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LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE: 2 ADDITIONAL CASES
0022-5347/97/15851783$03.00/0 T H E JOIIRNAI. OF UROLCKY Copyright 0 1997 by AMERICAN UROLOCICAL ASSOCIATION, INC.
Vol. 158,1785-1786, November 1997 Printed in U S A
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE: 2 ADDITIONAL CASES CARL0 TROMBETTA, GIOVANNI LIGUORI, SALVATORE SIRACUSANO, GIANFRANCO SAVOCA AND EMANUELE BELGRANO From the Department of Urology, University of Trieste, Trieste, Italy
ABSTRACT
Purpose: Microsurgical revascularization of the penis in vasculogenic impotence is an accepted surgical procedure in young men with a history of blunt pelvic or perineal trauma. Most penile revascularization techniques use the inferior epigastric artery in direct artery-to-arteryrevascularization or dorsal vein arterialization procedures. To obviate the wide pararectal incision laparoscopic mobilization of the inferior epigastric vessels has been recently proposed. We present 2 cases of successful laparoscopically assisted penile revascularization. Materials and Methods: With the patient under general anesthesia the first trocar was inserted in the umbilical region and pneumoperitoneum was induced. Two other trocars were positioned laterally. As soon as the inferior epigastric vessels were accessed, dissection was initiated below the level of the arcuate line. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level. The inferior epigastric pedicle was ligated with clips and transected at the cephalad edge of the dissection. It was then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels. Results: The anastomosis was patent and hemostasis was satisfactory. Operative time in the 2 cases was 4.3 and 5.2 hours, respectively. At 3 months both patients reported complete erections. Conclusions: Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perfom fast, accurate excision of the epigastric bundle. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided. WORDS: penis, impotence, revascularization, laparoscopy jection of 15 mcg. prostaglandin El arteriovenous penile color Doppler ultrasound revealed maximum systolic velocities of the right and leR cavernous artery of 31 and 33 cm. per second, respectively. Corporeal veno-occlusive dysfunction was excluded and intracavernous therapy with vasodilators was not effective. Common iliac arteriography showed truncation of the left iliac artery and a normal epigastric artery (fig. 1).On the right side selective catheterization of the internal iliac artery was possible and arteriograms showed narrowing of the right dorsal penile artery, while the right cavernous artery was seen only at the proximal site. The patient elected penile revascularization with laparoscopic mobilization of the inferior epigastric artery using a Iaparoscopic approach. Case 2. A 45-year-old man with a history of heavy smoking and hypertension was evaluated for complete erectile dysfunction 10 years in duration. For the last 3 years he had been unable to have an erection adequate for vaginal intercourse. ARer intracavernous injection of 20 mcg. prostaglandin El penile color Doppler ultrasound suggested arkriogenic obstruction above the cavernous arteries, since all measurements of maximum systolic velocities were low. Veno-occlusive dysfunction was ruled out using diastolic flow velocities and resistance index parameters. The patient reported no improvement in erectile rigidity after intracorpoCASE HISTORIES real injections of vasodilators and a nocturnal penile tumesCase 1. A 45-year-old man sustained pelvic and thigh frac- cence study revealed no satisfactory erectile episodes. A tures in an automobile accident. Despite correct treatment selective internal iliac arteriogram revealed complete obthe trauma led to severe urinary incontinence and the pa- struction of the right pudendal artery and partial obstruction tient had complete erectile failure. ARer intracavernous in- of the left pudendal artery pmxhally. Various options, including a vacuum device and penile prosthesis. were offered Accepted for publication April 18, 1997. 1783
Microsurgical revascularization of the penis is an accepted surgical procedure for vasculogenic imp~tence.'-~The best candidates for this surgery are young men with no significant vascular risk factors in whom impotence is associated with pelvic bone fracture or blunt perineal trauma,6*' particularly those in whom arterial revascularization is considered. TOday improved laparoscopic techniques and the availability of a wide array of laparoscopic surgical equipment in urological operating rooms have made this procedure suitable for a large number of surgical, including some unusual, objective~.~ In most penile revascularization techniques the inferior epigastric artery has been used in direct arterial-to-arterial revascularization and dorsal vein arterialization procedures. Unfortunately it requires a wide pararectal, transverse or midline incision, which results in poor esthetic and sometimes causes postoperative complications. To obviate this drawback Lund et a1 recently suggested the laparoscopic mobilization of the inferior epigastric vessels.' We report 2 consecutive cases of successful laparoscopically assisted penile revascularization for vasculogenic impotence. We investigated whether it is possible to mobilize the inferior epigastric vessels using a laparoscopic approach and follow pedicle extraction to avoid torsion of the vessels.
1784
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION
FIG.2. Case 2. First trocar is inserted a t lateral border of rectus muscle a t level of umbilical line through Hasson incision. Other 2 trocars are placed laterally and additional trocar is introduced through infrapubic incision.
FIG. 1. Case 1. Common iliac arteriography reveals truncation of left iliac artery and normal epigastric artery.
but the patient refused them and, thus, revascularization of the penile vessels was planned. With the patient under general anesthesia the first trocar was inserted a t the lateral border of the rectus muscle at the level of the umbilical line through a Hasson incision and pneumoperitoneum was induced. Two additional trocars were positioned laterally on the opposite side of the abdomen to the epigastric artery that was to be dissected (fig. 2). As soon as the inferior epigastric vessels were accessed, dissecFIG. 3. Case 2. Left inferior epigastric artery is tunneled through tion of the inferior epigastric artery was initiated below the infrapubic incision at base of penis, arcuate line level. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level, avoiding unnecessary separation of the artery from its accompanying veins. The inferior epigas- because of arteriosclerotic degeneration of the dorsal artertric pedicle was ligated with clips and transected at the ies. cephalad edge of the dissection. It was then mobilized and RESULTS tunneled through a n infrapubic incision a t the base of the penis for subsequent microvascular anastomosis with The anastomosis was patent and hemostasis was satisfacthe penile vessels (fig. 3). The peritoneum was not closed, tory in both patients. Operative time was 4.3 and 5.2 hours, which is common in laparoscopic surgery. respectively. There were no complications during convalesIn case 1 the anastomosis was created according to the cence and the patients were discharged home on day 3 postSharlip technique. The inferior epigastric artery was anasto- operatively. Aspirin was recommended for 1 month after mosed end-to-end to the proximal stump of the transected the operation. In addition, they received self-injected vasoacdorsal penile artery using 12 discontinuous stitches of 9-zero tive treatment (20 mcg. prostaglandin E l ) for 3 months as to 1-0 polypropylene, so that the cavernous artery was revas- well as behavioral sex therapy. At 3 months the initial pacularized in a retrograde manner through the common penile tient reported complete erections and no further need for trunk. In case 2 a microvascular anastomosis was con- drug therapy, while the other noted that the quality of sponstructed end-to-side between 1 branch of the inferior epigas- taneous erections had improved and vasoactive therapy was tric artery and an isolated segment of the deep dorsal vein needed less often a t a decreased dose. It is significant that
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION both patients were unresponsive to intracorporeal injections before the intervention. A selective internal iliac arteriogram 3 months postoperatively revealed a patent microvascular anastomosis in case 1 (fig.4).This finding was confirmed by duplex scanning. The other patient refused a postoperative iliac arteriogram but color Doppler ultrasound showed a high flow rate through the arteriovenous bypass. In addition, after injection of 20 mcg. prostaglandin E l maximum systolic velocities in the right and left cavernous arteries were 33 and 36 cm. per second, respectively. DISCUSSION
Penile revascularization in vasculogenic posttraumatic impotence is a useful urological tool but correct patient selection is mandatory to obtain the best results. The ideal candidates for this kind of surgery are young men with no significant vascular risk factors in whom impotence is associated with arterial lesions of the pudendal, common penile or cavernous arteries due to pelvic bone fracture or blunt perineal trauma." Concurrent traumatic veno-occlusive dysfunction following blunt pelvic or perineal trauma is not a rare finding.6 Traumatic corporeal veno-occlusive dysfunction affects the prognosis unfavorably in bypass surgery, since surgical intervention appears to provide no obvious long-term benefit.g Patients with significant vascular risk factors are poor candidates for bypass surgery and they are encouraged to consider other options for treating impotence." In case 2 there was widespread atherosclerosis. Various options, including a vacuum device or penile prosthesis, were discussed but the patient refused them and, thus, revascularization of the penile vessels was planned. Various penile revascularization techniques have been described in the last 20 but in our opinion the technique should be individualized depending on the pathological findings in each case. In addition, preference should be given to physiological revascularization procedures whenever possible. In case 1the anastomosis was created according to the Sharlip technique, which in our opinion is the best solution because it involves retrograde revascularization of the cavernous artery through the common penile trunk. In case 2 this kind of microvascular anastomosis was not possible, since the dorsal arteries were affected by serious atheriosclerotic degeneration. Thus, an end-to-side microvascular anas-
1785
tomosis was constructed between 1 branch of the inferior epigastric artery and an isolated segment of the deep dorsal vein. The inferior epigastric artery is used in direct artery-toartery revascularization and dorsal vein arterialization. To date the inferior epigastric artery has been mobilized via a lower midline or pararectal abdominal incision. Laparoscopic mobilization of the inferior epigastric vessels was previously performed in 1995 by Lund et al.' In our 2 cases we evaluated the possibility of mobilizing the inferior epigastric artery through a laparoscopic approach to avoid a long abdominal incision and resection of the rectus muscle. In these patients the operation was performed using a transperitoneal approach. We did not consider the preperitoneal approach because we had little experience with it and believed that it would be difficult, even for expert laparoscopic surgeons, to create a sufficient extraperitoneal laparoscopic working space in the space of Retzius to mobilize the inferior epigastric artery. The advantages of the laparoscopic approach are significantly decreased postoperative morbidity, pain, scarring and convalescence. Laparoscopy is a simple procedure when performed by an experienced surgeon. The only necessary precaution is positioning the trocars as laterally as possible to allow greater angulation of the laparoscopic instruments. In this manner excellent access to the inferior epigastric bundle is achieved. Laparoscopic magnification allows quite simple and quick dissection of the inferior epigastric bundle. During laparoscopic dissection the artery is separated fkom its accompanying veins, which may result in arterial injuries. Adequate length is obtained and the artery is transected at the umbilical level. It is then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels. Extraction of the pedicle is followed up laparoscopically to avoid torsion of the vessels. This procedure has been previously described using 4 working trocars. In our opinion only 3 trocars as well as one used to pass the artery through the lower incision are sufficient. Introduction of an additional, optional trocar through the infrapubic incision allows safer extraction. CONCLUSIONS
Laparoscopically assisted penile revascularization was recently performed in a young patient with impotence and cavernous arterial insufficiency resulting from trauma induced occlusive arterial disease. Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perform rapid, accurate excision of the epigastric bundle from its point of origin at the external iliac vessels to a cephalad point. Thus, sufficient length is obtained for the vessels to reach the penile incision. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided. The availability of laparoscopic devices provides opportunities for appling new solutions to problems that are rarely encountered in ordinary urological practice. In our cases laparoscopy has proved to be a viable alternative to the traditional surgical approach, and it is as safe and effective. Experience in laparoscopic techniques results in decreased postoperative pain, and considerably shorter hospitalization and recovery. REFERENCES
FIG. 4. Case 1. Postoperative selective internal ihac.a*ripgraphy
patent microvascular anastomosis. Metalllc chp 1s vlstble on epigastric vein near anastomosis.
1. Virag, R.: Revascularization of the penis. In: Management of Male Impotence. Edited by A. H. Bennet. Baltimore: Williams & Wilkins, DD. 219-233. 1982. 2. McDougal, W:8. and Jeff&, R. F.: Microscopic penile rev-larization. J. Urol., 129: 517, 1982. 3. Janssen, T.,Sarramon, J. P., Rischmann, P., Bennis, S. and
1786
LApARoscopIcAuy ASSISTED PENILE REVASCULARIZATION
Malavaud, B.: Mimurgical arterio-arterial and art,erio-venous 8. Lund, G. 0..Winfield, H. N. and Donovan, J. F.: Laparoscopic d y assisted penile revascularization for vasculogenic impopenile revascularizationin patients with pure arteriogenici m p tence. Brit. J. Urol.. 75: 561.1994. tence. J. Urol., 183: 1923,1995. 4. Lizza, E. F.and Zorgniotti, A. W.: Experience with the long-term 9. Merckx, L.A., De Bruyne, R. M. G., Goes, E.,Derde, M. P. and effect of microsurgical penile revascdanm ' tion. Int. J. I m p Keuppens, F.: The value of dynamic color duplex canning in tence Res., 6 145,1994. the diagnosis of venogenic impotence. J. Urol., 148: 318,1992. 5. Goldstein, I. and Krane, R. J.: Diagnosis and therapy of erectile 10. Hatzichristou, D. G.and Goldstein, I.: Arterial by-pass surgery dysfunction. In: Campbell's Urology, 6th ed. Edited by P. C. for impotence. Curr.Opin. Urol., 1: 114,1992. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. 11. Shaw, W.W. and Zorgniotti, A. W.: Surgical techniques in penile Philadelphia: W. B. Saundem Co., chapt. 84, pp. 30333070, revascularization. Urology, special NO., 23: 76,1984. 1992. 12. Newman, H.F.and h i s s , H.: Method for exposure of cavernous 6. Munarriz, R. M., Yan, Q. G., Nehra, A,, Udelson, D. and artery. Urology, 19: 61,1982. Goldstein, 1.: Blunt trauma: the pathophysiology of hemodynamic injury leading to erectile dysfunction. J. Urol., 183: 13. Sharlip, I. D.: Retrograde revascularization of the dorsal artery for arteriogenic erectile dysfunction. J. Urol., part 2, 131: 1831,1995. 232A,abstract 513, 1984. 7. h m b e t t a , C., Liguori, G., Savoca, G., Siracusano, S., Brattovich, A. and Belgrano, E.: Unusual application of lapa- 14. Sharaby, J. S.,Benet, A. E. and Melman, A.: Penile revascularization. Urol. Clin. N. h e r . , 2 2 821, 1995. roscopy in urology. Eur. Urol., suppl. 2.30: 193,1996.
Vol. 158,1785-1786, November 1997 Printed in U S A
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION FOR VASCULOGENIC IMPOTENCE: 2 ADDITIONAL CASES CARL0 TROMBETTA, GIOVANNI LIGUORI, SALVATORE SIRACUSANO, GIANFRANCO SAVOCA AND EMANUELE BELGRANO From the Department of Urology, University of Trieste, Trieste, Italy
ABSTRACT
Purpose: Microsurgical revascularization of the penis in vasculogenic impotence is an accepted surgical procedure in young men with a history of blunt pelvic or perineal trauma. Most penile revascularization techniques use the inferior epigastric artery in direct artery-to-arteryrevascularization or dorsal vein arterialization procedures. To obviate the wide pararectal incision laparoscopic mobilization of the inferior epigastric vessels has been recently proposed. We present 2 cases of successful laparoscopically assisted penile revascularization. Materials and Methods: With the patient under general anesthesia the first trocar was inserted in the umbilical region and pneumoperitoneum was induced. Two other trocars were positioned laterally. As soon as the inferior epigastric vessels were accessed, dissection was initiated below the level of the arcuate line. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level. The inferior epigastric pedicle was ligated with clips and transected at the cephalad edge of the dissection. It was then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels. Results: The anastomosis was patent and hemostasis was satisfactory. Operative time in the 2 cases was 4.3 and 5.2 hours, respectively. At 3 months both patients reported complete erections. Conclusions: Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perfom fast, accurate excision of the epigastric bundle. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided. WORDS: penis, impotence, revascularization, laparoscopy jection of 15 mcg. prostaglandin El arteriovenous penile color Doppler ultrasound revealed maximum systolic velocities of the right and leR cavernous artery of 31 and 33 cm. per second, respectively. Corporeal veno-occlusive dysfunction was excluded and intracavernous therapy with vasodilators was not effective. Common iliac arteriography showed truncation of the left iliac artery and a normal epigastric artery (fig. 1).On the right side selective catheterization of the internal iliac artery was possible and arteriograms showed narrowing of the right dorsal penile artery, while the right cavernous artery was seen only at the proximal site. The patient elected penile revascularization with laparoscopic mobilization of the inferior epigastric artery using a Iaparoscopic approach. Case 2. A 45-year-old man with a history of heavy smoking and hypertension was evaluated for complete erectile dysfunction 10 years in duration. For the last 3 years he had been unable to have an erection adequate for vaginal intercourse. ARer intracavernous injection of 20 mcg. prostaglandin El penile color Doppler ultrasound suggested arkriogenic obstruction above the cavernous arteries, since all measurements of maximum systolic velocities were low. Veno-occlusive dysfunction was ruled out using diastolic flow velocities and resistance index parameters. The patient reported no improvement in erectile rigidity after intracorpoCASE HISTORIES real injections of vasodilators and a nocturnal penile tumesCase 1. A 45-year-old man sustained pelvic and thigh frac- cence study revealed no satisfactory erectile episodes. A tures in an automobile accident. Despite correct treatment selective internal iliac arteriogram revealed complete obthe trauma led to severe urinary incontinence and the pa- struction of the right pudendal artery and partial obstruction tient had complete erectile failure. ARer intracavernous in- of the left pudendal artery pmxhally. Various options, including a vacuum device and penile prosthesis. were offered Accepted for publication April 18, 1997. 1783
Microsurgical revascularization of the penis is an accepted surgical procedure for vasculogenic imp~tence.'-~The best candidates for this surgery are young men with no significant vascular risk factors in whom impotence is associated with pelvic bone fracture or blunt perineal trauma,6*' particularly those in whom arterial revascularization is considered. TOday improved laparoscopic techniques and the availability of a wide array of laparoscopic surgical equipment in urological operating rooms have made this procedure suitable for a large number of surgical, including some unusual, objective~.~ In most penile revascularization techniques the inferior epigastric artery has been used in direct arterial-to-arterial revascularization and dorsal vein arterialization procedures. Unfortunately it requires a wide pararectal, transverse or midline incision, which results in poor esthetic and sometimes causes postoperative complications. To obviate this drawback Lund et a1 recently suggested the laparoscopic mobilization of the inferior epigastric vessels.' We report 2 consecutive cases of successful laparoscopically assisted penile revascularization for vasculogenic impotence. We investigated whether it is possible to mobilize the inferior epigastric vessels using a laparoscopic approach and follow pedicle extraction to avoid torsion of the vessels.
1784
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION
FIG.2. Case 2. First trocar is inserted a t lateral border of rectus muscle a t level of umbilical line through Hasson incision. Other 2 trocars are placed laterally and additional trocar is introduced through infrapubic incision.
FIG. 1. Case 1. Common iliac arteriography reveals truncation of left iliac artery and normal epigastric artery.
but the patient refused them and, thus, revascularization of the penile vessels was planned. With the patient under general anesthesia the first trocar was inserted a t the lateral border of the rectus muscle at the level of the umbilical line through a Hasson incision and pneumoperitoneum was induced. Two additional trocars were positioned laterally on the opposite side of the abdomen to the epigastric artery that was to be dissected (fig. 2). As soon as the inferior epigastric vessels were accessed, dissecFIG. 3. Case 2. Left inferior epigastric artery is tunneled through tion of the inferior epigastric artery was initiated below the infrapubic incision at base of penis, arcuate line level. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level, avoiding unnecessary separation of the artery from its accompanying veins. The inferior epigas- because of arteriosclerotic degeneration of the dorsal artertric pedicle was ligated with clips and transected at the ies. cephalad edge of the dissection. It was then mobilized and RESULTS tunneled through a n infrapubic incision a t the base of the penis for subsequent microvascular anastomosis with The anastomosis was patent and hemostasis was satisfacthe penile vessels (fig. 3). The peritoneum was not closed, tory in both patients. Operative time was 4.3 and 5.2 hours, which is common in laparoscopic surgery. respectively. There were no complications during convalesIn case 1 the anastomosis was created according to the cence and the patients were discharged home on day 3 postSharlip technique. The inferior epigastric artery was anasto- operatively. Aspirin was recommended for 1 month after mosed end-to-end to the proximal stump of the transected the operation. In addition, they received self-injected vasoacdorsal penile artery using 12 discontinuous stitches of 9-zero tive treatment (20 mcg. prostaglandin E l ) for 3 months as to 1-0 polypropylene, so that the cavernous artery was revas- well as behavioral sex therapy. At 3 months the initial pacularized in a retrograde manner through the common penile tient reported complete erections and no further need for trunk. In case 2 a microvascular anastomosis was con- drug therapy, while the other noted that the quality of sponstructed end-to-side between 1 branch of the inferior epigas- taneous erections had improved and vasoactive therapy was tric artery and an isolated segment of the deep dorsal vein needed less often a t a decreased dose. It is significant that
LAPAROSCOPICALLY ASSISTED PENILE REVASCULARIZATION both patients were unresponsive to intracorporeal injections before the intervention. A selective internal iliac arteriogram 3 months postoperatively revealed a patent microvascular anastomosis in case 1 (fig.4).This finding was confirmed by duplex scanning. The other patient refused a postoperative iliac arteriogram but color Doppler ultrasound showed a high flow rate through the arteriovenous bypass. In addition, after injection of 20 mcg. prostaglandin E l maximum systolic velocities in the right and left cavernous arteries were 33 and 36 cm. per second, respectively. DISCUSSION
Penile revascularization in vasculogenic posttraumatic impotence is a useful urological tool but correct patient selection is mandatory to obtain the best results. The ideal candidates for this kind of surgery are young men with no significant vascular risk factors in whom impotence is associated with arterial lesions of the pudendal, common penile or cavernous arteries due to pelvic bone fracture or blunt perineal trauma." Concurrent traumatic veno-occlusive dysfunction following blunt pelvic or perineal trauma is not a rare finding.6 Traumatic corporeal veno-occlusive dysfunction affects the prognosis unfavorably in bypass surgery, since surgical intervention appears to provide no obvious long-term benefit.g Patients with significant vascular risk factors are poor candidates for bypass surgery and they are encouraged to consider other options for treating impotence." In case 2 there was widespread atherosclerosis. Various options, including a vacuum device or penile prosthesis, were discussed but the patient refused them and, thus, revascularization of the penile vessels was planned. Various penile revascularization techniques have been described in the last 20 but in our opinion the technique should be individualized depending on the pathological findings in each case. In addition, preference should be given to physiological revascularization procedures whenever possible. In case 1the anastomosis was created according to the Sharlip technique, which in our opinion is the best solution because it involves retrograde revascularization of the cavernous artery through the common penile trunk. In case 2 this kind of microvascular anastomosis was not possible, since the dorsal arteries were affected by serious atheriosclerotic degeneration. Thus, an end-to-side microvascular anas-
1785
tomosis was constructed between 1 branch of the inferior epigastric artery and an isolated segment of the deep dorsal vein. The inferior epigastric artery is used in direct artery-toartery revascularization and dorsal vein arterialization. To date the inferior epigastric artery has been mobilized via a lower midline or pararectal abdominal incision. Laparoscopic mobilization of the inferior epigastric vessels was previously performed in 1995 by Lund et al.' In our 2 cases we evaluated the possibility of mobilizing the inferior epigastric artery through a laparoscopic approach to avoid a long abdominal incision and resection of the rectus muscle. In these patients the operation was performed using a transperitoneal approach. We did not consider the preperitoneal approach because we had little experience with it and believed that it would be difficult, even for expert laparoscopic surgeons, to create a sufficient extraperitoneal laparoscopic working space in the space of Retzius to mobilize the inferior epigastric artery. The advantages of the laparoscopic approach are significantly decreased postoperative morbidity, pain, scarring and convalescence. Laparoscopy is a simple procedure when performed by an experienced surgeon. The only necessary precaution is positioning the trocars as laterally as possible to allow greater angulation of the laparoscopic instruments. In this manner excellent access to the inferior epigastric bundle is achieved. Laparoscopic magnification allows quite simple and quick dissection of the inferior epigastric bundle. During laparoscopic dissection the artery is separated fkom its accompanying veins, which may result in arterial injuries. Adequate length is obtained and the artery is transected at the umbilical level. It is then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels. Extraction of the pedicle is followed up laparoscopically to avoid torsion of the vessels. This procedure has been previously described using 4 working trocars. In our opinion only 3 trocars as well as one used to pass the artery through the lower incision are sufficient. Introduction of an additional, optional trocar through the infrapubic incision allows safer extraction. CONCLUSIONS
Laparoscopically assisted penile revascularization was recently performed in a young patient with impotence and cavernous arterial insufficiency resulting from trauma induced occlusive arterial disease. Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perform rapid, accurate excision of the epigastric bundle from its point of origin at the external iliac vessels to a cephalad point. Thus, sufficient length is obtained for the vessels to reach the penile incision. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided. The availability of laparoscopic devices provides opportunities for appling new solutions to problems that are rarely encountered in ordinary urological practice. In our cases laparoscopy has proved to be a viable alternative to the traditional surgical approach, and it is as safe and effective. Experience in laparoscopic techniques results in decreased postoperative pain, and considerably shorter hospitalization and recovery. REFERENCES
FIG. 4. Case 1. Postoperative selective internal ihac.a*ripgraphy
patent microvascular anastomosis. Metalllc chp 1s vlstble on epigastric vein near anastomosis.
1. Virag, R.: Revascularization of the penis. In: Management of Male Impotence. Edited by A. H. Bennet. Baltimore: Williams & Wilkins, DD. 219-233. 1982. 2. McDougal, W:8. and Jeff&, R. F.: Microscopic penile rev-larization. J. Urol., 129: 517, 1982. 3. Janssen, T.,Sarramon, J. P., Rischmann, P., Bennis, S. and
1786
LApARoscopIcAuy ASSISTED PENILE REVASCULARIZATION
Malavaud, B.: Mimurgical arterio-arterial and art,erio-venous 8. Lund, G. 0..Winfield, H. N. and Donovan, J. F.: Laparoscopic d y assisted penile revascularization for vasculogenic impopenile revascularizationin patients with pure arteriogenici m p tence. Brit. J. Urol.. 75: 561.1994. tence. J. Urol., 183: 1923,1995. 4. Lizza, E. F.and Zorgniotti, A. W.: Experience with the long-term 9. Merckx, L.A., De Bruyne, R. M. G., Goes, E.,Derde, M. P. and effect of microsurgical penile revascdanm ' tion. Int. J. I m p Keuppens, F.: The value of dynamic color duplex canning in tence Res., 6 145,1994. the diagnosis of venogenic impotence. J. Urol., 148: 318,1992. 5. Goldstein, I. and Krane, R. J.: Diagnosis and therapy of erectile 10. Hatzichristou, D. G.and Goldstein, I.: Arterial by-pass surgery dysfunction. In: Campbell's Urology, 6th ed. Edited by P. C. for impotence. Curr.Opin. Urol., 1: 114,1992. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. 11. Shaw, W.W. and Zorgniotti, A. W.: Surgical techniques in penile Philadelphia: W. B. Saundem Co., chapt. 84, pp. 30333070, revascularization. Urology, special NO., 23: 76,1984. 1992. 12. Newman, H.F.and h i s s , H.: Method for exposure of cavernous 6. Munarriz, R. M., Yan, Q. G., Nehra, A,, Udelson, D. and artery. Urology, 19: 61,1982. Goldstein, 1.: Blunt trauma: the pathophysiology of hemodynamic injury leading to erectile dysfunction. J. Urol., 183: 13. Sharlip, I. D.: Retrograde revascularization of the dorsal artery for arteriogenic erectile dysfunction. J. Urol., part 2, 131: 1831,1995. 232A,abstract 513, 1984. 7. h m b e t t a , C., Liguori, G., Savoca, G., Siracusano, S., Brattovich, A. and Belgrano, E.: Unusual application of lapa- 14. Sharaby, J. S.,Benet, A. E. and Melman, A.: Penile revascularization. Urol. Clin. N. h e r . , 2 2 821, 1995. roscopy in urology. Eur. Urol., suppl. 2.30: 193,1996.