Penile vascular surgery for treating erectile dysfunction: Current role and future direction

Abstract

Penile vascular surgery for treating erectile dysfunction (ED) is still regarded cautiously. Thus we reviewed relevant publications from the last decade, summarising evidence-based reports consistent with the pessimistic consensus and, by contrast, the optimistically viable options for vascular reconstruction for ED published after 2003. Recent studies support a revised model of the tunica albuginea of the corpora cavernosa as a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat. Additional studies show a more sophisticated venous drainage system than previously understood, and most significantly, that the emissary veins can be easily occluded by the shearing action elicited by the inner and outer layers of the tunica albuginea. Pascal’s law has been shown to be a significant, if not the major, factor in erectile mechanics, with recent haemodynamic studies on fresh and defrosted human cadavers showing rigid erections despite the lack of endothelial activity. Reports on revascularisation surgery support its utility in treating arterial trauma in young males, and with localised arterial occlusive disease in the older man. Penile venous stripping surgery has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated, with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is appropriate using a sound method. It should be a promising option in the near future.

Surgical niche for the treatment of erectile dysfunction

“…122 For currently refined penile venous stripping surgery, the innovative venous anatomy of the penis has served as a blueprint. 115,123 A circumferential incision is first made, and Buck's fascia overlying the dorsal aspect of the penis is entered. DDV is ready for identification and stripping initiated from the level of the coronary sulcus distally.…”

The current situation in penile transplantation; a morphological evaluation

“…[7,8] A. pudenda interna, a. perinealis dalını verdikten sonraki kısmı bazı kaynaklarda a. penis communis olarak adlandırılmaktadır. [9,10] Bu kısımdan üç dal çıkmaktadır; a. bulbourethralis, a. dorsalis profunda penis ve a. profunda penis (a. cavernosa). [7] A. dorsalis profunda penis'ler bazı kaynaklarda a. dorsalis penis olarak geçmektedir, fakat bu adlandırma sırttaki a. dorsalis superficialis penis ve kavernöz cismin içindeki a. profunda penis (cavernosa) ile karıabilmektedir.…”

“…Bu damarlar penis derisi ve prepitium penis'in venöz drenajını yaparlar ve ereksiyon mekanizmasında etkileri yoktur. [10] Ara venler; V. circumlexa'lar, corpus spongiosum'dan çıkarlar ve corpus cavernosum etrafında dairesel olarak sırta do¤ru yükselirler. Bu venler özellikle penis gövdesinin distal 2/3'ünde bulunurlar sayıları 3 ile 10 arasında de¤iir.…”

“…[17][18][19] V. dorsalis profunda penis genelde tek olmasına ra¤men bazen çift olarak görülebilir. [10] V. paraarterialis medialis ve lateralis penis sırtında fascia profunda'nın altında her bir a. dorsalis profunda penis'in iki yanında birer çift olarak ilerlerler. Penis distalinde daha belirgindirler.…”

“…Arkada plexus venosus prostaticus'a (Santorini venöz pleksusu) veya v. pudenda interna'ya drene olurlar. [10,[17][18][19] V. cruralis, her bir crus penis'in iç yüzlerinden birer adet olarak çıkarlar ve v. cavernosa'lara açılarak en sonunda v. pudenda interna'ya açılırlar. Kavernöz cisimlerin arka bölümlerinin derin kısımlarını drene ederler.…”