Clinical and Imaging Outcomes up to 1 Year Following Balloon Angioplasty for Isolated Penile Artery Stenoses in Patients With Erectile Dysfunction: The PERFECT-2 Study

"Diabetic penile necrosis'': A rare but serious complication of diabetes mellitus

Penile tissue death caused by impaired blood flow and nerve damage is a severe but uncommon complication of diabetes mellitus known as diabetic penile necrosis. Diabetes related vascular and neurological issues result in reduced sensation and limited blood supply to the penis leading to this condition. The consequences on sexual function and quality of life are catastrophic though it's rare, hence early identification, treatment intervention cannot be over emphasized since they help prevent further deterioration including infections that arise from complications occasioned by delayed management.

Clinical study of comprehensive TCM therapy in the treatment of damp and hot stasis erectile dysfunction

BACKGROUND

The dilemma of male sexual dysfunction has been the focus of the whole society. Erectile dysfunction (ED) is one of the common sexual dysfunctions, and traditional Chinese medicine therapy has shown potential benefits in the treatment of ED. Comprehensive therapy of traditional Chinese medicine (CTTCM) is a comprehensive application of Chinese medicine therapy for auxiliary intervention. Through preliminary clinical observations, we found that CTTCM is simple, safe, and has good efficacy; however, there is a lack of rigorous clinical trials to support its application. Therefore, we designed a randomized controlled trial to evaluate the efficacy and safety of CTTCM for patients with ED of damp-heat stasis type, and to provide evidence for the clinical application of CTTCM and the construction of a traditional Chinese medicine andrology rehabilitation system.

METHODS

In this randomized controlled study, 108 eligible patients were assigned 1:1 to the CTTCM group or the tadalafil group. The treatment period was 8 weeks and the follow-up period was 8 weeks. The primary outcome will be the International Erectile Function Score and traditional Chinese medicine Syndrome Score. Secondary outcomes will include the Erection Quality Score, Patient Health Questionnaire-9, and the 7-item Generalized Anxiety Scale. Safety results will include electrocardiogram, blood tests (including blood, liver and kidney function), urine and stool. International Erectile Function Score-5, traditional Chinese medicine Syndrome Score, Erectile Quality Score, Patient Health Questionnaire-9, 7-item Generalized Anxiety Scale and all Safety outcomes will be conducted at baseline, 2th, 4th, 6th, and 8th week. Follow-up results will be assessed at 8th week after 8 weeks' treatment.

DISCUSSION

This study will provide preliminary evidence for the efficacy and safety of traditional Chinese medicine integrated therapy in the treatment of damp-heat stasis ED. In addition, it also provides a basis for the clinical application of Chinese medicine comprehensive therapy and the construction of Chinese medicine andrology rehabilitation system.

TRIAL REGISTRATION

Chinese clinical trial registration identifier, ChiCTR2200062016, registered on July 19, 2022.

The flow index provides a comprehensive assessment of erectile dysfunction by combining blood flow velocity and vascular diameter

Dynamic duplex sonography (DUS) is not comprehensive in the evaluation of arteriogenic erectile dysfunction (ED). We introduced a new parameter, the flow index (FI), into the assessment of arteriogenic ED. A retrospective review of a prospective database was conducted. Patients undergoing DUS and pelvic computed tomography angiography for the evaluation of ED were included. The FI was calculated from peak systolic velocity (PSV) and the percentages of pelvic arterial (PLA) stenosis. Correlations between PSV, PLA stenosis, the FI, and erectile function were calculated. Eighty-three patients were included. Compared with PSV, the FI had better correlations with the erection hardness score (EHS) (r_s = 0.405, P < 0.001 for FI; r_s = 0.294, P = 0.007 for PSV). For EHS < 3, the areas under the ROC curve of FI and PSV were 0.759 and 0.700, respectively. In patients with normal DUS but EHS < 3, PLA stenosis was more severe (62.5% vs. 10.0%, P = 0.015), and the FI was lower (8.35 vs. 57.78, P = 0.006), while PSV was not different. The FI is better than PSV in the evaluation of arteriogenic ED. On the other hand, assessment of the pelvic arterial system should be included in the evaluation of ED.

Cone-Beam CT-assisted navigation for endovascular treatment of erection-related artery stenosis in patients with erectile dysfunction

Background

Angioplasty and stenting have emerged as endovascular treatment options for arteriogenic erectile dysfunction over the past few years. Considerable anatomical variation of the erection related pelvic arteries can be challenging during these procedures, leading to time-consuming repetitive super-selective angiograms for navigation.

Technique

We report a novel technique of using C-arm Cone-Beam CT and vessel navigation software to facilitate super-selective catheterization.

Conclusion

Cone-Beam CT-guided navigation for vascular assessment of arteriogenic ED is an optional approach compared to exclusive angiographic assessment. Compared to CT angiography, C-arm Cone-Beam CT offers benefits regarding usage of contrast media and radiation exposure. It has the advantage to combine imaging with endovascular procedures in a single session, reduces time to target navigation in complex pelvic arteries anatomy and may increase therapy safety in endovascular treatment of ED.

A case report of pudendal arteries angioplasty with sirolimus drug-coated balloon and drug-eluting stent associated with intracavernous autologous peripheral blood mononuclear cells injection for untreatable vasculogenic erectile dysfunction

Background

Erectile dysfunction (ED) is a prevalent health problem that seriously impacts men's quality of life. The potential treatment of ED by percutaneous approach has emerged with valid angiographic results and a significant improvement in symptoms and quality of life. In addition, cell-based regenerative therapies aiming at enhancing neovascularization have been successfully performed with peripheral blood mononuclear cells (PBMNCs) in diabetic patients affected by critical limb ischaemia.

Case summary

We report a case of a young insulin dependent (ID) diabetic patients who suffered of severe vasculogenic erectile dysfunction associated with a poor response for more than 1 year to oral phosphodiesterase-5 inhibitors (PDE5i) and intracavernous (IC) phosphodiesterase type 1 (PDE1) therapy. At selective angiography of the pelvic district, a severe atherosclerotic disease of the internal iliac and pudendal artery was evident with absence of distal vascularization of the cavernous bodies. The patient was treated by mechanical revascularization with drug-coated balloon and drug-eluting stent placement associated with IC injection of autologous PBMNCs. Immediate and 1-year clinical and angiographic follow-up are described.

Discussion

Percutaneous revascularization with drug-coated balloon and drug-eluting stent associated with IC autologous PBMNCs cells injection is a safe and effective procedure to restore normal erectile function in diabetic patients affected by severe vasculogenic ED not responding to conventional oral drug therapies.

Erectile Dysfunction as a Cardiovascular Risk Factor: Time to Step Up?

BACKGROUND

Erectile dysfunction (ED) is a major health problem that affects a significant proportion of the general population, and its prevalence is even higher in patients with CV risk factors and/or disease. ED and cardiovascular (CV) disease share several common pathophysiological mechanisms, and thus, the potential role of ED as a predictor of CV events has emerged as a significant research aspect.

OBJECTIVE

The purpose of this review is to present and critically discuss data assessing the relation between ED and CV disease and the potential predictive value of ED for CV events.

METHODS

A comprehensive review of the literature has been performed to identify studies evaluating the association between ED and CV disease.

RESULTS

Several cross-sectional and prospective studies have examined the association between ED and CV disease and found an increased prevalence of ED in patients with CV disease. ED was shown to independently predict future CV events. Importantly, ED was found to precede the development of overt coronary artery disease (CAD) by 3 to 5 years, offering a "time window" to properly manage these patients before the clinical manifestation of CAD. Phosphodiesterase type 5 inhibitors are the first-line treatment option for ED and were shown to be safe in terms of CV events in patients with and without CV disease.

CONCLUSION

Accumulating evidence supports a strong predictive role of ED for CV events. Early identification of ED could allow for the optimal management of these patients to reduce the risk for a CV event to occur.

Endovascular Therapy for Arteriogenic Erectile Dysfunction With a Novel Sirolimus-Eluting Stent

BACKGROUND

Arteriogenic erectile dysfunction is a common disease oftentimes not satisfactory treatable with medical therapy.

AIM

To assess the safety and clinical success rate of endovascular revascularization of erection-related arteries with the angiolite BTK stent in patients with arteriogenic erectile dysfunction.

METHODS

A total of 100 consecutive men (61.8 ± 10 years) with atherosclerotic lesions in erection-related arteries agreed to participate and were included into a single-center all-comers registry. Endovascular therapy with angiolite BTK drug-eluting stents was performed on a total of 211 lesions. Patients received a baseline International Index of Erectile Function (IIEF)-15 questionnaire at first presentation and 3 and 12 months after stenting. An improvement by 4 points in the erectile function domain consisting of 6 questions (IIEF-6) was defined as minimal clinically important difference. A total of 24 patients with 52 stented arterial lesions underwent angiographic follow-up of the initially treated arterial side during secondary revascularization of the contralateral side (angiographic sub-study).

OUTCOME

Clinical improvement of erections in 100 patients undergoing endovascular revascularization of erection-related arteries.

RESULTS

No major adverse events occurred during endovascular revascularization or within 30 days thereafter. Technical success was achieved in all lesions and procedural success in all patients. At 1 year, 55 of 97 patients (56.7%) improved by at least 4 points in IIEF-6 score and thus achieved a clinically relevant improvement of erectile function.In the angiographic sub-study, arterial patency and binary restenosis were observed in 46 of 52 (88.5%) and in 8 of 52 (15.4%), respectively, after a mean follow-up of 9.6 ± 5.8 months.

CLINICAL IMPLICATIONS

In patients with arteriogenic erectile dysfunction, endovascular therapy with a novel thin-strut sirolimus eluting stent is a safe and feasible treatment option.

STRENGTHS & LIMITATIONS

This real-world arterial revascularization registry included patients with a multitude of risk factors for ED, thereby representing the heterogeneity in patients in the clinical practice, which is one of its strengths but also one of its weaknesses. Another strength was the focus being laid on analyzing outcomes of patients with arteriogenic ED using only a single endovascular device. Further studies are warranted to better define subgroups of patients with impaired clinical outcomes.

CONCLUSION

Within the present all-comers registry, endovascular therapy of erectile dysfunction with the angiolite BTK stent was shown to be a safe and feasible treatment option resulting in clinical improvement rates comparable to earlier clinical trials although also showing that further research is warranted to define patient subgroups with particular benefits of endovascular therapy. Schönhofen J, Räber L, Knöchel J, et al. Endovascular Therapy for Arteriogenic Erectile Dysfunction With a Novel Sirolimus-Eluting Stent. J Sex Med 2021;18:315-326.

Hypertension and erectile dysfunction: The role of endovascular therapy in Asia

The prevalence of erectile dysfunction (ED) is above 40% in both Asian and non-Asian male populations after the age of 40 years. The prevalence of ED among hypertensive patients is approximately double than that in normotensive population. Pelvic arterial insufficiency is the predominant cause of ED in men aged over 50 years. Stenosis in any segment of the iliac-pudendal-penile arterial system, which is considered an erectile-related arterial axis, could lead to ED. Pharmacotherapy with lifestyle modification is effective in alleviating sexual dysfunction, yet a substantial number of patients still develop ED. Given the established applicability of angioplasty for the entire iliac-pudendal-penile arterial system, penile duplex ultrasound, and pelvic computed tomography angiography could be considered as the routine screening tools in ED patients with poor response to phosphodiesterase-5 inhibitors. Endovascular therapy for pelvic arterial insufficiency-related ED has been shown to be a safe and effective treatment option in patients who have anatomically suitable vessels and functionally significant stenoses. Clinical improvement was achieved in over 60% of patients at one year following pelvic angioplasty in the PERFECT registry from Taiwan. A 30%-40% restenosis rate in distal internal pudendal and penile arteries remains a hurdle. Angioplasty for pelvic arterial occlusive disease could be considered as a viable approach to arteriogenic ED.

Endovascular therapy for erectile dysfunction: current knowledge and future perspectives

Erectile dysfunction (ED) is defined as the inability to attain or maintain penile erection sufficient for successful sexual intercourse. ED carries a notable influence on quality of life, with significant implications for family and social relationships. Because atherosclerosis of penile arteries represents one of the most frequent causes of ED, patients presenting with it should always be investigated for potential coexistent coronary or peripheral disease. Up to 75% of patients with ED have a stenosis of the iliac-pudendal-penile arteries, supplying perfusion of the male genital organ. Recently the potential treatment of this pathological condition by percutaneous approaches has emerged with good angiographic results and with a significant improvement in symptoms and quality of life. This review will focus on the normal anatomy and physiology of erection, the pathophysiology of ED, the relation between ED and cardiovascular diseases and, lastly, on new treatment modalities aimed at restoration of normal erectile function.

A Review of Current and Emerging Therapeutic Options for Erectile Dysfunction

Contemporary treatment algorithms for erectile dysfunction (ED) involve the use of medical therapies such as phosphodiesterase type 5 (PDE5) inhibitors and intracavernosal injection therapy of vasoactive agents, as well as vacuum erection devices and penile prosthesis implants in medically refractory cases. However, the current therapeutic options only address the symptoms of ED and not the underlying pathogenesis that results in ED. Newer and novel ED therapies aspire to reverse ED conditions by preventing cavernosal fibrosis, promoting endothelial revascularization and modulating various neuro-hormonal pathways. Regenerative therapeutic strategies such as low-intensity shock wave, gene and cellular-based therapies, and penile transplants are designed to improve penile hemodynamics and revitalize the cavernosal smooth muscle to mitigate and/or reverse underlying ED. This state-of-art article evaluates current and emerging therapeutic options for ED.

Endovascular Therapy for Erectile Dysfunction-Who Benefits Most? Insights From a Single-Center Experience

PURPOSE

To report the 1-year outcomes of a single-center, all-comers registry aimed to assess effectiveness and safety of endovascular revascularization for atherosclerotic erectile dysfunction (ED) in an unselected patient cohort.

MATERIALS AND METHODS

Between April 2016 and October 2017, 50 consecutive patients (mean age 59.6±10.3 years) underwent endovascular revascularization for ED owing to >50% stenosis in 82 erection-related arteries. Patients were treated by means of standard balloon angioplasty (16%), drug-coated balloon angioplasty (27%), or drug-eluting stent (55%) implantation. The primary feasibility outcome measure was the incidence of a minimum clinically relevant improvement of ≥4 in the 6-question International Index of Erectile Function Questionnaire (IIEF-6) score at 12 months. Clinical effectiveness was improvement in erectile function as quantified in the mean difference (MD) of the IIEF-15 score at 3 and 12 months as well as the mean changes in IIEF-15 questions 3 and 4.

RESULTS

Procedure success was achieved in 49 (98%) of 50 patients. At 12 months, 30 (65%) of 46 patients achieved a minimum clinically relevant improvement in the IIEF-6 score. The overall IIEF-15 score, as well as scores for questions 3 and 4, improved in 32 (65%) of 49 patients, 28 (57%) of 49 patients, and 29 (60%) of 48 patients, respectively. Change in the overall IIEF-15 score at 12 months was consistent among subgroups, except for elderly patients [MD -5.0 (95% CI -9.7 to -0.2), p=0.041] and those with hypertension [MD -11.0 (95% CI -20.5 to -1.5), p=0.025], who showed less improvement.

CONCLUSION

Endovascular revascularization was safe and efficacious in the majority of ED patients through 1 year.

Early Recoil After Balloon Angioplasty of Erection-Related Arteries in Patients With Arteriogenic Erectile Dysfunction

Purpose: To evaluate the incidence of elastic recoil in patients presenting with erectile dysfunction (ED) undergoing endovascular revascularization of the pudendal or penile arteries. Methods: A consecutive series of 21 ED patients (mean age 58.3±9.3 years) undergoing minimally invasive revascularization of 31 arteries was analyzed. ED lesions included the pudendal arteries (n=27) and the penile artery (n=4). Mean lesion length was 20.6±13.9 mm. Minimal lumen diameter (MLD) measurements were assessed at baseline, immediately after balloon angioplasty, and 10 minutes thereafter. Early recoil was defined as an MLD reduction >10%. Elastic recoil with >10% lumen compromise was treated with drug-coated balloons, while severe elastic recoil (>30%) required drug-eluting stents (DES). The International Index of Erectile Function (IIEF-15) score was obtained prior to and 3 months after the procedure to obtain information on functional outcomes subsequent to angioplasty. Results: Mean MLD at baseline was 0.9±0.6 mm, which improved to 2.0±0.9 mm immediately after balloon dilation. At 10 minutes after dilation, the MLD was 1.7±1.0 mm. Elastic recoil was observed in all 31 lesions and resulted in a mean lumen compromise of 21.2%. Severe (>30%) recoil was observed in 14 arteries, which underwent DES therapy. The IIEF-15 score improved from 31.3±11.2 at baseline to 49.8±16.8 (p<0.001) at the 3-month follow-up. Conclusion: Endovascular revascularization constitutes a safe and feasible treatment modality to restore erectile function in patients with arteriogenic ED and ineffective conservative management. Early elastic recoil is very frequent subsequent to balloon dilation of small-caliber erection-related arteries. Thus, mechanical scaffolding with DES is required in a high subset of ED patients to provide favorable early angiographic and clinical results.

Glans Ischemia after Circumcision in a 16-Year-Old Boy: Full Recovery after Angiography with Local Spasmolysis, Systemic Vasodilatation, and Anticoagulation

Circumcision is one of the most frequent procedures performed by pediatric surgeons. A dorsal penile nerve block (DPNB) is commonly used for perioperative analgesia. We report the case of a 16-year-old boy with ischemia of the glans who presented on the first postoperative day after circumcision under DPNB (0.25% bupivacaine) at an outside hospital. The patient underwent immediate angiography under sedation. An intra-arterial spasmolysis was performed with alprostadil and nitroglycerine and a sufficient perfusion of the glans penis was confirmed. Subsequently, systemic sildenafil, arginine, and heparin were given. Following this 3-day medical treatment, ischemia resolved completely. Our case emphasizes the role of invasive angiography in the diagnostic workup and the therapeutic possibilities of local spasmolysis, systemic vasodilatation, and anticoagulation.

Occlusion of bilateral dorsal penile arteries resulting in glans necrosis in an obese male truck driver

Ischemic penile gangrene is an uncommon urologic condition associated with significant morbidity. Etiology of the disease is due to vasculogenic ischemia of the penile tissue. Presented are a series of images from a case of a 51-year-old morbidly obese male truck driver with idiopathic ischemic penile gangrene. The patient was evaluated with penile angiography and treated with urinary diversion via suprapubic catheter placement and serial debridement of the necrotic tissue.