Transperineal ultrasound imaging of the internal pudendal artery in arteriogenic erectile dysfunction
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Objective: to study the anatomical-topographical relationship between the prostate gland (PG) and the vascular structures responsible for erection, to justify the new concept of erectile dysfunction pathogenesis after brachytherapy of prostate cancer (PCa).Materials and methods. The study included 66 patients with verified or suspected PCa. All patients performed magnetic resonance imaging 1.5 T in accordance with the established protocol (hybrid method of visualization of internal pudendal arteries (IPA)). 16 patients simultaneously performed computed tomography on a topometric tomography. The resulting images were analyzed using the Eclipse 4.0 (Varian Medical System, USA) system, which provides 3D models of PG, pelvic bones and critical structures of interest: IPA, cavernous crura and penile bulb.Results. The average volume of PG was 44.9 ± 18.7 (14.4—98.0) cm3. The width of penile bulb was 1.83 ± 0.38 (1.1—2.93) cm. According to the implantation technique of in brachytherapy, the damage to penile bulb can be observed in less than a fifth of patients — 18.5 % of cases.Analysis of the 3D models showed that the overlay of the distal third of the IPA on the predominantly anterior and, in part, lateral aspects of the PG was noted in 58 (87.9 %) of 66 observations. The average value of PG in a group with no interference was 25.7 ± 3.9 (18.2—29.9) cm3, with its presence — 47.6 ± 18.4 (14.4—98.0) cm3. The average length of the IPA, coinciding with the projection of the PG on the right and left is virtually no different (p >0.05) and is about 2.5 cm, and the maximum remote point of this combination lies in relation to the outer contour of the gland within 1 cm. The correlation analysis showed a strong direct correlation between the volume of PG with all the parameters of mutual spatial anatomy of the prostate and IPA (R = 0.63—0.71; p <0.0001).Conclusion. The anatomical-topographical relationship between PG and critical structures, among which the IPA plays a special role, points to the likely predominantly traumatic genesis of erectile dysfunction after PCa brachytherapy, as well as a number of other invasive procedures performed by perineal access (saturation biopsy).
Objective: to study the anatomical-topographical relationship between the prostate gland (PG) and the vascular structures responsible for erection, to justify the new concept of erectile dysfunction pathogenesis after brachytherapy of prostate cancer (PCa).Materials and methods. The study included 66 patients with verified or suspected PCa. All patients performed magnetic resonance imaging 1.5 T in accordance with the established protocol (hybrid method of visualization of internal pudendal arteries (IPA)). 16 patients simultaneously performed computed tomography on a topometric tomography. The resulting images were analyzed using the Eclipse 4.0 (Varian Medical System, USA) system, which provides 3D models of PG, pelvic bones and critical structures of interest: IPA, cavernous crura and penile bulb.Results. The average volume of PG was 44.9 ± 18.7 (14.4—98.0) cm3. The width of penile bulb was 1.83 ± 0.38 (1.1—2.93) cm. According to the implantation technique of in brachytherapy, the damage to penile bulb can be observed in less than a fifth of patients — 18.5 % of cases.Analysis of the 3D models showed that the overlay of the distal third of the IPA on the predominantly anterior and, in part, lateral aspects of the PG was noted in 58 (87.9 %) of 66 observations. The average value of PG in a group with no interference was 25.7 ± 3.9 (18.2—29.9) cm3, with its presence — 47.6 ± 18.4 (14.4—98.0) cm3. The average length of the IPA, coinciding with the projection of the PG on the right and left is virtually no different (p >0.05) and is about 2.5 cm, and the maximum remote point of this combination lies in relation to the outer contour of the gland within 1 cm. The correlation analysis showed a strong direct correlation between the volume of PG with all the parameters of mutual spatial anatomy of the prostate and IPA (R = 0.63—0.71; p <0.0001).Conclusion. The anatomical-topographical relationship between PG and critical structures, among which the IPA plays a special role, points to the likely predominantly traumatic genesis of erectile dysfunction after PCa brachytherapy, as well as a number of other invasive procedures performed by perineal access (saturation biopsy).
The study objective is to define the state of the problem of surgical methods for the treatment arteriogenic forms of erectile dysfunction (ED) in the Republic of Belarus, to systematize surgical methods for the correction of arteriogenic ED, to evaluate the results of interventional, surgical and combined methods of the treatment of arteriogenic forms of ED in the Republic of Belarus.Materials and methods. A comprehensive examination was carried out 65 men with arteriogenic ED (average age 52.2 ± 2.2 year, International Index of Erectile Function – 9.6 ± 1.3 points; the hardness of erection – 2.2 ± 0.3 according to the Yunem scale) included ultrasound, multispiral computed angiography, as results of stenosing and occlusive lesions of the aorto-iliac segments, internal pudendal artery (IPA) and distal branches were revealed. Of these, as a result of atherosclerotic damage to arteries – 59 (91 %) patients, hypoplasia of the IPA – 4 (6 %) patients and in 2 (3 %) – cases due to post-traumatic damage to the IPA during fracture of the pelvic bones. Pro- and retrospectively performed analysis of the results of endovascular, surgical and combined correction of chronic arterial insufficiency of penis. Based on the results of the study, blood flow deficiency was simulated in order to determine the possible level and method of its elimination. Subsequently, 34 reconstructive operations were performed, including endovascular: superselective stenting of IPA – in 1 case, angioplasty of IPA – one-bilateral – in 4 cases, stenting of the iliac arteries – in 14 cases, in 4 cases – aorto-femoral bypass or prosthetics. Microsurgical operations with epigastric-penile anastomosis were performed in 9 cases (Virag II type in 8 cases, Michal II – Scharlip in 1 case), including in 3 cases as a second stage to increase arterial perfusion of penis after endovascular interventions. In 3 cases, for severe arteriogenic ED and endothelial insufficiency, endophalloprosthesis was implanted (AMS-Spectra).Results. According to the results of testing of patients after endovascular intervention or microsurgical reconstruction, as well as after a two-stage correction that included both methods, patients showed a statistically significant improvement in erectile function on the scale of the International Index of Erectile Function – from 9–12 points (10.0 ± 0.31 points) before surgery to 16–19 points (17.5 ± 0.25 points) 12 months after surgery (p = 0.0009).Conclusions. Interventional methods of correction after micro surgical and combined operations in patients with arteriogenic ED allow achieving a satisfactory result during the first year after surgery, provided that patients are carefully selected using a comprehensive examination, including various ultrasound techniques, multispiral computed angiography, as well as the selection of an appropriate type of revascularization.
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.
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