The possibility of application of endovascular and two-stage combined revascularization of the penis in the arteriogenic ED treatment is shown. Twenty male patients with multifocal atherosclerotic lesions of the aorto-iliac-femoral segments underwent the analysis of the branching patterns of the IPA according to the classifcation by Adachi and Yamaki followed by the interventional endovascular intervention (angioplasty, stenting) of the iliac arteries. Seventeen patients underwent the unilateral and three patients – bilateral stenting of the common and external iliac arteries. Three patients out of the total number of the operated ones additionally underwent an open revascularization of the penis by epigastric-penic anastomosis. A complex preoperative examination of patients – candidates for revascularization of the penis for arteriogenic erectile dysfunction was performed and included ultrasound, МCT-angiography of the pelvic arteries, and electroneuromyographic examination of atherosclerotic lesions of the pool vessels of the inner pudental artery. Subsequently, endovascular and combined open revascularization operations were performed on the iliac and penis vessels. The erectile function improvement according to the IIEF-5 scale (8–12 scores before the operation vs 16–19 points after the operation) was noted in 1, 3, 6, 12 months (p< 0.05). Combined revascularization operations on the iliac and penis arteries (endovascular and open “bypass”) allow an adequate arterial blood perfusion to the penis in the steno-occlusive lesions of the pool vessels of the IPA affected by atherosclerosis.

Introduction. Secondary varicose small pelvic veins with the development of chronic venous insufficiency due to obstruction of the magistral venous vessels, in particular, the left common iliac vein and the right common iliac artery (May–Thurner syndrome), occupy a special place in the structure of the causes of venogenic erectile dysfunction (ED).The study objective is to present the clinical case of arteriovenous conflict (May–Thurner syndrome), leading to the development of secondary varicose small pelvic veins in men and venogenic ED, as well as modern methods of its verification and endovascular surgical repair.Clinical case. A clinical case of successful endovascular correction of venogenic ED is presented. The patient is diagnosed with: May– Thurner syndrome. Pelvic varicose disease С3 (according to CEAP Classification). Condition after endovascular balloon angioplasty and stenting of the left common iliac vein. Bilateral varicocele. Condition after bilateral varicocelectomy in 2018. Severe venogenic ED (pathological venous drainage, proximal type, International Index of Erectile Function (v. 5) – 12 points; Er3 according to the Unem Scale) in accordance with the Comprehensive Classification System for Chronic Venous Disorders. On July 24, 2019 endovascular occlusion of the Santorini’s plexus veins was performed with the installation of occlusion spirals in their lumen according to Gianturco. In order to provide visualization of the veins in the Santorini’s plexus, given the impossibility of cannulation of the deep vein of the penis, bilateral symmetrical cannulation of the cavernous bodies of the penis was carried out to perform cavernosophlebography. The left common iliac vein was catheterized according to the Crossover technique. Under phlebography control we ensured that the stent in the common iliac vein passed without signs of loss of its lumen. The internal pudental vein on the left was selectively catheterized. Hydrophilic guidewire was introduced through the veins of the periprostatic plexus into the right internal pudental vein. Selective catheterization of the periprostatic venous plexus was not possible due to pronounced tortuosity, valve flaps of the veins and small diameter of the catheterized veins. It was decided to pass the guidewire further through the right iliac vein system with access to the inferior vena cava. Further, the guidewire was again transferred to the left common iliac vein (double crossover). The left common femoral vein was punctured followed by the placement of 5 Fr introducer sheath according to Seldinger. The guidewire tip was fixed by the loop in the left common iliac vein, then captured and brought out through the introducer in the left common femoral vein. A catheter Сobra15 Fr was inserted through a crossover guide from the left common femoral vein into the right internal iliac vein and further into the periostatic venous plexus. Gradually veins of the Santorini’s plexus were selectively catheterized followed by Gianturco coils embolization.Conclusion. The first choice surgery for verified proximal type ED is endovascular occlusion of the veins in the Santorini’s plexus through the deep vein of the penis, which allows to change the hemodynamics in the penis and provide sufficient erection without resorting to endofalloprosthesis of the penis. Single or double-sided transfemoral access is suggested for patients when access through the deep vein of the penis is rather challenging or absent.

The study objective is to evaluate the effectiveness of the Speroton complex therapy in combined treatment of oligoasthenospermia in patients with varicocele after microsurgical phlebectomy of varicose veins of the spermatic cord.Materials and methods. Microsurgical phlebectomy of the spermatic cord was performed in 40 men (mean age 33.0 ± 2.3 years) with oligoasthenospermia and varicocele. The patients were divided into 2 groups: the main group included 20 men who were treated with the Speroton complex for 3 months in the postoperative period, and the control group included 20 men who did not take Speroton. The spermogram parameters were evaluated before and after the operation.Results. Three months after the start of treatment, a statistically significant improvement in spermogram indicators was noted in all study groups. It was determined that combined therapy that included the Speroton complex administration for 3 months, statistically significantly led to the more considerable increase in sperm parameters than in control group: the sperm concentration increased to 38.6 and 28.9 mln/ml, respectively, the percentage of progressive motile sperm – to 49.2 and 39.4 %, the percentage of motile forms – to 72.2 and 43.8 %, viable forms – to 67.8 and 58.1 %, and the percentage of sperm with DNA fragmentation decreased to 12.1 and 17.2 %, respectively, in the main and control groups.Conclusion. Combined treatment with postoperative Speroton therapy for men of reproductive age with infertility and varicocele determines the more significant improvement in the parameters of sperm than performing only surgical correction of varicocele.

Цель исследования-изучить эффективность комбинированной эктомии варикозно расширенных вен полового члена и вен семенного канатика при лечении веногенной эректильной дисфункции дистального типа в сочетании с варикоцеле (как андрогенитальной формы варикозной болезни вен малого таза). Материалы и методы. Выполнено 5 комбинированных флебэктомий у пациентов с андрогенитальной формой варикозной болезни вен малого таза, клинически проявлявшейся эректильной дисфункцией, варикозом полового члена, варикоцеле. Результаты. Предоперационное комплексное обследование пациентов, включавшее мультиспиральную компьютерную, магнитно-резонансную ангио-и фармакокавернозографию с ультразвуковым дуплексным сканированием сосудов полового члена, мошонки, простатического венозного сплетения позволило верифицировать варикозную болезнь вен малого таза, клинически проявлявшуюся эректильными, дисморфофобическими нарушениями в сочетании с варикоцеле. Комбинированная эктомия поверхностных вен полового члена в сочетании с операцией Мармара (эктомией вен семенного канатика) и с блокированием венозного оттока от полового члена в сафенофеморальный бассейн путем перевязки наружных половых вен во всех случаях дала положительный результат. После комбинированной флебэктомии международный индекс эректильной функции у всех пациентов увеличился с 12 ± 2 балла и составил 21 ± 1 балл (р <0,05). Заключение. Разобщение поверхностной и глубокой вен полового члена путем обнажающей циркумцизии с эктомией поверхностной вены полового члена, перевязкой ретрогландулярных вен в области венечной борозды полового члена, а также высокая перевязка поверхностной вены полового члена и ее ветвей (v. pudenda externa) в пахово-бедренной области в сочетании с эктомией вен семенного канатика (операцией Мармара) позволяет восстановить гемодинамическое равновесие между артериальным притоком к половому члену и венозным оттоком от него.