Long-term results of autologous venous grafts for penile morphological reconstruction.

In order to evaluate the long-term results of autologous venous grafts, we present an overview of patients who underwent a procedure utilizing a venous patch from the deep dorsal vein with or without combination of the cavernosal vein in treating penile deformity. From March 1995 to March 2005, a total of 85 consecutive patients with Peyronie disease or congenital penile deviation underwent venous grafting. Tunical corporotomy was covered using transplanted venous wall sutured microscopically to collagen bundles of the inner circular and outer longitudinal layer of the tunica albuginea. The vein was sutured with the serosal side outward, after it had been detubularized, properly constructed, and spliced together. In this cohort, 48 patients with Peyronie disease and 37 with congenital penile deviation were respectively categorized as belonging to the Peyronie and congenital groups. All patients were evaluated preoperatively and postoperatively with the International Index of Erectile Function (IIEF-5) scoring, angle measurement of erectile penis, satisfaction with the penile shape, and a cavernosogram which was further available for 15 patients. Histological confirmation in 5 cases was followed up for up to 10 years. The mean angle improvement was 44.8 +/- 3.6 degrees for the Peyronie group and 37.6 +/- 3.8 degrees for the congenital group. A satisfactory penile shape was achieved in 77 (90.6%) patients, although 8 men (9.4%) complained of mild deviation of the penis (<15 degrees). Erectile function was good in 81 patients, although 6 of them had to use oral sildenafil/tadalafil postoperatively. Overall, they had a mean preoperative IIEF-5 score of 19.7 +/- 2.8, which increased to a mean postoperative score of 21.6 +/- 2.2. The cavernosograms consistently disclosed a good penile shape. The histological confirmation showed that the donor vein retained its histological character despite the fact that perfect coalescence and lining up with the tunica albuginea were noted. The autologous vein appears to be an acceptable graft material, and the transplanted vein may have a modeling action rather than a scaffolding role in venous patch surgery on the penile tunica albuginea. Careful microsurgical manipulation is required to achieve a satisfactory, sustainable outcome.

The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable?

Although topical anesthetic blockage for penile surgeries has been substantially reported in the medical literature, its methodology, reliability, and reproducibility have not been consistent. We report on several methods of topical blocks for local anesthesia in patients with indications for penile surgeries. From March 1993 to March 2003, a total of 1131 men, ages 19 to 87, underwent penile surgeries in which 165, 203, 708, 45, and 10 patients received penile implantation, modified Nesbit procedure, venous surgery, venous patches, and arterial revascularization respectively, under pure local anesthesia on an outpatient basis. They were categorized into the implant, Nesbit, venous, patch, and arterial groups respectively. Proximal dorsal nerve blockage, peripenile infiltration, and topical injection, although challenging, were sufficient local anesthesia for patients in the last 4 patient groups. A new method of crural blockade, however, was also required for optimal anesthesia of the cavernous nerve for implantation purposes. The anesthetic effects and postoperative results were satisfactory. Common immediate side effects included puncture of the corpus spongiosum or the deep dorsal vein as well as the innominate vessel, subcutaneous ecchymosis, transient palpitations, and acceptable low level of pain. There were no significant late complications. In the implant group, however, 6.1% of patients (10/165) had experienced pain over the perineum for 1 to 2 weeks postoperatively. Overall there were statistical differences in scoring between the 5 groups in which the implant group stood out when a visual analog scale of 100 mm was used. Topical nerve blockades proved to be reliable, simple, and safe, with minimal complications. They offer the advantages of less morbidity, reduced effects of anesthesia, protection of privacy, and a rapid return to preoperative daily activity.

Insufficient response to venous stripping surgery: is the penile vein recurrent or residual?

There is currently controversy on whether the insufficient response to penile venous surgery done in an attempt to restore erectile function is due to recurrent or residual veins. In order to elucidate this issue, we report a study on those patients who failed to respond to the first venous surgery and subsequently underwent or declined a second operation. From July 1996 to July 2003, a total of 83 patients, aged 25 to 83, who were dissatisfied with their first venous surgery and were later diagnosed with a persistent veno-occlusive dysfunction via our dual cavernosography, were recruited into our study. Subsequently, 45 men underwent penile venous stripping surgery for a second time and were assigned to the surgery group, whereas the remaining 38 men were subject to follow-up and routine management and were assigned to the control group. All were evaluated with the abridged 5-item version of the international index of erectile function (IIEF-5) every 6 months for 1 to 5 years and cavernosogram, if necessary. In the surgery group their preoperative IIEF-5 score was 10.1 +/- 3.7, which increased to 17.1 +/- 3.2 (P < .001) after the first surgery and further increased to 20.7 +/- 3.1 (P < .001) after a second venous stripping of the cavernosal vein that was consistently demonstrated on the cavernosogram. Overall, 41 men (91.1%) reported a positive response to further venous surgery, with more satisfactory coitus, after the residual veins were stripped thoroughly, although eventually 4, 3, and 3 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. The follow-up period ranged from 12 months to 72 months, with an average of 37.0 +/- 11.5 months. In the control group, however, their corresponding IIEF-5 score changed from 17.4 +/- 2.9 to 16.9 +/- 3.2 (P > .05). Finally, 11, 7, and 8 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. Although there was no statistical significance between the 2 groups in the first postoperative IIEF-5 scores, there was a significant difference in their IIEF-5 after further venous surgery. In this study, we propose that the clinical relapse of erectile dysfunction is a result of "residual" veins rather than "recurrent" ones.

Outpatient varicocelectomy performed under local anesthesia.

AIM: To report a series of varicocelectomy performed under pure local anesthesia. METHODS: From July 1988 to June 2003, a total of 575 patients, aged between 15 and 73 years, underwent high ligation of the internal spermatic vein for treatment of a varicocele testis under a regional block in which a precise injection of 0.8 % lidocaine solution was delivered to involved tissues after exact anatomical references were made. A 100-mm visual analog scale (VAS) was used to assess whether the pain level was acceptable. RESULTS: The surgeries were bilateral in 52 cases, and unilateral in 523 cases. All were successfully performed on an outpatient basis except in the case of two patients, who were hospitalized because their surgeries required general anesthesia. Overall, 98.6 % (567/575) of men could go back to work by the end of the first post-operative week and only 8 (1.4 %) men reported feeling physical discomfort on the eighth day. The VAS scores varied from 11 mm to 41 mm with an average of (18.5+/-11.3) mm that was regarded as tolerable. CONCLUSION: This study has shown varicocelectomy under local anesthesia to be possible, simple, effective, reliable and reproducible, and a safe method with minimal complications. It offers the advantages of more privacy, lower morbidity, with no notable adverse effects resulting from anesthesia, and a more rapid return to regular physical activity with minor complications.

The synergism of penile venous surgery and oral sildenafil in treating patients with erectile dysfunction.

A possible synergistic effect between penile venous surgery and oral sildenafil was inadvertently found in treating patients with erectile dysfunction in our clinic. We therefore sought to elucidate the possible synergic effect between venous surgery and sildenafil through studying patients who were non-responders preoperatively. From July 1998 to July 2003, 128 patients were diagnosed with veno-occlusive dysfunction. Subsequently, 65 of them underwent penile venous surgery and were assigned to the surgical treatment group. The remaining 63 men were assigned to the control group, and were subject to a simple re-exposure of oral sildenafil. All patients were evaluated with the international index of erectile function (IIEF-5) scoring. Sildenafil (12.5-100 mg) was prescribed postoperatively to all surgical patients as venous surgery alone was unsatisfactory and similarly, 100 mg preparation was prescribed for patients in the control group. The IIEF-5 scoring in the control group changed from a preoperative mean IIEF-5 score of 9.4 +/- 3.9 to 10.7 +/- 3.5 postoperatively. In surgical patients, however, the mean preoperative IIEF-5 score of 9.2 +/- 5.0, which increased to 15.1 +/- 5.0 (p < 0.001) postoperatively, further increased to 20.1 +/- 5.4 (p < 0.0001) after the addition of sildenafil. Although there was no significant difference between the two groups characteristics, there was a statistically significant difference between treatment results (p < 0.001). Overall, 61 men (93.8%) reported a positive response to sildenafil after venous stripping surgery. In contrast, only eight patients (12.7%) felt a beneficial response in the control group (p < 0.001). Forty-one of 65 patients had scores of > or =22, and 19 of these had a score of 25. No response was found in three (4.6%), and a decrease of 7 was seen in one (1.5%). In summary, patients in whom sildenafil was not effective preoperatively can become excellent responders after careful penile venous surgery. It appears that together, oral sildenafil and penile venous surgery may provide an encouraging solution to impotent patients with veno-occlusive dysfunction who are non-responders to sildenafil.

The progression of the penile vein: could it be recurrent?

Our aim was to study retrospectively the destiny of the deep dorsal vein of the penis in the event of its stripping surgery or its simple ligation in patients diagnosed with venoocclusive dysfunction 17 years ago. From June 1986 to May 1987, a total of 31 men were seen for erectile dysfunction due to venous leakage resulting from priapism, aging, or congenital or idiopathic factors. Of these, 23 men underwent venous stripping of the deep dorsal vein and are referred to as the stripping group. The remaining 8 patients received a simple ligation of the deep dorsal vein and are classified as the ligation group. A total of 21 patients (16 of the 23 and 5 out of the 8) were available for follow-up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and cavernosograms. In the ligation group, the imaging demonstrates some compensatory veins that are commensurate with impotence postoperatively. In the stripping group, however, the follow-up cavernosograms disclosed no venous recurrence, but residual ones that were not crucial to the rigidity. The IIEF-5 scoring in the ligation group changed from a preoperative mean IIEF-5 score of 10.0 +/- 4.5 to 9.8 +/- 3.6 postoperatively. In the stripping group, however, the mean preoperative IIEF-5 score of 9.8 +/- 4.1 increased to a mean postoperative IIEF-5 score of 18.9 +/- 2.1. Although there was no significant difference between the 2 groups' preoperative IIEF-5 score, there was a statistically significant difference between treatments (P <.001). The penile venous vasculature bears no evidence of regeneration even as long as 17 years after their removal. This finding is in contrast to what is commonly believed, that erectile dysfunction will recur about 2 years after ligation of the deep dorsal vein. We therefore believe that the clinical recurrence may not be due to venous regeneration, and penile venous surgery, if properly performed, may be durable, although larger studies will be required.

The effect of electrocoagulation on the sinusoids in the human penis.

We give an overview of patients who have undergone removal of the deep dorsal vein for venous grafting in treating Peyronie disease with or without a Bovie effect. From June 1998 to May 2002, 23 men received grafting of the deep dorsal vein for morphologic correction. Among them, 7 men underwent electrocoagulation treatment of bleeders per surgeons' customary practice during the entire procedure and were categorized as the electrocoagulation group. Sixteen patients received simple ligation of bleeding stumps, with 6-0 nylon sutures, and were classified as the ligation group. All were followed for satisfaction of penile morphology and assessed by the abridged 5-item version of the international index of erectile function (IIEF-5) scoring for erectile capability. In the electrocoagulation group, a mean preoperative IIEF-5 score of 22.5 +/- 1.6 decreased to a mean postoperative IIEF-5 score of 17.9 +/- 4.1. Among them 2 men (28.6%) had sustained postoperative infection. Follow-up cavernosograms showing relatively poor filling are commensurate with intracavernosal fibrosis. In the ligation group, however, the mean IIEF-5 score was 22.3 +/- 1.9 preoperative and 22.9 +/- 2.0 postoperative. Although there was no statistical significance between the 2 groups in preoperative IIEF scores, there was a significant difference between groups postoperatively. Application of electrocoagulation appears to be disadvantageous in preserving erectile tissues. A Bovie effect should be avoided in this erectile organ in order to preserve erectile capability and avoid infection.

Outpatient penile implantation with the patient under a novel method of crural block.

Although local anaesthesia for penile implants has been substantially reported, its methodology, simplicity and reliability left room for improvement. We would like to report on an innovative penile crural block using local anaesthesia in patients who underwent penile implantation as outpatient surgery. From March 1987 to March 1991, a total of 21 organically impotent men, aged from 27 to 77 years, received penile prosthesis implantation. All these were performed under pudendal nerve block as an outpatient procedure. From August 1992 to January 2003 a proximal dorsal nerve block with peripenile infiltration and penile crural block was developed to replace the anaesthesia method of pudendal nerve blocks in 137 consecutive patients (aged from 35 to 83 years) undergoing penile implants. The anaesthetic effects and postoperative results with the crural block were very satisfactory. Common immediate side-effects included puncture of the vessels, subcutaneous ecchymosis, transient palpitations and dilation pain, but there were no significant late complications. In the group of pudendal nerve blockage, 42.9% patients (nine of 21) experienced severe aching pain over the perineum for 1-2 weeks postoperatively, whereas the newly developed method of crural block markedly reduced these adverse effects. This new anaesthetic method proved to be reliable, simple, and safe with fewer complications. It offers the advantages of less morbidity, preservation of patient's privacy, reduced adverse effects of anaesthesia, and a more-rapid return to activity with minimal complications.

Anatomy of the human penis: the relationship of the architecture between skeletal and smooth muscles.

To investigate the anatomy of the ischiocavernosus muscle, bulbospongiosus muscle, and tunica albuginea and to determine their relationships to smooth muscle, which is a key element of penile sinusoids, we performed cadaveric dissection and histologic examinations of 35 adult human male cadavers. The tunica of the corpora cavernosa is a bilayered structure that can be divided into an inner circular layer and an outer longitudinal layer. The outer longitudinal layer is an incomplete coat that is absent between the 5-o'clock and 7-o'clock positions where 2 triangular ligamentous structures form. These structures, termed the ventral thickening, are a continuation of the anterior fibers of the left and right bulbospongiosus muscles. On the dorsal aspect, between the 1-o'clock and 11-o'clock positions, is a region called the dorsal thickening, a radiating aspect of the bilateral ischiocavernosus muscles. In the corpora cavernosa, skeletal muscle contains and supports smooth muscle, which is an essential element in the sinusoids. This relationship plays an important part in the blood vessels' ability to supply the blood to meet the requirements for erection, whereas in the corpus spongiosum, skeletal muscle partially entraps the smooth muscle to allow ejaculation when erect. In the glans penis, however, the distal ligament, a continuation of the outer longitudinal layer of the tunica, is arranged centrally and acts as a trunk of the glans penis. Without this strong ligament, the glans would be too weak to bear the buckling pressure generated during coitus. A significant difference exists in the thickness of the dorsal thickening, the ventral thickening, and the distal ligament between the potent and impotent groups (P < or =.01). Together, the anatomic relationships between skeletal muscle and smooth muscle within the human penis explain many physiologic phenomena, such as erection, ejaculation, the intracavernous pressure surge during ejaculation, and the pull-back force against the glans penis during anal constriction. This improvement in the modeling of the anatomic-physiologic relationship between these structures has clinical implications for penile surgeries.

Penile venous anatomy: an additional description and its clinical implication.

The human penile venous system has been well studied and described but the demonstration of extra venous channels in imaging films prompted us to seek refinement of our anatomical knowledge of this venous system. Cavernosography in 37 patients who had venous stripping surgery and now suffered recurrent erectile dysfunction consistently showed an independent vein, smaller than the deep dorsal vein, running almost in the same position of the deep dorsal vein even though the latter had been removed unequivocally in previous surgery. Cavernosography in 9 patients who underwent intraoperative films also demonstrated the presence of this cavernosal vein in addition to the deep dorsal vein. Meticulous dissection of the penis under the microscope was then performed in 21 male cadavers and we found a cavernosal vein coursing along each corpus cavernosum all the way distally to the glans and draining directly into the Santorini's plexus in 19 subjects. This is in contrast to the previous description that this cavernosal vein was a short vein in the penile hilum. Two sets of para-arterial veins, which have not been reported in the literature, were found to accompany each dorsal artery in all 21 subjects. This more extensive and extra venous drainage might have important implication for venous stripping surgery in the treatment of erectile dysfunction.

Outpatient surgery for penile venous patch with the patient under local anesthesia.

Although local anesthesia for penile surgery has been widely reported, its application for penile venous patch, however, has not been published. We evaluated an anesthetic and surgical technique on an outpatient basis. From March 1993 to September 2001, a total of 29 men with penile deformity, aged 27 to 77 years (mean 55 years) received a penile venous patch for morphologic correction. They received autologous grafting of the deep dorsal vein under local anesthesia as an outpatient procedure. The anesthetic effect and postoperative results were satisfactory. The average available area of the deep dorsal vein was 5.7 x 2.5 cm(2). The common immediate side effects included puncture of the vessels, subcutaneous ecchymosis, and transient palpitation, but there were no significant late complications. All patients returned home uneventfully. This has been proven to be a cost-effective, simple, and safe method with fewer complications. It offers the advantages of lower morbidity, protection of privacy, fewer adverse effects of anesthesia, and a more rapid return to activity with minimal complications.

Penile venous anatomy: application to surgery for erectile disturbance.

AIM: The structure of the human penile venous system has been well studied, but disappointing outcomes of penile venous surgery in certain patients have called into question on the anatomy. We planned to extend the anatomic knowledge with the ultimate goal of improving operative success. METHODS: Thirty-five patients, who had undergone penile venous surgery, complained of poor erection developed gradually 6 months to 7 years postoperatively. Cavernosography was performed again during their return visit. Seven new patients underwent spongiosography followed by immediate cavernosography. Eleven male cadavers were carefully dissected. The anatomical findings were applied to venous surgery in 155 patients, who were then followed with the International Index of Erectile Function Questionnaire-5 (IIEF-5). RESULTS: Imaging observation demonstrated that the deep dorsal vein served as a common vessel of the corpora cavernosa and corpus spongiosum. A prominent cavernosal vein was found coursing along each corpus cavernosum distally to the glans, in contrast to its reported description as a short segment at the penile hilum. All cadavers had two sets of para-arterial veins sandwiching the dorsal artery. In 148 men available for follow-up, their mean IIEF-5 score was 9.3 preoperative and increased to 22.7 after the operation. The 88.5% (131/148) of the patients believed that venous stripping was a worthy treatment modality. Five cases required sildenafil to maintain their potentia, which was not working preoperatively. CONCLUSIONS: The failure of penile venous surgery has traditionally been ascribed to penile vein regeneration. However, our finding of a long and independent cavernosal vein and an independent set of para-arterial veins may be the principal cause in patients experiencing poor postoperative results.

Curvature correction in patients with tunical rupture: a necessary adjunct to repair.

PURPOSE: We review our experience with traumatic tunical rupture repair with and without simultaneous penile curvature correction. MATERIALS AND METHODS: Since November 1987, 11 men 23 to 39 years old have presented to us with tunical rupture, of whom 10 underwent surgical repair. All except 1 of the 8 men injured during sexual activity reported a curved penile appearance during erection. After patient 3 in our series sustained repeat rupture 5 months postoperatively due to penile curvature the next 7 underwent simultaneous curvature correction, which since 1996 has been done using 6-zero nylon. RESULTS: Recovery was uneventful in 2 of the 3 men who underwent simple tunical repair with 4-zero polyglactin or polyglycolic acid. All 7 of subsequent patients in whom curvature correction was performed simultaneously recovered satisfactorily with resumed erectile capability. CONCLUSIONS: Although coital position may be an important factor in tunical rupture during sexual activity, penile curvature may be contributory and should be corrected simultaneously with tunical repair.