Cardiovasc lntervent Radiol 11990) 13:3 )4-~;05
CarffloVascular andInterventional
Radio [y
9 Springer-Verlag New York Inc. 1990
Pelvic Vasculature
Glans lschemia After Penis Revascularization: Therapeutic Embolization G. Wilms, ~ R. Oyen, I L. Claes] W. Boeckx, 3 A.L. Baert, I and L. Baert 2 Departments of Radiology, ~ Urology,-" and Surgery, 3 University Hospitals K.U. Leuven, Belgium
Abstract. A case of hypervascularization of the penis with glans ischemia after venous leakage procedure followed by revascularization of the penis is reported. The venous bypass between the inferior epigastric artery and the dorsal penile artery was misplaced on the deep dorsal vein leading to venous hypertension of the glans. Transcatheter embolization of the venous bypass cured this complication. Key words: Arteries. therapeutic blockade--Arteries, pudendal--Penis, angiograph'y--Penis, diseases
In the last decade several surgical techniques were developed to increase arterial flow to the penis in the treatment of vascular impotence [1-8]. Initial techniques such as femoral-pudendal bypass [6] and direct anastomosis to the corpus cavernosum [5] were frequently complicated by priapism and hypervascularization of the penis with penile edema. These complications are much less frequent and clinical results are better with the newer technique of artery to artery anastomosis [I, 3, 5]. We wish to report a patient in whom a venous leakage procedure followed by an inadvertent amistomosis of the inferior epigastric artery to the dorsal penile vein (instead of the artery), was complicated by hypervascularization of the penis with glans ischemia. Transcatheter embolization of the venous bypass was successfully performed.
Case Report A 26-year-old m a n with psychosocial instability complained for 5 years of intermittent impotence. On the basis of cavernosonogAddress reprint requests to: Prof. Dr. G. Wilms, Department of Radiology, University Hospitals K . U . Leuven. Herestraat 49, B3(/00 L e u v e n , Belgium
raphy demonstrating a venous leak, surgery was performed. On the venous side, the deep dorsal vein of the penis was resected and several side branches were ligated. A (Nesbitt) plasty of the left corpus c a v e r n o s u m was also done. B e c a u s e of an insufficient clinical result, 8 m o n t h s later bilateral internal lilac angiography was performed in a n o t h e r hospital and interpreted as bilateral occlusion of the internal pudendal arteries. Revascularization of the penis was attempted with a v e n o u s bypass between the inferior epigastric artery and both dorsal arteries of the penis. A few days later the patient developed severe e d e m a of the penis with ischemia of the glans, c a u s i n g c o n s t a n t h e a v y burning pain especially during nocturnal erections. On clinical e x a m i n a tion there was a bluish-black discoloration of the glans penis and preputial edema. Angiography performed via the right femoral route demonstrated patency o f the venous b y p a s s graft (Fig. IA). The bypass appeared to end in the deep dorsal penile vein instead of the dorsal penile artery. T h e r e was h y p e r t e n s i o n in the corpora cavernosa and total c o m p r e s s i o n of tbe v a s c u l a r structures to the glans IFig. IB). After an interdisciplinary discussion it was decided to embolize the venous bypass. This was performed with a small Gianturco coil (Fig. 21. After the procedure the improvement was spectacular with fast regression of the preputial e d e m a and regression of the ischemia of the glans over 2-3 weeks. After the procedure the erections of the patient normalized as recorded with nocturnal t u m e s c e n c e measurements.
Discussion In this patient the decision for microsurgical arterial anastomosis of the penis was made on the basis of poor quality angiographic data. The dorsal penile arteries were not visualized due to insufficiently selective catheterization, inadequate intraarterial vasodilatation, and neglect of intracavernosal pharmacotherapy [9-14]. Furthermore, the venous drainage of the penis in this patient was compromised by a venous leakage procedure. The surgeon attempted to use a personal technique in revascularization of the penis, consisting of an anastomosis between the inferior epigastric artery and the dorsal penile artery. In misplacing the venous bypass to the dorsal penile vein, he per-
G. Wilms et al.: Glans lschemia after Penis Revascularizalion
3115
V I ,i
Fig. 1. A. Right external lilac angiogram. Good patency of the venous bypass graft. B. Selective angiogram of the graft. No filling of the corpora cavernosa. The deep dorsal penile vein is opacified and dilated, with flow through multiple circumferential veins, draining into the corpus spongiosum. Pudendal and obturator veins are opacified by collaterals around the ligated portion of the deep dorsal vein. There is hypervascularization of the penis with edema and c~.~mpression of the vanculature of the glans.
Fig. 2. Right external iliac angiogram after embolization. Complete occlusion of the graft. Notice Gianturco coil (arrow).
formed an anastomosis between the epigastric artery and the deep dorsal vein, corresponding to the type I operation of Virag [15-17]. Hypervascttlarization of the corpora spongiosa is a known complication of this technique, but is usually evident during the operation [16, 18]. When such a complication occurs after the operation, surgical reintervention is often difficult due to fibrosis. Embolization of the venous bypass was an easy way of treating the venous hypervascularization and the glans ischemia.
References 1. Carmignani G, Pirozzi F, Spano G, Corbu C, De Stefani S 119871 Cavernous artery revascularization in vasculngenic impotence: New simplified techniques. Urology 311:23-26 2. Goldstein 1 119871 Penile revascularization. Urol Clin North Am 14:805-813 3. Mac Gregor RJ, Konnak JW 119821 Treatment of vasculogenie erectile dysfunction by direct ana~,lc,mosis of the infe-
rior epigastric artery Io the central artery of the corpun cavernosum. J Urol 127:136-139
4. McDougal WS, Jeffrey RF (1983) Microscopic penile revascularization. J U rol 129:517-52 I 5. Michal V. Kramar R, Pospical J, Hejhal I, (19771 Arterial epict~strico-cavernous anastmosis for the treatment of sexual impotence. World J Surg 1:515--519 6. Michal V, Kramar R. Bartak V 119741 Femoral-pudendal bypass in the treatment of sexual impotence. J Cardiova,,,c Surg 15:356--359 7. Balko A, Malhotra CM, Wincze JP. Susset JG, Bansal S, Carney WI, Hopkins RW ( 19861 Deep-penile vein arlerialization for arterial anti venous impotence. Arch Sur 121:774-777 8. Pearl RM. McChee RD 119871 Penile revascularization in the treatment of vasculogenic impotence. Plast & Reconstruct Surg 80:284-289 9. Zorgniotti AW, Rossi G. Padula G, Marovskyr D ( 19801 Diagnosis and therapy of vascutogenic impotence. J Urol 123:674-676 10. Delcour C, Katoto RM, Richoz B, Van Bunnen Y, Wery D, Struyven J (19891 Penile arteriography: Technical improvements. [nt J Impotence Res 1:43-47 1I. Detcour C, Vandenbosch G, Delatte Ph, Wespes E, Struyven J 119881 Technical advances in penile arteriography. AJR
150:803-804 12. B/ihren W, Gall H, Scherb W, Stief C, Thon W (1988) Arterial anatomy and arteriographic diagnosis of arteriogenic impotence. Cardiovasc Intervent Radiol l 1:195-210 13. Bookstein JJ ( 19881 Penile angiography: The last angiographic frontier. AJR 150:47-54 14. B,,)okstein JJ. Lang EV (19871 Penile magnification pharmacoarteriography: Details of intrapcnite arterial anatomy. A JR 148:883-888 15. Virag R ( 19841 Principles and long term evaluation ofrevascularization and venous surgery for impotence. In: Ed by CERI (Centre d'6tudes et de Recherches de l'impuissance) Proceeding of the First World Meeting on Impotence. Paris, France, pp 285-290 16. Virag R, Frydmann D. Legman H, Bouilly P 119831 Possibilit6s chirurgicates darts l'impuissance vasculaire. Gaz Med de France 90:2031-2038 17. Virag R (19811 Syndrome d'erections instables par insuffisanee veineuse. Diagnostic et Correction Chirurgicale J.M.V. 6:121-123 18. Bennett AH. Rivard DJ, Raymond PB. Moran M (19861 Reconstructive surgery for vasculogenic impotence. J Urol 136:599-601
CarffloVascular andInterventional
Radio [y
9 Springer-Verlag New York Inc. 1990
Pelvic Vasculature
Glans lschemia After Penis Revascularization: Therapeutic Embolization G. Wilms, ~ R. Oyen, I L. Claes] W. Boeckx, 3 A.L. Baert, I and L. Baert 2 Departments of Radiology, ~ Urology,-" and Surgery, 3 University Hospitals K.U. Leuven, Belgium
Abstract. A case of hypervascularization of the penis with glans ischemia after venous leakage procedure followed by revascularization of the penis is reported. The venous bypass between the inferior epigastric artery and the dorsal penile artery was misplaced on the deep dorsal vein leading to venous hypertension of the glans. Transcatheter embolization of the venous bypass cured this complication. Key words: Arteries. therapeutic blockade--Arteries, pudendal--Penis, angiograph'y--Penis, diseases
In the last decade several surgical techniques were developed to increase arterial flow to the penis in the treatment of vascular impotence [1-8]. Initial techniques such as femoral-pudendal bypass [6] and direct anastomosis to the corpus cavernosum [5] were frequently complicated by priapism and hypervascularization of the penis with penile edema. These complications are much less frequent and clinical results are better with the newer technique of artery to artery anastomosis [I, 3, 5]. We wish to report a patient in whom a venous leakage procedure followed by an inadvertent amistomosis of the inferior epigastric artery to the dorsal penile vein (instead of the artery), was complicated by hypervascularization of the penis with glans ischemia. Transcatheter embolization of the venous bypass was successfully performed.
Case Report A 26-year-old m a n with psychosocial instability complained for 5 years of intermittent impotence. On the basis of cavernosonogAddress reprint requests to: Prof. Dr. G. Wilms, Department of Radiology, University Hospitals K . U . Leuven. Herestraat 49, B3(/00 L e u v e n , Belgium
raphy demonstrating a venous leak, surgery was performed. On the venous side, the deep dorsal vein of the penis was resected and several side branches were ligated. A (Nesbitt) plasty of the left corpus c a v e r n o s u m was also done. B e c a u s e of an insufficient clinical result, 8 m o n t h s later bilateral internal lilac angiography was performed in a n o t h e r hospital and interpreted as bilateral occlusion of the internal pudendal arteries. Revascularization of the penis was attempted with a v e n o u s bypass between the inferior epigastric artery and both dorsal arteries of the penis. A few days later the patient developed severe e d e m a of the penis with ischemia of the glans, c a u s i n g c o n s t a n t h e a v y burning pain especially during nocturnal erections. On clinical e x a m i n a tion there was a bluish-black discoloration of the glans penis and preputial edema. Angiography performed via the right femoral route demonstrated patency o f the venous b y p a s s graft (Fig. IA). The bypass appeared to end in the deep dorsal penile vein instead of the dorsal penile artery. T h e r e was h y p e r t e n s i o n in the corpora cavernosa and total c o m p r e s s i o n of tbe v a s c u l a r structures to the glans IFig. IB). After an interdisciplinary discussion it was decided to embolize the venous bypass. This was performed with a small Gianturco coil (Fig. 21. After the procedure the improvement was spectacular with fast regression of the preputial e d e m a and regression of the ischemia of the glans over 2-3 weeks. After the procedure the erections of the patient normalized as recorded with nocturnal t u m e s c e n c e measurements.
Discussion In this patient the decision for microsurgical arterial anastomosis of the penis was made on the basis of poor quality angiographic data. The dorsal penile arteries were not visualized due to insufficiently selective catheterization, inadequate intraarterial vasodilatation, and neglect of intracavernosal pharmacotherapy [9-14]. Furthermore, the venous drainage of the penis in this patient was compromised by a venous leakage procedure. The surgeon attempted to use a personal technique in revascularization of the penis, consisting of an anastomosis between the inferior epigastric artery and the dorsal penile artery. In misplacing the venous bypass to the dorsal penile vein, he per-
G. Wilms et al.: Glans lschemia after Penis Revascularizalion
3115
V I ,i
Fig. 1. A. Right external lilac angiogram. Good patency of the venous bypass graft. B. Selective angiogram of the graft. No filling of the corpora cavernosa. The deep dorsal penile vein is opacified and dilated, with flow through multiple circumferential veins, draining into the corpus spongiosum. Pudendal and obturator veins are opacified by collaterals around the ligated portion of the deep dorsal vein. There is hypervascularization of the penis with edema and c~.~mpression of the vanculature of the glans.
Fig. 2. Right external iliac angiogram after embolization. Complete occlusion of the graft. Notice Gianturco coil (arrow).
formed an anastomosis between the epigastric artery and the deep dorsal vein, corresponding to the type I operation of Virag [15-17]. Hypervascttlarization of the corpora spongiosa is a known complication of this technique, but is usually evident during the operation [16, 18]. When such a complication occurs after the operation, surgical reintervention is often difficult due to fibrosis. Embolization of the venous bypass was an easy way of treating the venous hypervascularization and the glans ischemia.
References 1. Carmignani G, Pirozzi F, Spano G, Corbu C, De Stefani S 119871 Cavernous artery revascularization in vasculngenic impotence: New simplified techniques. Urology 311:23-26 2. Goldstein 1 119871 Penile revascularization. Urol Clin North Am 14:805-813 3. Mac Gregor RJ, Konnak JW 119821 Treatment of vasculogenie erectile dysfunction by direct ana~,lc,mosis of the infe-
rior epigastric artery Io the central artery of the corpun cavernosum. J Urol 127:136-139
4. McDougal WS, Jeffrey RF (1983) Microscopic penile revascularization. J U rol 129:517-52 I 5. Michal V. Kramar R, Pospical J, Hejhal I, (19771 Arterial epict~strico-cavernous anastmosis for the treatment of sexual impotence. World J Surg 1:515--519 6. Michal V, Kramar R. Bartak V 119741 Femoral-pudendal bypass in the treatment of sexual impotence. J Cardiova,,,c Surg 15:356--359 7. Balko A, Malhotra CM, Wincze JP. Susset JG, Bansal S, Carney WI, Hopkins RW ( 19861 Deep-penile vein arlerialization for arterial anti venous impotence. Arch Sur 121:774-777 8. Pearl RM. McChee RD 119871 Penile revascularization in the treatment of vasculogenic impotence. Plast & Reconstruct Surg 80:284-289 9. Zorgniotti AW, Rossi G. Padula G, Marovskyr D ( 19801 Diagnosis and therapy of vascutogenic impotence. J Urol 123:674-676 10. Delcour C, Katoto RM, Richoz B, Van Bunnen Y, Wery D, Struyven J (19891 Penile arteriography: Technical improvements. [nt J Impotence Res 1:43-47 1I. Detcour C, Vandenbosch G, Delatte Ph, Wespes E, Struyven J 119881 Technical advances in penile arteriography. AJR
150:803-804 12. B/ihren W, Gall H, Scherb W, Stief C, Thon W (1988) Arterial anatomy and arteriographic diagnosis of arteriogenic impotence. Cardiovasc Intervent Radiol l 1:195-210 13. Bookstein JJ ( 19881 Penile angiography: The last angiographic frontier. AJR 150:47-54 14. B,,)okstein JJ. Lang EV (19871 Penile magnification pharmacoarteriography: Details of intrapcnite arterial anatomy. A JR 148:883-888 15. Virag R ( 19841 Principles and long term evaluation ofrevascularization and venous surgery for impotence. In: Ed by CERI (Centre d'6tudes et de Recherches de l'impuissance) Proceeding of the First World Meeting on Impotence. Paris, France, pp 285-290 16. Virag R, Frydmann D. Legman H, Bouilly P 119831 Possibilit6s chirurgicates darts l'impuissance vasculaire. Gaz Med de France 90:2031-2038 17. Virag R (19811 Syndrome d'erections instables par insuffisanee veineuse. Diagnostic et Correction Chirurgicale J.M.V. 6:121-123 18. Bennett AH. Rivard DJ, Raymond PB. Moran M (19861 Reconstructive surgery for vasculogenic impotence. J Urol 136:599-601
