Venous ligation procedures: rationale and technical considerations

The previous terms venous leakage, venous vasculogenic dysfunction or venogenic ED have been replaced by the more precise term CVOD [11]. CVOD may be due to structural alterations in the corporal smooth muscle, trabecular framework or tunica albuginea. The location and degree of venous leakage is variable and can occur anywhere along the tunica albuginea of the corpus cavernosum. Hyperc- holesterolemia and arterosclerotic-induced ische- mia can be associated with alterations in the fibroelastic components of the trabeculae [24]. A strong correlation has been demonstrated between measures of cavernosal venous leakage and trabecular smooth muscle content [25].

In addition, congenital anomalies and post- traumatic changes in the tunica albuginea can produce localized venous leakage [26,50]. Localiza- tion and severity of veno-occlusive dysfunction may

be determined by invasive dynamic intracavernosal cavernosometry and cavernosography (DICC) [27].

A less invasive screening test for patients with sus- pected CVOD is color-coded duplex sonography of the penile vessels with artificial erection stimulated by intracavernous injection of vaso-active drugs such as alprostadil or papaverine. Duplex sonography should be considered prior to DICC [28].

Ligating or resecting penile veins is symptomatic treatment but does not cure the underlying disease. Most methods of penile venous surgery were invented before basic research defined the patho- physiologic mechanisms of CVOD. The extensive collateral venous drainage of the penis is probably a major reason that these surgical procedures fail [29]. With respect to the disappointing long-term results of venous ligation and resection procedures dis- cussed later in this chapter, these operations are no longer recommended by several panels [4,30] and authors [31,32]. Nevertheless, better preoperative selection of young patients with rare congenital or post-traumatic isolated crural leakage, and the use of more sophisticated operative techniques for crural ligation or banding, may offer better long-term results in the future [50].

On the other hand, the concept of deep dorsal vein arterialization is still appealing for the treatment of

the literature from 1993 to 2003 was evaluated [4]. Eight studies were selected for evaluation (see Table 12.1). In Table 12.1 one further study, which appeared in 2004, is included [38].

The goal of an invasive vascular procedure for ED is to provide a durable and satisfying spontaneous erection with sexual stimulation without relying on pharmacologic augmentation. Using these strict criteria, success in these studies ranged from 27 to 94% for all procedures with no identified difference in success among the different techniques [4].

The best instrument for evaluating subjective success is the international index for erectile function (IIEF). This instrument has only been used in one study [34] and only for the postoperative evaluation. The IIEF was not administered to patients before surgery in this study.

In view of these data, it is impossible to draw def- inite conclusions concerning selection criteria for penile revascularization. If the arterial blood supply to the penis is impaired by systemic arteriosclerot- ic disease, no vascular reconstruction is appropri- ate because there are significant abnormalities in intracavernous structures [31]. Many authors have drawn conclusions concerning their own selection criteria, which are based on their personal experience. Advanced age (>50 years), smoking and the presence of severe corporal veno-occlusive dysfunction (CVOD) have been identified to have a signifi-cant negative impact on postoperative results [15,16,31,40,41,42]. The ideal candidate for penile revascularization is a young man with localized interruption of penile arterial supply after pelvic or straddle trauma, and without concomitant neural damage. Apart from the fact that these patients are very rare, the only published multicen- ter study in such a highly selected subgroup of patients showed a disappointing success rate of only 22% [21,43].

Complications of penile revascularization Complications occur in up to 25% of patients after penile revascularization [4,37,39]. Glans hyperemia is the most common complication after these procedures. Inguinal hernia formation and postoperative hematoma have occurred in up to 25% of patients as well [4].

Surgical Treatment of Erectile Dysfunction 131

CVOD [10,33,34], because in this operation venous ligation is combined with improved arterial inflow into the corpora, producing hypothetical beneficial effects on damaged intracavernosal tissue [34].

Recently, a new extraperitoneal laparoscopic approach to venous ligation has been suggested. With this approach, it is easy to gain access to the deep dorsal vein complex overlying the anterior prostatic surface. Suture ligation can be performed quite easily without damaging the dorsal penile structures. However, no long-term success data are available for this new approach to penile venous ligation [54].

Results As in penile revascularization, the literature on the results of venous surgery has been repeatedly reviewed for several consensus meetings. During the NIH consensus meeting in 1993, it was recommended that penile venous surgery should be used only in investigational settings in experienced centers with prospective outcome evaluation [35]. In 1994, a Medline®-based literature research revealed 30 studies with short-term follow up (<12 months) and a range of subjective success rates between 10 and 95% (median 62.3%) [21]. Twenty- two studies were found with long-term follow up data of more than 12 months. The success rates ranged from 13 to 74% with a median 41.4%. Only

12 studies compared short and long-term results. In these studies, the median short-term success rate dropped from 70 to 37.3% [21]. The AUA guideline panel recommendations from 1996 were not significantly different from the NIH recommendations in 1993 [36]. The updated 2005 AUA ED guideline recommends: “Surgeries performed with the intent to limit the venous outflow of the penis are not recommended” (http://auanet.org/ timssnet/products/guidelines/main_reports/ edmgmt/chapter1.pdf). During the Second Inter- national Consultation on Erectile Dysfunction in Paris 2003, it was concluded that meaningful data comparison between surgical series is not possible due to the varying diagnostic criteria, selection criteria, surgical techniques and length of follow-up and outcome assessment [4]. Six studies with a follow up of more than one year between 1997 and 1999 again showed success rates between 11.2 and

74% [4]. In Table 12.2, three recent studies are added to the original six studies from reference [4].

Several authors have tried to identify selection criteria, which might produce better results after penile venous surgery. In one study, only young, non- smoking patients with mild to moderate CVOD were selected, excluding those with significant smooth muscle degeneration and arterial pathology. But even in these patients success rates dropped to less than 50% after more than one year of follow up [4,45,46]. Even extensive ligation and resection procedures show the same steep decline in success after longer follow-up [32]. Perhaps there is a spe- cific subgroup of young, otherwise healthy patients with trauma-induced or congenital circumscribed veno-occlusive dysfunction who might profit from venous resection or plication procedures [26,48,50]. However at the present time, the weight of evidence is that no clear indication for venous surgery can be identified [4,30]. The weight of evidence against the value of penile venous surgery is so strong that single center reports showing excellent long-term results must be interpreted with caution [47,50].

Venous embolization has the advantage of being minimally invasive. It also allows immediate proof of venous ablation and obstruction [4,49]. Overall short-term results after venous embolization or ablation show the same range of success between 26 and 73% as open procedures. There is no agreement on indications and techniques for this approach to the treatment of CVOD.

Long-term results on laparoscopic suture ligation of the deep dorsal vein complex are not yet available. Early follow-up data using IIEF for evaluation of success reveal promising results in a small patient group [54].

Venous arterialization of the dorsal penile artery has been investigated as a treatment for CVOD [10,34]. In these two studies, the IIEF score was used for success evaluation but the results must be interpreted with caution. In Sarramon’s study, postoperative, but not preoperative, IIEF evaluation was done in 55% of patients. In Kayigil’s study, only 18% were evaluable for postoperative controls. Sarramon and Kayigil reported subjective success rates of 55% and 75%, respectively, but success declined with length of follow-up.

132 Chapter 12 Table 12.2 Outcome data of penile venous ligations surgery for CVOD. From [4,32,46,50].

Study Date pts.

Evaluation Outcome

12 Not specified 74% spontaneous

(mean 41)

deep dorsal,

months,

erections at 12

and emissary

term

55% long-term

vein ligation

deep and

19% ICI response Al Assal

vein ligation

Ligation of DDV,

Not specified Age < 40

(mean 45)

abnormal veins,

years

years:76%

cavernosal veins,

“cured” Lukkarinen

Ligation DDV,

52% ICI-response Basar

25 Not specified 6 months 15%

ligation

months

complete erection 23% partial erection

Schultheiss 1997 147

DDV ligation

spontaneous questionnaire

erection Rahman

34 IIEF score 80% subjective

success score from

8.9 to 17.5 (median)

54 Patient report 25.7%

(mean

ligations (no

crural vein

or PDE5-

ligation)

supported erections

Da Ros 2000

(occasionally erections crural plication)

Surgical Treatment of Erectile Dysfunction 133

Complications The vast majority of patients with CVOD have Complications of penile venous surgeries are signifi-

intracavernosal myopathy as the underlying cause cant and numerous. Wound infections, penile cur-

of venous leakage [31]. The well-known capacity vature or shortening, skin necrosis, and painful

of venous collaterialization after venous resection erection, as well as loss of glans, and shaft sensitivity,

may also explain the rapid decline of postoperative have been reported [4]. A recent report showed a

success. Only carefully selected young patients complication rate of 23.9% in 134 patients [46].

with isolated congenital or post-traumatic CVOD, When venous arterialization has been applied to

and without other concomitant pathologies, may patients with CVOD, up to 32% of patients have

benefit from individualized ligation procedures. experienced complications. This includes 8% who

The same restrictions are valid for percutaneous had glans hyperemia [10].

embolization techniques and for the application of venous arterialization procedures in CVOD patients.

After a careful analysis of literature on this subject,

Conclusions

the most recent recommendation of the erectile dys- The application of penile revascularization proce-

function guideline panel of the AUA concluded that dures even in highly selected patients performed by

surgeries performed with the intent to limit the venous well-trained experienced surgeons results in a vari-

outflow of the penis are not recommended [30]. able and unpredictable outcome. The precise mecha-

Further research should focus on diagnostic possi- nism by which these procedures yield their potential

bilities to differentiate isolated venous leakage benefit has not been fully elucidated. In the 2005

from systemic intracavernosal disease. Results of update of the AUA ED guideline, narrow criteria

evidence-based medicine meta-analyses in surgery were chosen for outcome evaluation. These criteria

of the venous system should be integrated in our were well-circumscribed arterial occlusive disease

future approaches [29]. Basic research on intracor- without obvious cavernous myopathy. Only four

poral hemodynamics should be pursued [44,51, studies with a total of 50 subjects who fit these crite-

ria could be found in the literature. The panel con- For future clinical studies, validated survey instru- cluded, that a patient population of 50 is too small to

ments such as the IIEF should be administered both determine whether arterial reconstructive surgery is effica-

pre- and post-operatively to determine long-term cious or not [30]. This conclusion coincides with the

success [4].

final recommendation of the Second International Consultation on Erectile Dysfunction from 2004 [4].

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136 Chapter 12

Venous ligation procedures: rationale and technical considerations