Vascular Surgery for Erectile Dysfunction

  • Jacqueline D. Villalta
  • Tom F. Lue
Part of the Current Clinical Urology book series (CCU)


The incidence of erectile dysfunction (ED) after blunt pelvic trauma is between 11 and 30 % and increases greatly with concomitant urethral injury and/or bilateral pubic rami. Most patients with ED after pelvic trauma respond to intracavernosal injection therapy, suggesting that there is a neurogenic component. Only a very select group of patients are candidates for a revascularization procedure. Potential candidates are young (usually less than 55 years old), have a focal occlusive disease of the penile or cavernosal artery on arteriography, no vascular risk factors, no evidence of neurologic erectile dysfunction, and a history of acute or chronic perineal or pelvic trauma. Specifics as to the penile revascularization surgical technique of inferior epigastric artery to dorsal artery of the penis anastomosis and as an alternative to the dorsal vein are detailed within. Overall reported success rates are from 50 to 60 %.

Venous leak erectile dysfunction typically results from atrophy of the intracorporal muscles or of the tunica albuginea. These patients are not amenable to penile venous surgery as they have an uncorrectable physiology. A minority of patients have either congenital or acquired isolated proximal penile venous anomalies. Congenital venous leakage results in large ectopic, superficial dorsal veins or large crural veins. Blunt perineal trauma may result in structural changes in crural erectile tissue resulting in isolated crural venous leak. Although initial published series with 1-year follow-up demonstrated poor outcomes, highly select patients with isolated crural venous leak treated by crural ligation may have significant improvement in erectile function. The Report on the Treatment of Organic Erectile Dysfunction, however, does not recommend venous leak surgery and considers it experimental.


Tunica Albuginea Inferior Epigastric Artery Dorsal Vein Venous Leak Cavernosal Artery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Michal V. Arterial disease as a cause of impotence. Clin Endocrinol Metab. 1982;11:725–48.PubMedCrossRefGoogle Scholar
  2. 2.
    El-Sakka AI, Morsy AM, Fagih BI, et al. Coronary artery risk factors in patients with erectile dysfunction. J Urol. 2004;172:251–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Levine FJ, Greenfield AJ, Goldstein I. Arteriographically determined occlusive disease within the hypogastric-cavernous bed in impotent patients following blunt perineal and pelvic trauma. J Urol. 1990;144:1147–53.PubMedGoogle Scholar
  4. 4.
    Machtens S, Gänsslen A, Pohlemann T, et al. Erectile dysfunction in relation to traumatic pelvic injuries or pelvic fractures. BJU Int. 2001;87:441–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Malavaud B, Mouzin M, Tricoire JL, et al. Evaluation of male sexual function after pelvic trauma by the international index of erectile function. Urology. 2000;55:842–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Mark SD, Keane TE, Vandemark RM, et al. Impotence following pelvic fracture urethral injury: incidence, aetiology and management. Br J Urol. 1995;75:62–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Rajfer J, Rosciszewski A, Mehringer M. Prevalence of corporeal venous leakage in impotent men. J Urol. 1988;140:69–71.PubMedGoogle Scholar
  8. 8.
    Iacono F, Barra S, de Rosa G, et al. Microstructural disorders of tunica albuginea in patients affected by impotence. Eur Urol. 1994;26:233–9.PubMedGoogle Scholar
  9. 9.
    Dalkin BL, Carter MF. Venogenic impotence following dermal graft repair for Peyronie’s disease. J Urol. 1991;146:849–51.PubMedGoogle Scholar
  10. 10.
    Ebbehoj J, Wagner G. Insufficient penile erection due to abnormal drainage of cavernous bodies. Urology. 1979;13:507–10.PubMedCrossRefGoogle Scholar
  11. 11.
    Tsao CW, Lee SS, Meng E, et al. Penile blunt trauma induced veno-occlusive erectile dysfunction. Arch Androl. 2004;50:151–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Stief CG, Gall H, Scherb W, et al. Erectile dysfunction due to ectopic penile vein. Urology. 1988;31:300–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Michal V, Kramar R, Pospichal J, et al. Direct arterial anastomosis on corpora cavernosa penis in the therapy of erective impotence. Rozhl Chir. 1973;52:587–90.PubMedGoogle Scholar
  14. 14.
    Michal V, Kramer R, Hejhal L. Revascularization procedures of the cavernous bodies. In: Zorgniotti AW, Rossi G, editors. Vasculogenic impotence: proceedings of the first international conference on corpus cavernosum revascularization. Springfield: CC Thomas; 1980.Google Scholar
  15. 15.
    Virag R, Zwang G, Dermange H, et al. Vasculogenic impotence – a review of 92 cases with 54 surgical operations. Vasc Surg. 1981;15:9–17.CrossRefGoogle Scholar
  16. 16.
    Furlow WL, Fisher J. Deep dorsal vein arterialization: clinical experience with a new technique for penile revascularization. J Urol. 1988;139:298A.Google Scholar
  17. 17.
    Hauri D. Possibilities in revascularization for vasculogenic impotence. Aktuel Urol. 1984;15:350–4.CrossRefGoogle Scholar
  18. 18.
    Montague DK, Barada JH, Belker AM, et al. Clinical guidelines panel on erectile dysfunction: summary report on the treatment of organic erectile dysfunction. The American Urological Association. J Urol. 1996;156:2007–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Montague DK, Jarow JP, Broderick GA, et al. Chapter 1: The management of erectile dysfunction: an AUA update. J Urol. 2005;174:230–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Ang LP, Lim PH. Penile revascularisation for vascular impotence. Singapore Med J. 1997;38:285–8.PubMedGoogle Scholar
  21. 21.
    DePalma RG, Olding M, Yu GW, et al. Vascular interventions for impotence: lessons learned. J Vasc Surg. 1995;21:576–84; discussion 584–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Jarow JP, DeFranzo AJ. Long-term results of arterial bypass surgery for impotence secondary to segmental vascular disease. J Urol. 1996;156:982–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Grasso M, Lania C, Castelli M, et al. Deep dorsal vein arterialization in vasculogenic impotence: our experience. Arch Ital Urol Nefrol Androl. 1992;64:309–12.PubMedGoogle Scholar
  24. 24.
    Munarriz R, Uberoi J, Fantini G, et al. Microvascular arterial bypass surgery: long-term outcomes using validated instruments. J Urol. 2009;182:643–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Munarriz RM, Yan QR, Nehra A, et al. Blunt trauma: the pathophysiology of hemodynamic injury leading to erectile dysfunction. J Urol. 1995;153:1831–40.PubMedCrossRefGoogle Scholar
  26. 26.
    Rosen RC, Riley A, Wagner G, et al. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Quam JP, King BF, James EM, et al. Duplex and color Doppler sonographic evaluation of vasculogenic impotence. AJR Am J Roentgenol. 1989;153:1141–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Chung WS, Park YY, Kwon SW. The impact of aging on penile hemodynamics in normal responders to pharmacological injection: a Doppler sonographic study. J Urol. 1997;157:2129–31.PubMedCrossRefGoogle Scholar
  29. 29.
    Lue TF, Hricak H, Marich KW, et al. Vasculogenic impotence evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis. Radiology. 1985;155:777–81.PubMedGoogle Scholar
  30. 30.
    Jarow JP, Pugh VW, Routh WD, et al. Comparison of penile duplex ultrasonography to pudendal arteriography. Variant penile arterial anatomy affects interpretation of duplex ultrasonography. Invest Radiol. 1993;28:806–10.PubMedGoogle Scholar
  31. 31.
    Naroda T, Yamanaka M, Matsushita K, et al. Clinical studies for venogenic impotence with color Doppler ultrasonography – evaluation of resistance index of the cavernous artery. Nihon Hinyokika Gakkai Zasshi. 1996;87:1231–5.PubMedGoogle Scholar
  32. 32.
    Munarriz R. Penile microvascular arterial bypass surgery: indications, outcomes, and complications. Sci World J. 2010;10:1556–65.CrossRefGoogle Scholar
  33. 33.
    Hatzichristou D, Goldstein I. Penile microvascular arterial bypass: indications and surgical considerations. Surg Annu. 1993;25(Pt 2):207–29.PubMedGoogle Scholar
  34. 34.
    Shabsigh R, Fishman IJ, Toombs BD, et al. Venous leaks: anatomical and physiological observations. J Urol. 1991;146:1260–5.PubMedGoogle Scholar
  35. 35.
    Lue TF, Hricak H, Schmidt RA, et al. Functional evaluation of penile veins by cavernosography in papaverine-induced erection. J Urol. 1986;135:479–82.PubMedGoogle Scholar
  36. 36.
    Lund GO, Winfield HN, Donovan JF. Laparoscopically assisted penile revascularization for vasculogenic impotence. J Urol. 1995;153:1923–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Raynor MC, Davis R, Hellstrom WJ. Robot-assisted vessel harvesting for penile revascularization. J Sex Med. 2010;7:293–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Mueller SC, Lue TF. Evaluation of vasculogenic impotence. Urol Clin North Am. 1988;15:65–76.PubMedGoogle Scholar
  39. 39.
    Kim SH, Kim SH. Post-traumatic erectile dysfunction: Doppler US findings. Abdom Imaging. 2006;31:598–609.PubMedCrossRefGoogle Scholar
  40. 40.
    Lue TF. Surgery for crural venous leakage. Urology. 1999;54:739–41.PubMedCrossRefGoogle Scholar
  41. 41.
    Wespes E, Moreira de Goes P, Sattar AA, et al. Objective criteria in the long-term evaluation of penile venous surgery. J Urol. 1994;152:888–90.PubMedGoogle Scholar
  42. 42.
    Rahman NU, Dean RC, Carrion R, et al. Crural ligation for primary erectile dysfunction: a case series. J Urol. 2005;173:2064–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Virag R, Paul JF. New classification of anomalous venous drainage using caverno-computed tomography in men with erectile dysfunction. J Sex Med. 2011;8:1439–44.PubMedCrossRefGoogle Scholar
  44. 44.
    Flores S, Tal R, O’Brien K, et al. Outcomes of crural ligation surgery for isolated crural venous leak. J Sex Med. 2011;8:3495–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Kim ED, McVary KT. Long-term results with penile vein ligation for venogenic impotence. J Urol. 1995;153:655–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Freedman AL, Costa Neto F, Mehringer CM, et al. Long-term results of penile vein ligation for impotence from venous leakage. J Urol. 1993;149:1301–3.PubMedGoogle Scholar
  47. 47.
    Berardinucci D, Morales A, Heaton JPW, et al. Surgical treatment of penile veno-occlusive dysfunction: is it justified? Urology. 1996;47:88–92.PubMedCrossRefGoogle Scholar
  48. 48.
    Austoni E, Pisani E. Development and progress in the therapy of penile induration: 15 years’ experience. Arch Ital Urol Nefrol Androl. 1988;60:231–57.PubMedGoogle Scholar
  49. 49.
    Stief CG, Djamilian M, Truss MC, et al. Prognostic factors for the postoperative outcome of penile venous surgery for venogenic erectile dysfunction. J Urol. 1994;151:880–3.PubMedGoogle Scholar
  50. 50.
    Treiber U, Gilbert P. Venous surgery in erectile dysfunction: a critical report on 116 patients. Urology. 1989;34:22–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Rhee AC, Licht MR, Lewis RW. Microvascular arterial bypass surgery for erectile dysfunction. In: Graham SD, Keane T, editors. Glenn’s urologic surgery. 7th ed. Philadelphia/London: Lippincott, Williams & Wilkins; 2009.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of UrologyUniversity of California San FranciscoSan FranciscoUSA

Personalised recommendations