Penile Revascularization for Erectile Dysfunction Secondary to Arterial Insufficiency: A Case Series

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Arteriogenic erectile dysfunction (AED) is caused by disrupted circulation in the distal internal pudendal, common penile, or proximal cavernosal artery causing diminished perfusion pressure to the corpora cavernosa. While frequently the result of atherosclerotic disease, AED may present in young patients secondary to blunt trauma to the pelvic, penile, or perineal region, which can cause endothelial dysfunction even in the absence of classic risk factors like hypertension, smoking, and diabetes.^1,2 For patients refractory to pharmacologic management and intracavernous injection, microsurgical revascularization can successfully restore blood flow and perfusion pressure to the corpus cavernosa and allow patients to achieve and maintain an erection.^1,3-5

Penile revascularization for AED was first described by Michal et al in 1972, with various techniques since documented.⁶ Surgical approaches include anastomosing the donor deep inferior epigastric artery (DIEA) to recipient corpus cavernosum (original Michal technique), recipient dorsal penile vein (DPV), and/or recipient dorsal penile artery in an effort to bypass the obstructed vasculature.¹ Reported success rates range from 36% to 91% depending on AED etiology and surgical approach.⁷ Risk factors including advanced age, diabetes, tobacco use, and chronic systemic disease are associated with decreased success rates.¹ Hyperemia of the glans is a common complication in patients undergoing DIEA to DPV and is reported in 7% to 22% of patients.^4,7

The utilization of penile revascularization in cases of vasculogenic impotence has primarily been commented upon in urology literature, with relatively little published in plastic surgery. We completed 2 penile revascularization procedures from 2021-2022 using the DIEA to DPV for AED secondary to pelvic trauma. The aim of this report is to contribute to the sparse literature with a review of our technique and discussion of outcomes.

Case 1

A 39-year-old male with refractory AED secondary to a crush injury in February 2019 presented. At the time of injury, he underwent pelvic reconstruction and colostomy creation with reversal. The patient initially presented to an outside hospital after his injury and initial evaluation prior to seeking care with our plastic surgery team for the AED in April 2021. His operation was performed in July 2021, after his colostomy reversal was completed and he had recovered from that operation. Other than being unable to achieve an erection, the patient denied other urologic symptoms. Patient was a former smoker with 34-pack-year history. Urologic workup included a pelvic angiogram showing complete occlusion of the anterior division of the left internal iliac artery and the left internal pudendal artery without significant collateral reconstitution. Our plan involved revascularization of the penis utilizing the right DIEA with anastomosis to DPV in conjunction with urology. CT angiogram of the abdomen and pelvis was performed to assess the donor vessels preoperatively.

While urology exposed the dorsal penile vessels, our plastic surgery team proceeded with exposure of the DIEAs. Through a unilateral low transverse incision, dissection was carried down to abdominal wall fascia, then continued cranially until periumbilical perforators were encountered. A longitudinal incision was made in the anterior rectus fascia and the muscle was bluntly mobilized medially, exposing the deep inferior epigastric. Intramuscular dissection proceeded from the identified perforators to the main vessel trunk. The cranial aspect of the perforator and deep inferior epigastric vessels were clipped and divided.

The inferior epigastric bundle was wrapped in a Penrose drain and passed through a tunnel created between the external and internal inguinal rings. The penis was everted through the scrotal incision. The dorsal penile artery appeared atretic and insufficient for anastomosis, so we proceed with anastomosis to the dorsal penile vein. A valvulotome was used to open the venous valves. The vessels were prepared using the operating microscope, and an end-to-end anastomosis between the deep inferior epigastric artery perforator and dorsal penile vein was performed using 8-0 nylon interrupted sutures. Brisk pulsation and a strong Dopplerable arterial signal through a tensionless anastomosis were appreciated following anastomosis.

Urology then proceeded to ligate the proximal dorsal vein and its side branches to minimize distal tip hyperemia. The penoscrotal incision was closed in a layered fashion.

The abdominal wall closure proceeded in a layered fashion over a drain.

Immediate postoperative course was uneventful, and patient was discharged on postoperative day (POD) 1. At the time of discharge, Doppler signals were triphasic, the shaft and glans of the penis were well perfused, and there was expected postoperative shaft edema. During the patient's follow-up appointments with urology on POD5 and POD12, despite penile edema there was no documented concern for urinary retention at that time. His postoperative course was complicated by urinary retention on POD 22 requiring Foley placement, and development of a pelvic seroma 1 month following operation requiring interventional radiology (IR) drain placement. Prolonged postoperative glans edema (Figure 1) ultimately progressed to phimosis and balantis and required a dorsal slit procedure 1 month following the index operation. By 7 months postoperatively, patient endorsed returning to 80% of normal erections with only daily 5 mg tadalafil.

Figure 1. Persistent glans edema in our first patient.

Case 2

This case is a 32-year-old male with refractory AED secondary to a crush injury in June 2019. He initially presented to an outside hospital before meeting with our plastic surgery team in January 2022, with his operation performed in March 2022. Following his original trauma, he required open suprapubic tube placement and multiple cystoscopies for a urethral injury as well as open fixation of a pelvic fracture. Recovery was complicated by a membranous urethral stricture requiring a posterior urethroplasty in November 2019. At the time of our assessment, the patient was voiding spontaneously but was unable to achieve an erection. The patient denied a history of smoking. Workup with urology included a pelvic angiogram showing patent bilateral iliac arteries and bilateral inferior epigastric arteries but complete occlusion of the distal left internal pudendal artery with no filling of the left dorsal or cavernosal penile artery branches as well as complete occlusion of the distal right penile artery. Our plan was for circumcision and revascularization of the penis utilizing the right DIEA with anastomosis to DPV in conjunction with urology. Computed tomography angiogram of the abdomen and pelvis was performed to assess the donor vessels preoperatively.

A similar procedure was completed as for the first patient, with successful microvascular anastomosis of the DIEA to the DPV. In addition, urology completed a circumcision.

The immediate postoperative course was uneventful, and patient was discharged on POD 5. Patient subsequently developed glans edema 2 months postoperatively, ultimately requiring a revision circumcision at 8 months postoperative. At 3 months postoperatively, patient was able to achieve partial erections with 5 mg tadalafil daily.

In patients with diffuse AED secondary to blunt trauma, DPV arterialization using the DIEA is preferred as no suitable local arteries may exist for reliable direct anastomoses (Figure 2). Success rates have ranged from 25% to 70%, and this broad range may be related to the subjective and multifaceted nature of satisfactory sexual function.⁷ Both patients in our case series demonstrated improved sexual function, with the ability to achieve erections. The first patient was able to achieve erection and penetration without the use of pharmacotherapy, while the second patient was able to achieve erection with the use of minimal pharmacotherapy.

Figure 2. Deep dorsal penile vein arterialization. (A) Harvesting of DIEA using a low transverse scar. Vessels were passed through the internal and external inguinal rings. (B) DIEA was then anastamosed end-to-side to the deep dorsal vein, which was ligated proximal to anastomosis and proximal to retrocoronal plexus. (C) PP, periprostatic plexus; IPV, internal pudendal vein; DIEA, deep inferior epigastric artery; SDV, superficial dorsal vein; DDV, deep dorsal vein; EV, emissary veins; BF, Buck fascia.

Physiologic mechanisms by which the procedure causes erections are not well understood.⁹ The initial hypothesis was dynamic correction of an arterial/venous flow imbalance. However, this theory does not consider the fact that corpus cavernosum smooth muscle contractility is integral to achieving and maintaining an erection.⁸ Local production of nitric oxide by endothelial and neuronal nitric oxide synthase triggers cavernous muscle relaxation and erection—a pathway partially regulated by penile oxygen tension.⁸ Arteriovenous fistulas in the general circulation and consequent shear stress have been shown to induce the expression of nitric oxide synthase in endothelial cells and thus endothelial-dependent relaxation.^10,11 Therefore, dorsal vein arterialization may cause an erection by not only the retrograde inflow into the corpus cavernosum, but also by enhancing endothelial nitric oxide synthase expression and subsequent cavernous muscle relaxation.⁸

In both cases, the DIEV and DIEA were transferred to the base of the penis as a unit. While the penile inflow was reestablished through arterialization of the DPV, the presence of the DIEV allows this to act as a prefabricated flap. The vascular pedicle is introduced into the base of the penis, supporting neovascularization, while small interconnections between the deep inferior epigastric arterial and venous system support continued flow even if the artery were to clot.

The most common risk of this procedure is glans hyperemia, which both our patients experienced postoperatively (Figure 1). Rates of hyperemia range from 7% to 22%, and severe cases can result in urethral compression and even glans ulceration.^4,7,12 Treatment of hyperemia is the ligation of the distal deep dorsal vein via the retro-coronal plexus.¹³ Given the high risk of hyperemia and postoperative edema, it is important to consider the patient's circumcision status. Our first patient was not circumcised and developed severe balantis secondary to edema-induced pressure ischemia of the glans. Although this was treated with a dorsal slit creation and local wound care, complications may have been prevented by performing circumcision at the time of the first operation.

Revascularization surgery for penile AED has primarily been commented upon in the urology and IR literature. IR teams are often able to intervene on these patients when anatomy allows, reestablishing blood flow through angioplasty and stent placement.¹⁴ While there was no documented discussion on why IR intervention was not attempted on the 2 patients presented in this report, it was likely due to significant crush injuries to the vessels preventing stent placement.

Despite the presence of literature describing penile revascularization for AED from the urology and IR communities, relatively little has been published from the perspective of plastic surgeons. The aim of this paper is to provide a unique plastic surgery perspective as well as highlight the benefit of a multidisciplinary approach in conjunction with urology. A limitation to this study is the experience of only 2 cases. Despite this limitation, we hope the discussion of surgical technique and multidisciplinary teamwork will provide a unique perspective to the literature.