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Penile Vascular Surgery for Erectile Dysfunction

Geng-Long Hsu*, Po-Cheng Huang, Hong-Chiang Chang

Given penile vascular surgery for restoring erectile function has been chronologically studied across the latest three centuries, it is still regarded as experimental. We sought to provide an overview of the relevant publications since 1873 and new developments in this issue in the recent three decades. It is commonly believed on the medieval version of penile fibro-vascular anatomy as a single circumferential tunica encircling the corpora cavernosa (CC) and one single dorsal vein (DDV) for draining the CC. In contrast, recent studies disclose a breakthrough penile fibro-vascular assembly as a bi-layered tunica with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat and the CC drainage veins composed of a single DDV, a pair of cavernosal veins (CVs), and two pairs of para-arterial veins (PAVs) between Buck's fascia and the tunica albuginea. The overlooked outer tunica is extended from the bilateral ischiocavernosus and bulbospongiosus proximally and an indispensable structure for fulfilling the corporal-veno-c-occlusive function. Thus the erection restoring strategy ought to be the focus on the location between the inner and outer tunica particularly approved via hemodynamic study on fresh and defrosted human male cadavers. Given most males are with asymmetrical penile arterial distribution and the cavernosal drainage veins are so complicated, subsequently, an anatomy-physiology-based penile erection restoration strategy ensues. CC is the most ideal milieu for applying Pascal’s Law if no venous leak in the entire human body. Recent hemodynamic studies disclose the penile veins play a pivotal role in rigid erection on fresh and defrosted human cadavers despite the lack of endothelial activation. Without a functional cardiac supply, the erectile function cannot speak volume. Not surprisingly, recent reports on penile arterial surgery support its utility in arterial trauma in young males, and with a localized arterial occlusive disease in the older male. Penile erection restoration surgery was first attempted by Lyston in 1895 and has been revisited several times subsequently with a controversy. An anatomy-physiology-based penile venous stripping is so sustainable that application conduct in over three thousand men in over three decades. Thus it has been shown to be beneficial in correcting veno-occlusive dysfunction, with outstanding results particularly feasible in most ED males. Give the negligible blood loss, neither a Bovie and nor a suction apparatus is required in the entire procedure, It can be ambulatory via acupuncture-assisted pure local anesthesia. The traditional complications of irreversible penile numbness and deformity have been virtually eliminated with the venous ligation technique superseding venous cautery. Penile vascular reconstructive surgery is viable if, and only if, the surgical handling is properly conducted using a sound method. It ought to be optimistically promising for the young surgeons.