Definition & Overview
Penile revascularisation is the surgical process of connecting the inferior epigastric artery to the dorsal penile artery or the deep dorsal vein, or both. It is performed to treat erectile dysfunction resulting from vascular injuries following trauma to the male genital area. This procedure is also known as microvascular arterial bypass surgery for the penis.
Erectile dysfunction, or impotence, is a major health issue among men. It is defined as the inability of keeping an erection during sexual intercourse. It can cause significant mental stress among patients, which could lead to relationship problems. It can also greatly reduce overall self-confidence. In some cases, erectile dysfunction is caused by underlying health issues such as diabetes, atherosclerosis, obesity, multiple sclerosis, and a whole lot of other physical and metabolic issues. However, there are instances that this condition results from blunt trauma to the male genital area, damaging blood vessels supplying the penis and reducing blood flow needed to sustain an erection.
This procedure was first described and practiced by Dr. Vaclav Michal. To this day, variations of techniques in performing this surgery are named after him.
Who Should Undergo and Expected Results
Male individuals who suffered blunt perineal trauma can experience erectile dysfunction. The perineum is the area between the anus and the scrotum. This area is the entry point for nerves and arteries going into the penis. Any injury to the perineum can cause damage to the penile artery, leading to reduced blood supply. Erectile dysfunction can occur immediately after the injury or gradually develop over time. Studies have indicated that men who rode bicycles regularly have a higher risk of developing this condition.
This procedure is also offered to patients who suffered blunt pelvic trauma and exhibit symptoms of erectile dysfunction afterwards. The injuries they sustained could be caused by a bad fall, vehicular or motor accidents, or sports injuries. The pelvis bones could crush and damage the blood vessels supplying the penis, leading to impotence.
It is good to note that penile revascularisation is not indicated for patients who have extended vascular diseases such as diabetes, hypertension, atherosclerosis, and other related conditions. This procedure does not provide long-term benefits for such patients because erectile dysfunction is known to recur even after surgery due to underlying health issues.
Penile revascularisation is considered a safe procedure with a great success rate. Most patients report high satisfaction after surgery, allow them to regain and maintain an erection. This results in improved quality of life. There is also a significant correlation between surgery success rates with a stringent patient selection process. This means that if the procedure is performed on patients who fit all the criteria, there is a high chance of success and reduced complication rate.
Patients are expected to rest for several days after surgery. They are also advised to continue psychological support as they slowly regain function of their sexual organ.
How is the Procedure Performed?
Prior to surgery, the surgeon obtains arteriogram images of the surgical site to evaluate and select the most suitable donor inferior epigastric artery and the most suitable recipient dorsal penile artery, the left or right. The arteriogram also allows the study of the veins involved, if the procedure entails venous graft.
The patient is placed under general anaesthesia. The first step is the dissection of the penile dorsal artery. The surgeon makes an incision near the scrotum. The penis is stretched and inverted to identify and preserve the fundiform ligament. The dorsal artery is identified and mobilised by making a cut in the proximal part. To prevent vasospasm, the surgeon irrigates the surgical site with papaverine hydrochloride solution. The scrotum is temporarily closed using surgical staples and the penis is placed in its original position.
To harvest the inferior epigastric artery, the surgeon makes another incision in the area below the navel. The overlying fascia and rectus muscles are dissected to locate and identify the inferior epigastric artery. Papaverine hydrochloride is also utilised to prevent vasospasm. The surgeon then proceeds to cut the artery at its distal end, near the navel. The staples placed in the scrotum are removed and the inferior epigastric artery is made to pass through the external inguinal ring. This is the method of transferring the artery to the dorsal part of the penis. Before proceeding with the surgery, the surgeon closes the incision made near the navel using sutures.
The penis is then reinverted and stretched out. The dorsal penile artery is divided in its proximal part and cauterised to prevent bleeding. An aneurismal clip is also placed on the arteries that would be later connected to prevent excessive bleeding. The connection is made by microsurgery to connect the distal end of the inferior epigastric artery and the dorsal penile artery. Once the stitches are in placed, the aneurismal clip is removed and blood flow is resumed between the two connected arteries. After the surgeon has made sure that no leaks occur, the penis is placed in its normal position. The scrotum is closed with sutures. The patient is also placed under Doppler ultrasound to confirm that complete anastomosis was achieved with no leak.
In some cases, the surgeon would prefer to perform a triple anastomosis procedure. This involves the inclusion of the deep dorsal vein into the connection. This is believed to improve neo-arterial run-off.
The third modification of penile revascularisation technique is connecting the inferior epigastric artery to the deep dorsal vein of the penis. This enables the flow of arterial blood into the vein. This also involves the ligation of several branches and trunks of the vein.
Possible Risks and Complications
There is the risk of bleeding and wound infection following penile revascularisation. Some patients report the occurrence of inguinal hernia, in which tissues are pushed through the inguinal canal. This can cause pain during movement.
There are also complaints of decreased sensitivity of the penis. This could be caused by injury or damage to the nerves supporting the penis. In some cases, patients observed penis shortening due to the scarring or fibrosis of the fundiform ligament.
Glans hyperemia or high-flow priapism is another possible complication. This is characterised by prolonged erection even without sexual stimulation. This condition is addressed by another surgical procedure to relieve this often painful condition.
Vickers MA Jr., Benson JB, Richie JP. High resolution sonography and pulsed wave Doppler for detection of corporovenous incompetence in erectile dysfunction. J Urol. 1990;143:1125-1127.
Mulhall J, Golstein I. Arterial surgery for erectile dysfunction: microvascular arterial bypass. In: Hellstrom WJG, ed. Male Infertility and Sexual Dysfunction. New York, NY: Springer-Verlag Inc.; 1997: 514-528.