VASCULAR INTERVENTIONS FOR IMPOTENCE - LESSONS LEARNED

Purpose: The purpose of this study was to analyze the results of vascu lar interventions for impotence in men with this complaint. Methods: B etween September 1983 and March 1993, 1094 men with the chief complain t of impotence (average age 54.5 years) were screened by use of penile plethysmography and penile brachial indexes: 635 were considered to h ave normal flow and 459 were considered to have abnormal arterial flow , 12.2% of whom were found to have aortoiliac disease. Based on negati ve neural screening results, absence of erectile responses on increasi ng doses of intracavernously injected papaverine or prostaglandin E(1) (ICI), surgical candidates for microvascular procedures were referred for dynamic infusion cavernosography (DICC) and pudendal arteriograph y. 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 diabet es and those not requiring blood pressure medications were selected fo r microvascular procedures. We report our experience and surgical outc omes at average follow-ups of 33 to 48 months. Four types of operation s were performed on 67 men (age 18 to 79 years). These included 17 aor toiliac reconstructions, 11 dorsal penile artery bypasses, 12 dorsal v ein 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 proc edures (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 mont hs. Among 11 men with dorsal penile artery bypasses, 27% functioned sp ontaneously and 45% used ICI at an average follow-up time of 34.5 mont hs. Among 12 men with dorsal vein arterialization, 33% functioned spon taneously, and 47% used ICI at an average follow-up time of 48 months. Among 27 with venous interruption, 33% functioned spontaneously and 4 4% used ICI. In seven of eight aneurysms of 4.5 to 6.0 cm in size, imp otence workup led to discovery; probable embolic mechanisms existed in three. Venous interruption efficacy correlated with postoperative DIC C results when how to maintain erection was 40 mi or less. Apart from two cases of glans hyperemia, no surgical complications occurred in th e microvascular procedures. There was one episode of bleeding caused b y 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 funct ional after operation. Men undergoing aortoiliac reconstruction has a significantly higher rate (58%) of spontaneous function as compared wi th those undergoing microvascular procedures.