin of the dissection. Through an oblique incision at the base of the penis a 12 mm. trocar sheath unit was directed above the symphysis pubis and into the pelvis under direct laparoscopic visualization. The superior end of the dissected inferior epigastric vessels was grasped and drawn into the sheath. The sheath was then carefully withdrawn, transporting the vessels into the area of the penile incision (fig. 3). A microvascular anastomosis using 9-zero nylon was then performed end-to-side between 1 branch of the inferior epigastric artery and an
FIG. 3. Posterior aspect of anterior abdominal view. Curved arrow shows 12 mm. laparoscopic port entering peritoneal cavity from base of penis.
isolated segment of the deep dorsal vein, and end-to-end between the other branch of the inferior epigastric artery and the proximal segment of the left dorsal penile artery. The anastomoses were patent and hemostasis was satisfactory. Total operative time was 6 hours (3 hours for laparoscopic surgery and 3 hours for the microsurgical anastomoses). The set-up and change with time for the laparoscopic and microsurgical equipment accounted for a n additional 2 hours. Estimated blood loss was 150 cc. Subcutaneous heparin (5,000 units every 8 hours) was administered for 48 hours postoperatively and then 325 mg. aspirin per day were instituted. The patient was instructed to avoid any erections or intercourse for the next 6 weeks, and was prescribed amyl nitrite (inhalationall to inhibit or reverse spontaneous erections. The patient had some suprapubic pain and swelling that were treated with 24 mg. intramuscular morphine during the first 24 hours postoperatively. He requested no additional narcotic analgesics. On postoperative day 2 he tolerated a general diet. He was kept at bedrest for 48 hours and was discharged home on postoperative day 4. At followup 2 weeks later he had mild supraDubic swelling and tenderness. A small suprapubic hematoma was notgd but there was no evidence of infection. He was well, the hematoma had resolved at 6 weeks, and he was allowed to resume all physical and sexual activity. At 3 months he reported full erections with successful intercourse at least weekly. Repeat penile Doppler ultrasound 12 weeks postoperatively revealed preinjection right and left cavernous artery maximum systolic velocities of 8 and 6 cm. per second, respectively, which increased to 65 and 66 cm. per second, respectively, following injection of 0.1 ml. of the 3-drug solution (table 1). The diameters of the cavernous and dorsal penile arteries also increased following injection compared to preoperatively (table 2). DISCUSSION
Impotence occurs frequently after fractures of the bony pelvis and lower urinary tract.10,*1 The etiology of erectile dysfunction in these patients may be due t o injury of the
LAPAROSCOPIC PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE TABLE1. Results
of
cavernous artery Doppler ultrasound Maximum Systolic Velocity (cmJsec.) Before Injection Rt.
Lt.
After Injection Rt.
Lt.
Preop. I 10 53* 8 6 65t 12 wks. postop. * Intracorporeal injection of 0.15 ml. 3-drug solution. t Intracorporeal injection of 0.10 d. 3-drug solution.
55* 66t
TABLE 2. Color Doppler ultrasound measurement diameters (mm.) Preop.* Cavernous artery: Rt. 2.0 Lt. 1.2 Dorsal artery: Rt. Nonmeasurable Lt. 1.0 * Intracorporeal injection of 0.15 d.3-drugsolution. f Intracorporeal injection of 0.10 ml. 3-drug solution.
of
penile arterial
12 wks. P0stop.t 2.4
1.6 2.4
1.7
arteries or nerves supplying the penis. The sole arterial blood supply to the corpus cavernosum is furnished by the internal pudendal artery, which is a terminal branch of the hypogastric artery. The internal pudendal artery courses within Alcock‘s canal and is at risk for injury with fracture of the inferior pubic ramus.3 Subsequent arteriogenic impotence is often amenable to arterial revascularization. It appears that patient selection is the most important factor in determining success following penile arterial revascularization. Ideal candidates are those with discrete arterial lesions of the pudendal, common penile or cavernous arteries due to pelvic or perineal trauma.12 As with other types of vascular bypass surgery, patients with diffuse arterial disease or small vessel involvement have poorer results with arterial revascularization and are best treated with other modalities. The duplex ultrasound findings in this case were puzzling in that the excellent peak systolic velocities preoperatively would suggest that no significant arterial disease was present. In addition, reversal of flow was noted, indicating that the corporo-venous occlusive mechanism was intact. However, table 2 demonstrates the marked increase in diameter of the penile arteries following revascularization in comparison with the preoperative state. The good systolic velocity and increased arterial diameters would translate into a larger volume of flow into the corporeal bodies, allowing for an improved erection. This was demonstrated by the normal erectile ability at 12 weeks postoperatively. Michal first reported successful penile revascularization in 1973.3 In this procedure the inferior epigastric artery was anastomosed directly to the corpora through a corporotomy. This type of operation, however, often subsequently failed due to thrombosis of the anastomosis or development of high flow priapism. Since that time, a variety of revascularization operations for vasculogenic impotence have been deseribed.1.3.13.14 Most of these procedures use the inferior epigastric artery as the new arterial source, since this vessel is expendable, readily accessible and easily mobilized to the level of the required anastomosis. Previous reports describe mobilization of the inferior epigastric artery through a lower 14.l5 midline, paramedian or transverse abdominal in~ision.~. Although to our knowledge there are no data in the literature, one may assume that because these are long abdominal incisions and transection of the rectus muscle may be required, postoperative morbidity, especially pain, scarring and convalescence. may be significant. Furthermore, an i m Portant limitation ‘of the traditional open surgical approach
1925
that the inferior epigastric vessels can be dissected only within the rectus sheath. Because of the great advances made recently in the area of laparoscopic surgery, it is feasible and even logical to approach the mobilization of these vessels laparoscopically. Due to the location on the anterior abdominal wall posterior to the rectus muscles, visualization of and access to the inferior epigastric vessels are excellent. However, because they are located directly anterior, it is advisable to place the working ports as far lateral as possible on the side contralatera1 to the vessel being harvested so as to allow for greater angulation of the laparoscopic instruments and clip appliers toward the area of dissection. Additionally, a 30 or 45-degree lens allows for a more panoramic view of the surgical field of interest. The magnification provided by the laparoscope and video monitor facilitates a fine, accurate dissection of these vessels from their origin at the external iliac vessels to a cephalad point that allows sufficient length for the vessels to reach the penile incision. No attempt is made to separate the inferior epigastric artery from the inferior epigastric veins during the laparoscopic dissection. These vessels may be dissected together as a packet to avoid injury to the artery. Following passage of these vessels to the area of intended anastomosis, the artery may be carefully dissected free of surrounding tissue with the aid of magnification provided by the dissecting microscope. The laparoscopic clip applier proved to be adequate to interrupt the many perforating branches between the inferior epigastric vessels and the rectus muscle. No laparoscopic suturing or knot tying was required but these may be considered in future operations. Use of a 12 mm. trocar sheath unit advanced through the penile incision into the abdominal cavity under direct laparoscopic visualization was a safe, gentle and most direct method to deliver the transected end of the vessels into the area of anastomosis.
1.s 1
CONCLUSIONS
Laparoscopic surgery is continually gaining acceptance as an alternative, minimally invasive method of performing many urological procedures. Laparoscopic mobilization of the inferior epigastric vessels is yet another application of this technology by which the patients may benefit in terms of decreased postoperative pain, hospitalization and recovery time, as well as improved cosmesis. Prospective laparoscopic series will hopefully confirm these predictions. Dr.Monzer M.Abu Yousef, Department of Radiology (u1trasound), University of Iowa College of Medicine, provided support and advice. REFERENCES
1. Bennett, A. H.: Venous arterialization for erectile impotence. Urol. Clin. N. Amer., 16: 111, 1988. 2. Cookson, M.S.,Phillips, D. L., Huff, M. E. and Fitch, W. P., 111: Analysis of microsurgical penile revascularization results by etiology of impotence. J. Urol., 149 1308,1993. 3. Goldstein, I., Hartzichristou, D. G. and Pescatori, E. S.: Pelvic, perirenal, and penile trauma-associated arteriogenic impotence: pathophysiologicmechanisms and the role of microvascular arterial bypass surgery. In: Impotence: Diagnosis and Management of Erectile Dysfunction. Edited by A. H. Bennett. Philadelphia: W. B. Saunders Co., chapt. 16, pp. 213-228, 1994. 4. Winfield, H. N., Donovan, J. F., See, W. A., Loening, S. A. and Williams, R. D.: Laparoscopic pelvic lymph node dissection for genitourinary malignancies: indications, techniques, and results. J. Endourol., 6 103, 1992. 5. Donovan, J. F. and Winfield, H. N.: Laparoscopic varix ligation with Nd:YAG laser. J. Endourol., 6: 165, 1992. 6. Albala, D. M.,Schuessler, W. W. and Vaneaillie, T. G.: LapscoDic bladder neck suspension. J. Endourol.,6 137, 1992.
1926
LAPAROSCOPIC PENILE REVASCUMIZATION FOR VASCULOGENIC IMPOTENCE
12. Goldstein, I. and Krane, R. J.: Diagnosis and therapy of erectile dysfunction. In: Campbell’s Urology 6th ed. Edited by P. C. Figenshau, R. S. and Chandhoke, P. S.: Laparoscopic nephrecWalsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, J r . tomy: review of the initial 10 cases. J . Endourol., 6 127,1992. Philadelphia: W. B. Saunders Co., chapt. 84,pp. 3033-3070, 8. Filipi, C. J., Fitzgibbons, R. J., Jr., Salerno, G. M. and Hart, 1992. R. 0.:Laparoscopic herniorrhaphy. Surg. Clin. N. Amer., 72 1109,1992. 13. Belker, A. M. and Bennett, A. H.: Applications of microsurgery in 9. Spaw, A T., Ennis, B. W. and Spaw, L. P.: Laparoscopic hernia urology. Surg. Clin. N. Amer., 68: 1157,1988. repair: the anatomic basis. J. L a p m n d o s c . Surg., 1:269,1991. 14. MacGregor, R. J. and Konnak, J. W.: Treatment of vasculogenic 10. Sharlip, I. D.:Penile arteriography in impotence after pelvic erectile dysfunction by direct anastomosis of the inferior epitrauma. J. Urol., 126 477,1981. gastric artery to the central artery to the corpus cavernosum. 11. Chambers, H. L. and Balfour, J.: The incidence of impotence J. Urol., 127: 136,1982. following pelvic fracture with associated urinary tract injury. 15. McDougal, W. S.and Jeffery, R. F.: Microscopic penile revascuJ . Urol., 89 702, 1963. larization. J. Urol., 129 517, 1983. 7. Clayman, R. V., Kavoussi, L. R., Soper, N. J., Albala, D. M.,
Vol. 153, 1923-1926,June 1995 Printed in U.S.A.
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE GREG 0. LUND, HOWARD N. WINFIELD AND JAMES F. DONOVAN From the Department of Urology, University of Iowa College of Medicine, Iowa City, Iowa
ABSTRACT
Young patients with impotence a n d cavernous arterial insufficiency resulting from traumainduced arterial occlusive disease are ideal candidates for microvascular arterial bypass surgery. To avoid the long abdominal incision required to harvest the inferior epigastric artery, a laparoscopic approach w a s used. We report a case of laparoscopically assisted penile revascularization for vasculogenic impotence. KEY WORDS:penile erection, impotence, laparoscopy, veins
Since the initial reports of penile revascularization by Michal in 1973, a multitude of procedures have been described for the treatment of vasculogenic erectile dysfunction.' These operations have been demonstrated to be effective in properly select patients.2 Young patients with impotence and cavernous arterial insufficiency resulting from trauma-induced arterial occlusive disease are considered ideal candidates for microvascular arterial bypass surgery.3 Most of these vascular reconstructions use the inferior epigastric artery, which is traditionally harvested through a long transverse, midline or paramedian abdominal incision. Laparoscopic surgery has gained a strong foothold in urology. Laparoscopic pelvic lymph node dissection is routinely performed as a staging technique for men with cancer of the prostate.4 Varix ligation by the laparoscopic approach has been a good option for correction of the clinically significant varicocele.5 During the last 18 months many of these laparoscopic procedures as well as others, such as bladder neck suspension, nephrectomy and inguinal herniorrhaphy have been performed by a preperitoneal or retroperitoneal approach.6-8 During intraperitoneal and preperitoneal laparoscopic procedures, the inferior epigastric vessels are easily identified emanating from the external iliac vessels, then coursing onto the posterior surface of each rectus abdominis muscle belly. For laparoscopic inguinal hernia repair these vessels serve as an important anatomical landmark in the dissection of the inguinal floor.9 Due to the ease of visualization of the inferior epigastric vessels, we proposed that they could be mobilized laparoscopically, then tunneled into the operative field at the base of the penis for subsequent microvascular anastomosis with the penile vessels. We report a case of trauma-induced arteriogenic impotence treated with laparoscopic-assisted mobilization of the inferior epigastric artery and microsurgical penile revascularization. CASE REPORT
A 27-year-old white man was involved in a motor vehicle accident in December 1992 and sustained multiple bony injuries, including pelvic, left acetabular, and bilateral superior and inferior pubic rami fractures. A partial urethral disruption was acutely treated with suprapubic catheter hainage and successful urethral catheter stenting. Followup wethrography revealed no evidence of stricture and he denied voiding dificulties. However, since the accident he comPlained of erectile dysfunction with moderate, sustained tumescence but of inadequate rigidity for penetration during mtercourse. Ejaculatory function was normal. There were no Accepted for publication December 2, 1994.
symptoms or findings to suggest endocrinopathy or psychogenic impotence. Arteriovenous penile color Doppler ultrasound revealed pre-injection right and left cavernous artery maximum systolic velocities of 7 and 10 cm. per second, respectively. Following intracavernous injection of 0.15 ml. of a 3-drug solution of 4.4 mg. papaverine, 0.15 mg. phentolamine and 1.5 yg. prostaglandin E l in 0.25 ml. saline there was an increase in the maximum systolic velocities to 53 and 55 cm. per second on the right and left sides, respectively, and reversal of flow was demonstrated. The right and left cavernous arteries measured 2 mm. and 1.2 m. in diameter, respectively. The left dorsal penile artery was patent at 1 mm. in diameter, while the right dorsal artery demonstrated only a trickle of flow and a marked decrease in caliber. The patient reported minimal improvement in the rigidity of erection with intracorporeal pharmacological injections. Selective internal iliac arteriography revealed truncation of the internal pudendal arteries proximally near the inferior pubic rami fractures, with diminutive branches distally and no filling of the penile arteries (fig. 1).ARer intra-arterial injection of 25 mg. tolazoline hydrochloride there was a vascular blush at the base of the penis with some retrograde filling of right collateral vessels. The dorsal penile and deep cavernous arteries were not visualized. Despite the high maximum systolic velocities aRer intracorporeal injection of vasodilators, the arteriographic findings suggested that erectile dysfunction was due to arterial insufficiency secondary to occlusion of the internal pudendal arteries within Alcock's canal. Various options, including vacuum erection devices, insertion of a penile prosthesis, and penile revascularization, were discussed and the patient elected primary revascularization with dissection and mobilization of the inferior epigastric vessels by a laparoscopic approach. With the patient under general anesthesia, a 4 cm. infraumbilical incision was made through the linea alba. A preperitoneal plane was developed with blunt finger dissection. Because the patient had previously undergone surgery in the space of Retzius at the initial injury, attempts to create an adeauate laparoscopic extraperitoneal working space were unHuccessf&. Therefore, transperitoneal accesswas secured with a 10/11 mm. Hasson type cannula. Then, 3 additional 10 mm. ports were placed on the right side of the abdomen at sites further lateral than typically used for laparoscopic pelvic procedures. This placement allowed for greater angulation of the laparoscopic instruments to reach the anterior abdominal wall and gain access to the inferior epigastric vessels (fig. 2). Dissection was initiated on the left inferior epigastric ves-
1923
1924
LAPAROSCOPIC PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE
feet
head FIG. 1. Selective right internal iliac arteriogram demonstrates truncation of internal pudendal artery.
FIG.2. Patient positioning to afford access to left inferior epigastric vessels (transverse lower abdominal view).
sels below the level of the arcuate line. Gentle downward traction was used on the inferior epigastric bundle to pull the vessels away from the rectus muscle, and perforating branches were clip ligated and divided. The vessels were dissected cephalad to a bifurcation point of the inferior epigastric artery above the level of the umbilicus and caudad close to their point of origin from the external iliac vessels. The inferior epigastric vessel bundle was clip ligated and transected at the cephalad margin of the dissection. Through an oblique incision at the base of the penis a 12 mm. trocar sheath unit was directed above the symphysis pubis and into the pelvis under direct laparoscopic visualization. The superior end of the dissected inferior epigastric vessels was grasped and drawn into the sheath. The sheath was then carefully withdrawn, transporting the vessels into the area of the penile incision (fig. 3). A microvascular anastomosis using 9-zero nylon was then performed end-to-side between 1 branch of the inferior epigastric artery and an
FIG. 3. Posterior aspect of anterior abdominal view. Curved arrow shows 12 mm. laparoscopic port entering peritoneal cavity from base of penis.
isolated segment of the deep dorsal vein, and end-to-end between the other branch of the inferior epigastric artery and the proximal segment of the left dorsal penile artery. The anastomoses were patent and hemostasis was satisfactory. Total operative time was 6 hours (3 hours for laparoscopic surgery and 3 hours for the microsurgical anastomoses). The set-up and change with time for the laparoscopic and microsurgical equipment accounted for a n additional 2 hours. Estimated blood loss was 150 cc. Subcutaneous heparin (5,000 units every 8 hours) was administered for 48 hours postoperatively and then 325 mg. aspirin per day were instituted. The patient was instructed to avoid any erections or intercourse for the next 6 weeks, and was prescribed amyl nitrite (inhalationall to inhibit or reverse spontaneous erections. The patient had some suprapubic pain and swelling that were treated with 24 mg. intramuscular morphine during the first 24 hours postoperatively. He requested no additional narcotic analgesics. On postoperative day 2 he tolerated a general diet. He was kept at bedrest for 48 hours and was discharged home on postoperative day 4. At followup 2 weeks later he had mild supraDubic swelling and tenderness. A small suprapubic hematoma was notgd but there was no evidence of infection. He was well, the hematoma had resolved at 6 weeks, and he was allowed to resume all physical and sexual activity. At 3 months he reported full erections with successful intercourse at least weekly. Repeat penile Doppler ultrasound 12 weeks postoperatively revealed preinjection right and left cavernous artery maximum systolic velocities of 8 and 6 cm. per second, respectively, which increased to 65 and 66 cm. per second, respectively, following injection of 0.1 ml. of the 3-drug solution (table 1). The diameters of the cavernous and dorsal penile arteries also increased following injection compared to preoperatively (table 2). DISCUSSION
Impotence occurs frequently after fractures of the bony pelvis and lower urinary tract.10,*1 The etiology of erectile dysfunction in these patients may be due t o injury of the
LAPAROSCOPIC PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE TABLE1. Results
of
cavernous artery Doppler ultrasound Maximum Systolic Velocity (cmJsec.) Before Injection Rt.
Lt.
After Injection Rt.
Lt.
Preop. I 10 53* 8 6 65t 12 wks. postop. * Intracorporeal injection of 0.15 ml. 3-drug solution. t Intracorporeal injection of 0.10 d. 3-drug solution.
55* 66t
TABLE 2. Color Doppler ultrasound measurement diameters (mm.) Preop.* Cavernous artery: Rt. 2.0 Lt. 1.2 Dorsal artery: Rt. Nonmeasurable Lt. 1.0 * Intracorporeal injection of 0.15 d.3-drugsolution. f Intracorporeal injection of 0.10 ml. 3-drug solution.
of
penile arterial
12 wks. P0stop.t 2.4
1.6 2.4
1.7
arteries or nerves supplying the penis. The sole arterial blood supply to the corpus cavernosum is furnished by the internal pudendal artery, which is a terminal branch of the hypogastric artery. The internal pudendal artery courses within Alcock‘s canal and is at risk for injury with fracture of the inferior pubic ramus.3 Subsequent arteriogenic impotence is often amenable to arterial revascularization. It appears that patient selection is the most important factor in determining success following penile arterial revascularization. Ideal candidates are those with discrete arterial lesions of the pudendal, common penile or cavernous arteries due to pelvic or perineal trauma.12 As with other types of vascular bypass surgery, patients with diffuse arterial disease or small vessel involvement have poorer results with arterial revascularization and are best treated with other modalities. The duplex ultrasound findings in this case were puzzling in that the excellent peak systolic velocities preoperatively would suggest that no significant arterial disease was present. In addition, reversal of flow was noted, indicating that the corporo-venous occlusive mechanism was intact. However, table 2 demonstrates the marked increase in diameter of the penile arteries following revascularization in comparison with the preoperative state. The good systolic velocity and increased arterial diameters would translate into a larger volume of flow into the corporeal bodies, allowing for an improved erection. This was demonstrated by the normal erectile ability at 12 weeks postoperatively. Michal first reported successful penile revascularization in 1973.3 In this procedure the inferior epigastric artery was anastomosed directly to the corpora through a corporotomy. This type of operation, however, often subsequently failed due to thrombosis of the anastomosis or development of high flow priapism. Since that time, a variety of revascularization operations for vasculogenic impotence have been deseribed.1.3.13.14 Most of these procedures use the inferior epigastric artery as the new arterial source, since this vessel is expendable, readily accessible and easily mobilized to the level of the required anastomosis. Previous reports describe mobilization of the inferior epigastric artery through a lower 14.l5 midline, paramedian or transverse abdominal in~ision.~. Although to our knowledge there are no data in the literature, one may assume that because these are long abdominal incisions and transection of the rectus muscle may be required, postoperative morbidity, especially pain, scarring and convalescence. may be significant. Furthermore, an i m Portant limitation ‘of the traditional open surgical approach
1925
that the inferior epigastric vessels can be dissected only within the rectus sheath. Because of the great advances made recently in the area of laparoscopic surgery, it is feasible and even logical to approach the mobilization of these vessels laparoscopically. Due to the location on the anterior abdominal wall posterior to the rectus muscles, visualization of and access to the inferior epigastric vessels are excellent. However, because they are located directly anterior, it is advisable to place the working ports as far lateral as possible on the side contralatera1 to the vessel being harvested so as to allow for greater angulation of the laparoscopic instruments and clip appliers toward the area of dissection. Additionally, a 30 or 45-degree lens allows for a more panoramic view of the surgical field of interest. The magnification provided by the laparoscope and video monitor facilitates a fine, accurate dissection of these vessels from their origin at the external iliac vessels to a cephalad point that allows sufficient length for the vessels to reach the penile incision. No attempt is made to separate the inferior epigastric artery from the inferior epigastric veins during the laparoscopic dissection. These vessels may be dissected together as a packet to avoid injury to the artery. Following passage of these vessels to the area of intended anastomosis, the artery may be carefully dissected free of surrounding tissue with the aid of magnification provided by the dissecting microscope. The laparoscopic clip applier proved to be adequate to interrupt the many perforating branches between the inferior epigastric vessels and the rectus muscle. No laparoscopic suturing or knot tying was required but these may be considered in future operations. Use of a 12 mm. trocar sheath unit advanced through the penile incision into the abdominal cavity under direct laparoscopic visualization was a safe, gentle and most direct method to deliver the transected end of the vessels into the area of anastomosis.
1.s 1
CONCLUSIONS
Laparoscopic surgery is continually gaining acceptance as an alternative, minimally invasive method of performing many urological procedures. Laparoscopic mobilization of the inferior epigastric vessels is yet another application of this technology by which the patients may benefit in terms of decreased postoperative pain, hospitalization and recovery time, as well as improved cosmesis. Prospective laparoscopic series will hopefully confirm these predictions. Dr.Monzer M.Abu Yousef, Department of Radiology (u1trasound), University of Iowa College of Medicine, provided support and advice. REFERENCES
1. Bennett, A. H.: Venous arterialization for erectile impotence. Urol. Clin. N. Amer., 16: 111, 1988. 2. Cookson, M.S.,Phillips, D. L., Huff, M. E. and Fitch, W. P., 111: Analysis of microsurgical penile revascularization results by etiology of impotence. J. Urol., 149 1308,1993. 3. Goldstein, I., Hartzichristou, D. G. and Pescatori, E. S.: Pelvic, perirenal, and penile trauma-associated arteriogenic impotence: pathophysiologicmechanisms and the role of microvascular arterial bypass surgery. In: Impotence: Diagnosis and Management of Erectile Dysfunction. Edited by A. H. Bennett. Philadelphia: W. B. Saunders Co., chapt. 16, pp. 213-228, 1994. 4. Winfield, H. N., Donovan, J. F., See, W. A., Loening, S. A. and Williams, R. D.: Laparoscopic pelvic lymph node dissection for genitourinary malignancies: indications, techniques, and results. J. Endourol., 6 103, 1992. 5. Donovan, J. F. and Winfield, H. N.: Laparoscopic varix ligation with Nd:YAG laser. J. Endourol., 6: 165, 1992. 6. Albala, D. M.,Schuessler, W. W. and Vaneaillie, T. G.: LapscoDic bladder neck suspension. J. Endourol.,6 137, 1992.
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LAPAROSCOPIC PENILE REVASCUMIZATION FOR VASCULOGENIC IMPOTENCE
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