Vascular interventions for impotence: lessons learned.

Abstract

PURPOSE: The purpose of this study was to analyze the results of vascular interventions for impotence in men with this complaint. METHODS: Between September 1983 and March 1993, 1094 men with the chief complaint of impotence (average age 54.5 years) were screened by use of penile plethysmography and penile brachial indexes: 635 were considered to have normal flow, and 459 were considered to have abnormal arterial flow, 12.2% of whom were found to have aortoiliac disease. Based on negative neural screening results, absence of erectile responses on increasing doses of intracavernously injected papaverine or prostaglandin E1 (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriography. Operations for men discovered to have aortoiliac disease were based on conventional indications including aneurysm size or limb ischemia. None of the subjects had diabetes. Only those patients without diabetes and those not requiring blood pressure medications were selected for microvascular procedures. We report our experience and surgical outcomes at average follow-ups of 33 to 48 months. Four types of operations were performed on 67 men (age 18 to 79 years). These included 17 aortoiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal vein arterializations, and 27 venous interruptions. Follow-up data were obtained by direct examination and noninvasive Doppler examinations; repeat arteriography (4 of 11); repeat DICC after venous ablation procedures (18 of 27) and postoperative ICI response. Mail questionnaires completed postoperative surveillance. RESULTS: Among 17 men undergoing aortoiliac intervention for aneurysms in eight and occlusive disease in nine, 58% functioned spontaneously after operation and 18% used ICI or vacuum constrictor devices at an average follow-up time of 38 months. Among 11 men with dorsal penile artery bypasses, 27% functioned spontaneously and 45% used ICI at an average follow-up time of 34.5 months. Among 12 men with dorsal vein arterialization, 33% functioned spontaneously, and 47% used ICI at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 44% used ICI. In seven of eight aneurysms of 4.5 to 6.0 cm in size, impotence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative DICC results when flow to maintain erection was 40 ml or less. Apart from two cases of glans hyperemia, no surgical complications occurred in the microvascular procedures. There was one episode of bleeding caused by DICC after aortic reconstruction. There were no deaths. CONCLUSIONS: With prospective screening criteria, 6% to 7% of impotent men became candidates for vascular intervention. Including those functioning with ICI or vacuum constriction devices, about 70% of these men were functional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) of spontaneous function as compared with those undergoing microvascular procedures.