Current surgical treatments for erectile dysfunction consist of correction of venous leak, arterial revascularization for inflow insufficiency and implantation of penile prostheses. Only the last of these, however, may truly be described as resulting in a reliably satisfactory outcome. In addition, patients with considerable deformity due to Peyronie’s disease may be helped by surgery designed to correct the penile curvature.
Correction of venous leak
Wespes originally described venous leak as a cause of erectile dysfunction. It was hoped that simple excision/ligation of the deep dorsal vein would be curative (
Figure 70). However, leakage points are usually multiple and, unfortunately, the improved function resulting from this procedure, even when combined with bilateral plication of the corpora or embolization of pelvic veins, is usually only temporary. This procedure should only occasionally be performed in fully informed consenting patients.
In younger patients with localized blockage of the internal arteries, such as those who have suffered major pelvic trauma, revascularization of the corpora may be a possible option. The donor vessel is usually the inferior epigastric artery (
Figure 71), which is mobilized and anastomosed either to the dorsal artery or to a combination of the dorsal artery and deep dorsal vein. Anastomosis to the flimsy cavernosal artery is not usually a realistic option. Unfortunately, because the run-off into the corpora is slow when the penis is flaccid, failure of revascularization often occurs in the longer term. Complications include glans hypervascularization, which may require reversal of the procedure.
Implantation of penile prostheses
For a number of years, it has been recognized that the insertion of silicone prostheses into the paired corpora cavernosa restores sufficient rigidity to the penis to permit intercourse. These prostheses are available in three basic forms: semi-rigid selfcontained single-piece devices that bestow limited rigidity and flaccidity, two-component inflatable devices, and three-component inflatable devices that provide the closest approximation to normality (
Implantation is accomplished under a general anesthetic with an antibiotic cover. A catheter is inserted to empty the bladder and reduce the risk of injury. Both corpora are incised and dilated to 14F in diameter and carefully measured. A prosthesis of the correct length is then implanted and the corpora closed (Figures 79, 80, 81, 82, 83, 84, 85 and 86). With the three-component prosthesis, the appropriate connections are then made to the pump located in the scrotum and to the reservoir (
Figure 87), which is implanted extraperitoneally anterolateral to the bladder. Prior to surgery, the patient should be counselled about the small risk of infection, which will necessitate device removal, and the possibility of subsequent mechanical failure of the device.
Surgical correction of erectile deformity
Deformity of the corpora cavernosa resulting in bending on erection may be congenital but, more often, is a result of scarring due to the disease described by Francois de la Peyronie (
Figure 92), and grafting of the defect with a segment of vein or other material. These procedures carry some risk of damage to the dorsal neurovascular bundle. Long-term outcome data are awaited to confirm that the initial benefit is sustained.
A proportion of patients with erectile dysfunction attribute their problem to the small size of their penis. In fact, a penis of any proportion is generally able to function effectively in terms of achieving sufficient rigidity for penetrative sexual intercourse.
Penile lengthening procedures have been described which involve division of the suspensory ligament and an advanced V-Y plasty of the intrapubic skin (
Figure 93). Liposuction of abdominal wall fat and subcutaneous injection have been described, but the long-term outcome has often proved to be a disappointment to both the patient and the surgeon.