Laparoscopically Assisted Penile Revascularization for Vasculogenic Impotence

Surgical niche for the treatment of erectile dysfunction

Penile erection implicates arterial inflow, sinusoidal relaxation and corporoveno-occlusive function. By far the most widely recognized vascular etiologies responsible for organic erectile dysfunction can be divided into arterial insufficiency, corporoveno-occlusive dysfunction or mixed type, with corporoveno-occlusive dysfunction representing the most common finding. In arteriogenic erectile dysfunction, corpora cavernosa show lower oxygen tension, leading to a diminished volume of cavernosal smooth muscle and consequential corporoveno-occlusive dysfunction. Current studies support the contention that corporoveno-occlusive dysfunction is an effect rather than the cause of erectile dysfunction. Surgical interventions have consisted primarily of penile revascularization surgery for arterial insufficiency and penile venous surgery for corporoveno-occlusive dysfunction, whatever the mechanism. However, the surgical effectiveness remained debatable and unproven, mostly owing to the lack of consistent hemodynamic assessment, standardized select patient and validated outcome measures, as well as various surgical procedures. Penile vascular surgery has been disclaimed to be the treatment of choice based on the currently available guidelines. However, reports on penile revascularization surgery support its utility in treating arterial insufficiency in otherwise healthy patients aged <55 years with erectile dysfunction of late attributable to arterial occlusive disease. Furthermore, it is noteworthy that penile venous surgery might be beneficial for selected patients with corporoveno-occlusive dysfunction, especially with a better understanding of the innovated venous anatomy of the penis. Penile vascular surgery might remain a viable alternative for the treatment of erectile dysfunction, and could have found its niche in the possibility of obtaining spontaneous, unaided and natural erection.

Robot-assisted vessel harvesting for penile revascularization

INTRODUCTION

Ideal candidates for penile revascularization include young patients with documented vasculogenic erectile dysfunction usually resulting from pelvic trauma. Historically, large midline incisions were necessary to harvest the epigastric vessels for penile revascularization. We report our experience with robot-assisted epigastric vessel harvesting for use in penile revascularization procedures.

AIM

To describe our technique and experience with robot-assisted vessel harvesting for use in penile revascularization.

METHODS

Five patients were selected for penile revascularization. Each patient suffered pelvic crush injuries resulting in post-traumatic erectile dysfunction. Each patient had no significant prior medical history and had normal erectile function prior to injury. Penile duplex Doppler ultrasound studies using vasoactive agents demonstrated decreased arterial inflow. Complementary pelvic angiography documented the corresponding arterial lesions. Each patient underwent attempted penile revascularization using a modified Virag-V technique. The epigastric artery was harvested robotically and transposed through a 3 cm incision at the base of the penis. Microscopic revascularization was performed by anastamosing the epigastric artery to the deep dorsal vein. Distal dorsal vein ligation of the subcoronal plexus was performed to limit glans hyperemia.

MAIN OUTCOME MEASURES

Description of a new method of vessel harvesting for penile revascularization.

RESULTS

Penile revascularization was successful in four out of five patients. One patient had complete thrombosis of the deep dorsal penile vein and underwent subsequent penile prosthesis implantation. Each patient undergoing successful revascularization was discharged home two days postoperatively and has reported resumption of sexual activity.

CONCLUSIONS

The robot-assisted approach to epigastric vessel harvesting is an ideal minimally-invasive complement to penile revascularization. This procedure negates the need for a large midline incision and may shorten recovery time. Our described technique offers a novel option for the application of minimally-invasive technology, but longer-term follow-up is needed to further evaluate the success of penile revascularization.

Laparoscopically assisted penile revascularization for vasculogenic impotence: 2 additional cases

PURPOSE

Microsurgical revascularization of the penis in vasculogenic impotence is an accepted surgical procedure in young men with a history of blunt pelvic or perineal trauma. Most penile revascularization techniques use the inferior epigastric artery in direct artery-to-artery revascularization or dorsal vein arterialization procedures. To obviate the wide pararectal incision laparoscopic mobilization of the inferior epigastric vessels has been recently proposed. We present 2 cases of successful laparoscopically assisted penile revascularization.

MATERIALS AND METHODS

With the patient under general anesthesia the first trocar was inserted in the umbilical region and pneumoperitoneum was induced. Two other trocars were positioned laterally. As soon as the inferior epigastric vessels were accessed, dissection was initiated below the level of the arcuate line. The vessels were dissected cephalad en bloc to a point of bifurcation of the inferior epigastric artery above the umbilical level. The inferior epigastric pedicle was ligated with clips and transected at the cephalad edge of the dissection. It was then mobilized and tunneled through an infrapubic incision at the base of the penis for subsequent microvascular anastomosis with the penile vessels.

RESULTS

The anastomosis was patent and hemostasis was satisfactory. Operative time in the 2 cases was 4.3 and 5.2 hours, respectively. At 3 months both patients reported complete erections.

CONCLUSIONS

Our experience confirms the extremely practical use of laparoscopy which, due to its magnification power, makes it possible to perform fast, accurate excision of the epigastric bundle. Moreover, a wide pararectal incision, which is a frequent cause of postoperative complications, is avoided.

Laparoscopy-assisted penile revascularization: a new method

Analysis of more than 100 penile revascularizations using the Mannheim modification showed a success rate as high as 82% in properly selected patients. However, the dissection of the epigastric artery requires a relatively large incision, with the risk of postoperative bleeding, pain, and hernia formation. Therefore, we designed a laparoscopic approach for dissection of the epigastric vessels. From January 1995 to October 1996, we performed laparoscopy-assisted penile revascularization in 15 pharmacotesting nonresponders with erectile dysfunction. The first step is dissection of the penile vessels to minimize the occlusion time of the epigastric arteries. Thereafter, the extraperitoneal cavity is exposed using a balloon-trocar system inserted via a 15-mm suprapubic incision. A pneumoextraperitoneum is established, and two further cannulas are inserted (10 mm subumbilical, 5 mm in the lower abdomen contralateral to the desired epigastric artery). The dissection of the epigastric vessels starts caudally at the origin from the external iliac vessels and continues to the periumbilical area. All branches are dissected between clips, keeping the artery and vein together. For extraction of the artery, we insert another 5-mm port through the incision at the penile base. After desufflation of the extraperitoneal space and closure of the trocar wounds, microsurgical penile revascularization is performed using the previously described modification of the Hauri procedure. The mean operating time for laparoscopic dissection of epigastric artery was 120 minutes. No intraoperative complication occurred. One patient suffered from an inguinal hematoma. After a median follow-up of 12 month, 53% of patients showed spontaneous erections, and another 27% achieved a full erection with the aid of additional pharmacotherapy. Laparoscopic dissection of the epigastric arteries proved to be feasible, resulting in a considerable reduction of overall morbidity of penile revascularization without reducing the efficacy of the procedure.

Urological laparoscopy: Some unusual applications

Since its introduction in 1991 laparoscopy has gained a strong foothold in Urology and during the last 5 years laparoscopic technology has been applied to many urological procedures. Today, better skills in laparoscopic techniques and availability of laparoscopic instruments in urological operating theatres, make these procedures suitable for a large number of surgical purposes, some even unusual. Laparoscopy appears to be an increasingly valid alternative to traditional surgery, being minimally invasive, safe and effective. Availability of proper technological devices and experience in laparoscopic techniques allow a considerable reduction in post-operative pain, hospitalization and recovery times.