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Pulmonary Migration of Coils Inserted for Treatment of Erectile Dysfunction Caused by Venous Leakage
0022-534 7 / 93/1495-13 16$03.00/ 0 THE JOURNAL OF UROLOGY Copyright © 1993 by AMERICAN UROLOGICAL ASSOCIATIO N, INC.
Vol. 149, 13 16-1318, May 1993
Printed in U.S.A.
PULMONARY MIGRATION OF COILS INSERTED FOR TREATMENT OF ERECTILE DYSFUNCTION CAUSED BY VENOUS LEAKAGE EVYATAR Z. MORIEL, C. MARK MEHRINGER, MARK SCHWARTZ
AND
JACOB RAJFER*
From the Division of Urology, Departments of Surgery and Radiology, UCLA School of Medicine, Harbor-UCLA Medical Center, Torrance, California
ABSTRACT
Embolization of penile veins by coils and/or detachable balloons has been reported as a possible effective form of treatment of venogenic erectile dysfunction_ The major appeal for this avenue of therapy in these patients is the reported low morbidity and negligible rate of complications compared to an open operation. We describe a case of asymptomatic pulmonary migration of a coil placed for venous leakage in a patient in whom the procedure was conducted through the femoral vein rather than the deep dorsal vein_ We conclude that patients undergoing coil embolization for venous leakage should be appraised of the potential for coil migration. KEY WORDS :
impotence; penile erection; embolization, therapeutic; venous insufficiency; pulmonary embolism
Vasculogenic impotence in man may be due to either insufficient blood flow to the corpora cavernosa,1 a defect in corporeal smooth muscle relaxation, failure to retain the blood within the corpora 2 or a combination of these 3 conditions. The inability to retain blood within the corpora, euphemistically termed venous leakage, is defined clinically by the inability to elevate and maintain intracorporeal pressure at or above mean systolic blood pressure during dynamic infusion cavernosometry. When there is a clinical suspicion of venous leak by dynamic infusion cavernosometry, cavernosography is used to visualize the veins that drain those areas of the corpora cavernosa that fail to entrap the corporeal blood. Treatment of venous leakage may consist of either surgical ligation 1 •3- 6 or radiological embolization of those veins that are identified on cavernosography as the leaking veins. Radiological embolization can be performed with either detachable balloons and/or coils. 1 • 5 While the advantage of such therapy is the low complication rate after embolization, the fear is the possibility of coil or balloon migration to the pulmonary tree. We describe an asymptomatic coil migration in a patient who was treated in this manner for erectile dysfunction. CASE REPORT
A 35-year-old white man presented because of an inability to obtain and maintain a rigid erection since age 17 years. History was unremarkable. Physical examination was completely normal as was the serum testosterone level. The patient underwent intracorporeal injections of a combination of prostaglandin El, papaverine and phentolamine but failed to achieve adequate penile rigidity with the regimen. A left curvature of the penis was noted compatible with either early Peyronie's disease or congenital curvature of the penis. A duplex scan of the penile arteries was normal. Dynamic infusion cavernosometry demonstrated an inability to elevate the intracorporeal pressure above 33 mm. Hg. Subsequently, a cavernosogram showed opacification of the cavernous veins. Through an inguinoscrotal incision, surgical ligation of the deep dorsal and cavernous veins was performed. There was no improvement postoperatively and a postoperative cavernosogram demonstrated extracorporeal contrast medium only in the crural veins bilaterally. Bilateral crural vein plication through a perinea! incision was then performed. Postoperatively, minimal improvement of the erection was achieved and a repeat cavernosogram demonstrated leakage only from the right crural Accepted for publication August 21, 1992.
* Requests for reprints: Division of Urology, Box 5, Harbor UCLA
FIG. 1. Anteroposterior view of pelvis demonstrates 5 coils in right internal pudenda! vein. Venogram shows no distal filling past coils.
veins. After informed consent, radiological insertion of 5, 4 X 30 mm. coilst into the crural vein effluent was performed using a femoral approach (fig. 1) . Following insertion of the coils there was again no significant improvement in erectile function. The patient was scheduled for another cavernosogram and on the scout film obtained before the cavernosogram only 3 of the 5 coils were observed in the pelvis (fig. 2). A chest x-ray revealed 2 coils in the chest (fig. 3) . DISCUSSION
When impotent patients are evaluated by cavernosography the most common venous channel seen draining the corpora is the cavernous veins. 3 • 4 In addition, the deep dorsal, crural and occasionally the urethral veins may also be visualized. The cavernous and crural veins drain into the internal pudenda! vein, which in turn drains into the internal iliac vein. 3 The deep dorsal and urethral veins provide drainage primarily from the glans penis, the distal corpora cavernosa and the corpus spongiosum, and then drain into the periprostatic plexus along the lateral wall of the bladder into the internal iliac vein.4 The surgical treatment of venous leakage consists mainly of ligation of the deep dorsal, cavernous, urethral and crural veins, as indicated by the results of the cavernosogram.1• 3 - 6 An alter-
Medical Center, 1000 W. Carson St., Torrance, California 90509. 1316
t Target Therapeutics, San Jose, California.
PuLMONA.RY rvHGRATION OF COILS INSERTED FOR TREATivl:ENT OF ERECTILE DYSFUNCTION
1317
treated in this fashion and the reported detachment rate in this disorder is still miniscule. In summary, venous embolization using detachable coils or balloons has been considered as a form of therapy for venogenic impotence. However, it should be noted that dislodgement and migration of these devices through the venous system into the pulmonary circulation may occur. While this is a potential complication from this procedure, patients who have experienced this adverse effect are characteristically asymptomatic and do not require any treatment for these migrating coils.
REFERENCES
FIG. 2. Anteroposterior view of pelvis 2 weeks after figure 1. Two most superior coils are no longer seen. Syringe overlies left side of patient.
native to surgical vein ligation is venous embolization via detachable balloons and/or coils. 5 Courtheoux et al first described occlusion of the deep dorsal vein with detachable balloons for the treatment of venous leakage.' There were no complications reported in any of their 31 patients, as well as the 13 patients treated by Bookstein and Lurie,7 the 6 patients treated by Sidi et al 8 and the 6 patients treated by Yu et al. 9 The use of coils and/or detachable balloons in the treatment of venous disease is not novel and has been extensive in the treatment of varicoceles. 10- 12 A potential complication from such therapy is the possibility of migration of these coils or balloons from the spermatic vein to the vena cava and then into the pulmonary arterial tree. In the only case reported to date that occurred following treatment for a varicocele"1 the patient was clinically unaware of the complication and was totally asymptomatic. The diagnosis was made by chest x-ray when plain abdominal x-rays did not identify the correct number of coils or balloons used in the procedure. 18 Similarly, in our patient the only index of suspicion came from such an abdominal x-ray. It may be argued that placement of these coils for venous leakage through a femoral rather than a dorsal vein approach may be more conducive to coil detachment from the venous system. However, patients with varicoceles are usually
1. Courtheoux, P., Maiza D., Henriet, J.P., Vaislic, C. D., Evrard, C. and Theron, J.: Erectile dysfunction caused by venous leakage: treatment with detachable balloons and coils. Radiology, 161: 807, 1986. 2. Rajfer, J., Rosciszewski, A. and Mehringer, M.: Prevalence of corporeal venous leakage in impotent men. J. Urol., 140: 69, 1988. 3. Bar-Moshe, 0., and Vandendris, M.: Treatment of impotence due to perinea! venous leakage by ligation of crura penis. J. Urol., 139: 1217, 1988. 4. Breza, J., Aboseif, S. R., Orvis, B. R., Lue, T. F. and Tanagho, E. A.: Detailed anatomy of penile neurovascular structures: surgical significance. J. Urol., 141: 437, 1989. 5. Rossman, B., Mieza, M. and Melman, A.: Penile vein ligation for corporeal incompetence: an evaluation of short-term and longterm results. J. Urol., 144: 679, 1990. 6. Wespes, E. and Schulman, C. C.: Venous leakage: surgical treatment of a curable cause of impotence. J. Urol., 133: 796, 1985. 7. Bookstein, J. J. and Lurie, A. L.: Transluminal penile venoablation for impotence: a progress report. Cardiovasc. Intervent. Rad., 11: 253, 1988. 8. Sidi, A. A., Hunter, D. W. and Becher, E. F.: Sclerotherapy and embolization for the treatment of venous incompetence. Int. J. Impotence Res., suppl. 2, 2: 356, 1990. 9. Yu G. W., Schwab, F. J., Melograna, F. S., DePalma, R. G., Miller, H. C. and Rickholt, A. L.: Preoperative and postoperative dynamic cavernosography and cavernosometry: objective assessment of venous ligation for impotence. J. Urol., 14 7: 618, 1992. 10. Riedl, P., Lunglmayr, G. and Stack!, W.: A new method of transfemoral testicular vein obliteration for varicocele using a balloon catheter. Radiology, 139: 323, 1981. 11. Berkman, W. A., Price, R. B., Wheatley, J. K., Fajman, W. A., Stones, P.J. and Casarella, W. J.: Varicoceles: a coaxial coil occlusion system. Radiology, 151: 73, 1984. 12. Fisch, H.: The surety of surgical repair of varicoceles. Contemp. Urol., 3: 68, 1991.
FIG. 3. Posteroanterior (A) and lateral (B) chest x-rays demonstrate 2 coils in right pulmonary artery (arrows)
1318
MORIEL AND ASSOCIATES
EDITORIAL COMMENT
of these men have psychogenic impotence and the mechanism of the erectile insufficiency is corporeal-venous occlusive dysfunction (venous leakage) secondary to anxiety mediated incomplete corporeal smooth muscle relaxation. 1' 2 For these reasons we believe that men should not be subjected to treatment for venous leak impotence unless in addition to abnormal pharmacocavernosometry they have evidence of impaired nocturnal penile tumescence.
This study is noteworthy because to my knowledge it is the first report of this complication of a relatively new treatment for the entity known as venogenic or venous leak impotence. However, I am concerned that this patient had 2 operations and 1 interventional radiological procedure without improvement in the erectile function, and the last procedure resulted in a potentially serious complication. Although the history is not clear, since erectile dysfunction was present from age 17 years this patient presumably had primary impotence. In our experience otherwise healthy men with primary impotence almost always have normal nocturnal penile tumescence. The majority
Drago K. Montague Department of Urology Cleveland Clinic Foundation Cleveland, Ohio 1. Montague, D. K., Lakin, M. M., VanderBrug Medendorp, S. and Tesar, L. J.: Infusion pharmacocavernosometry and nocturnal penile tumescence findings in men with erectile dysfunction. J. Urol., 145: 768, 1991. 2. Montague, D. K. and Lakin, M. M.: False diagnoses of venous leak impotence. J. Urol., 148: 148, 1992.
13. White, R. I., Jr., Kaufman, S. L., Barth, K. H., Kadir, S., Smyth, J. W. and Walsh, P. C.: Occlusion of varicoceles with detachable balloons. Radiology, 139: 327, 1981.
Vol. 149, 13 16-1318, May 1993
Printed in U.S.A.
PULMONARY MIGRATION OF COILS INSERTED FOR TREATMENT OF ERECTILE DYSFUNCTION CAUSED BY VENOUS LEAKAGE EVYATAR Z. MORIEL, C. MARK MEHRINGER, MARK SCHWARTZ
AND
JACOB RAJFER*
From the Division of Urology, Departments of Surgery and Radiology, UCLA School of Medicine, Harbor-UCLA Medical Center, Torrance, California
ABSTRACT
Embolization of penile veins by coils and/or detachable balloons has been reported as a possible effective form of treatment of venogenic erectile dysfunction_ The major appeal for this avenue of therapy in these patients is the reported low morbidity and negligible rate of complications compared to an open operation. We describe a case of asymptomatic pulmonary migration of a coil placed for venous leakage in a patient in whom the procedure was conducted through the femoral vein rather than the deep dorsal vein_ We conclude that patients undergoing coil embolization for venous leakage should be appraised of the potential for coil migration. KEY WORDS :
impotence; penile erection; embolization, therapeutic; venous insufficiency; pulmonary embolism
Vasculogenic impotence in man may be due to either insufficient blood flow to the corpora cavernosa,1 a defect in corporeal smooth muscle relaxation, failure to retain the blood within the corpora 2 or a combination of these 3 conditions. The inability to retain blood within the corpora, euphemistically termed venous leakage, is defined clinically by the inability to elevate and maintain intracorporeal pressure at or above mean systolic blood pressure during dynamic infusion cavernosometry. When there is a clinical suspicion of venous leak by dynamic infusion cavernosometry, cavernosography is used to visualize the veins that drain those areas of the corpora cavernosa that fail to entrap the corporeal blood. Treatment of venous leakage may consist of either surgical ligation 1 •3- 6 or radiological embolization of those veins that are identified on cavernosography as the leaking veins. Radiological embolization can be performed with either detachable balloons and/or coils. 1 • 5 While the advantage of such therapy is the low complication rate after embolization, the fear is the possibility of coil or balloon migration to the pulmonary tree. We describe an asymptomatic coil migration in a patient who was treated in this manner for erectile dysfunction. CASE REPORT
A 35-year-old white man presented because of an inability to obtain and maintain a rigid erection since age 17 years. History was unremarkable. Physical examination was completely normal as was the serum testosterone level. The patient underwent intracorporeal injections of a combination of prostaglandin El, papaverine and phentolamine but failed to achieve adequate penile rigidity with the regimen. A left curvature of the penis was noted compatible with either early Peyronie's disease or congenital curvature of the penis. A duplex scan of the penile arteries was normal. Dynamic infusion cavernosometry demonstrated an inability to elevate the intracorporeal pressure above 33 mm. Hg. Subsequently, a cavernosogram showed opacification of the cavernous veins. Through an inguinoscrotal incision, surgical ligation of the deep dorsal and cavernous veins was performed. There was no improvement postoperatively and a postoperative cavernosogram demonstrated extracorporeal contrast medium only in the crural veins bilaterally. Bilateral crural vein plication through a perinea! incision was then performed. Postoperatively, minimal improvement of the erection was achieved and a repeat cavernosogram demonstrated leakage only from the right crural Accepted for publication August 21, 1992.
* Requests for reprints: Division of Urology, Box 5, Harbor UCLA
FIG. 1. Anteroposterior view of pelvis demonstrates 5 coils in right internal pudenda! vein. Venogram shows no distal filling past coils.
veins. After informed consent, radiological insertion of 5, 4 X 30 mm. coilst into the crural vein effluent was performed using a femoral approach (fig. 1) . Following insertion of the coils there was again no significant improvement in erectile function. The patient was scheduled for another cavernosogram and on the scout film obtained before the cavernosogram only 3 of the 5 coils were observed in the pelvis (fig. 2). A chest x-ray revealed 2 coils in the chest (fig. 3) . DISCUSSION
When impotent patients are evaluated by cavernosography the most common venous channel seen draining the corpora is the cavernous veins. 3 • 4 In addition, the deep dorsal, crural and occasionally the urethral veins may also be visualized. The cavernous and crural veins drain into the internal pudenda! vein, which in turn drains into the internal iliac vein. 3 The deep dorsal and urethral veins provide drainage primarily from the glans penis, the distal corpora cavernosa and the corpus spongiosum, and then drain into the periprostatic plexus along the lateral wall of the bladder into the internal iliac vein.4 The surgical treatment of venous leakage consists mainly of ligation of the deep dorsal, cavernous, urethral and crural veins, as indicated by the results of the cavernosogram.1• 3 - 6 An alter-
Medical Center, 1000 W. Carson St., Torrance, California 90509. 1316
t Target Therapeutics, San Jose, California.
PuLMONA.RY rvHGRATION OF COILS INSERTED FOR TREATivl:ENT OF ERECTILE DYSFUNCTION
1317
treated in this fashion and the reported detachment rate in this disorder is still miniscule. In summary, venous embolization using detachable coils or balloons has been considered as a form of therapy for venogenic impotence. However, it should be noted that dislodgement and migration of these devices through the venous system into the pulmonary circulation may occur. While this is a potential complication from this procedure, patients who have experienced this adverse effect are characteristically asymptomatic and do not require any treatment for these migrating coils.
REFERENCES
FIG. 2. Anteroposterior view of pelvis 2 weeks after figure 1. Two most superior coils are no longer seen. Syringe overlies left side of patient.
native to surgical vein ligation is venous embolization via detachable balloons and/or coils. 5 Courtheoux et al first described occlusion of the deep dorsal vein with detachable balloons for the treatment of venous leakage.' There were no complications reported in any of their 31 patients, as well as the 13 patients treated by Bookstein and Lurie,7 the 6 patients treated by Sidi et al 8 and the 6 patients treated by Yu et al. 9 The use of coils and/or detachable balloons in the treatment of venous disease is not novel and has been extensive in the treatment of varicoceles. 10- 12 A potential complication from such therapy is the possibility of migration of these coils or balloons from the spermatic vein to the vena cava and then into the pulmonary arterial tree. In the only case reported to date that occurred following treatment for a varicocele"1 the patient was clinically unaware of the complication and was totally asymptomatic. The diagnosis was made by chest x-ray when plain abdominal x-rays did not identify the correct number of coils or balloons used in the procedure. 18 Similarly, in our patient the only index of suspicion came from such an abdominal x-ray. It may be argued that placement of these coils for venous leakage through a femoral rather than a dorsal vein approach may be more conducive to coil detachment from the venous system. However, patients with varicoceles are usually
1. Courtheoux, P., Maiza D., Henriet, J.P., Vaislic, C. D., Evrard, C. and Theron, J.: Erectile dysfunction caused by venous leakage: treatment with detachable balloons and coils. Radiology, 161: 807, 1986. 2. Rajfer, J., Rosciszewski, A. and Mehringer, M.: Prevalence of corporeal venous leakage in impotent men. J. Urol., 140: 69, 1988. 3. Bar-Moshe, 0., and Vandendris, M.: Treatment of impotence due to perinea! venous leakage by ligation of crura penis. J. Urol., 139: 1217, 1988. 4. Breza, J., Aboseif, S. R., Orvis, B. R., Lue, T. F. and Tanagho, E. A.: Detailed anatomy of penile neurovascular structures: surgical significance. J. Urol., 141: 437, 1989. 5. Rossman, B., Mieza, M. and Melman, A.: Penile vein ligation for corporeal incompetence: an evaluation of short-term and longterm results. J. Urol., 144: 679, 1990. 6. Wespes, E. and Schulman, C. C.: Venous leakage: surgical treatment of a curable cause of impotence. J. Urol., 133: 796, 1985. 7. Bookstein, J. J. and Lurie, A. L.: Transluminal penile venoablation for impotence: a progress report. Cardiovasc. Intervent. Rad., 11: 253, 1988. 8. Sidi, A. A., Hunter, D. W. and Becher, E. F.: Sclerotherapy and embolization for the treatment of venous incompetence. Int. J. Impotence Res., suppl. 2, 2: 356, 1990. 9. Yu G. W., Schwab, F. J., Melograna, F. S., DePalma, R. G., Miller, H. C. and Rickholt, A. L.: Preoperative and postoperative dynamic cavernosography and cavernosometry: objective assessment of venous ligation for impotence. J. Urol., 14 7: 618, 1992. 10. Riedl, P., Lunglmayr, G. and Stack!, W.: A new method of transfemoral testicular vein obliteration for varicocele using a balloon catheter. Radiology, 139: 323, 1981. 11. Berkman, W. A., Price, R. B., Wheatley, J. K., Fajman, W. A., Stones, P.J. and Casarella, W. J.: Varicoceles: a coaxial coil occlusion system. Radiology, 151: 73, 1984. 12. Fisch, H.: The surety of surgical repair of varicoceles. Contemp. Urol., 3: 68, 1991.
FIG. 3. Posteroanterior (A) and lateral (B) chest x-rays demonstrate 2 coils in right pulmonary artery (arrows)
1318
MORIEL AND ASSOCIATES
EDITORIAL COMMENT
of these men have psychogenic impotence and the mechanism of the erectile insufficiency is corporeal-venous occlusive dysfunction (venous leakage) secondary to anxiety mediated incomplete corporeal smooth muscle relaxation. 1' 2 For these reasons we believe that men should not be subjected to treatment for venous leak impotence unless in addition to abnormal pharmacocavernosometry they have evidence of impaired nocturnal penile tumescence.
This study is noteworthy because to my knowledge it is the first report of this complication of a relatively new treatment for the entity known as venogenic or venous leak impotence. However, I am concerned that this patient had 2 operations and 1 interventional radiological procedure without improvement in the erectile function, and the last procedure resulted in a potentially serious complication. Although the history is not clear, since erectile dysfunction was present from age 17 years this patient presumably had primary impotence. In our experience otherwise healthy men with primary impotence almost always have normal nocturnal penile tumescence. The majority
Drago K. Montague Department of Urology Cleveland Clinic Foundation Cleveland, Ohio 1. Montague, D. K., Lakin, M. M., VanderBrug Medendorp, S. and Tesar, L. J.: Infusion pharmacocavernosometry and nocturnal penile tumescence findings in men with erectile dysfunction. J. Urol., 145: 768, 1991. 2. Montague, D. K. and Lakin, M. M.: False diagnoses of venous leak impotence. J. Urol., 148: 148, 1992.
13. White, R. I., Jr., Kaufman, S. L., Barth, K. H., Kadir, S., Smyth, J. W. and Walsh, P. C.: Occlusion of varicoceles with detachable balloons. Radiology, 139: 327, 1981.