What is penile bypass surgery and who is a candidate?
The goal of penile bypass surgery is to increase blood flow to the penis so that spontaneous erections can occur. Because of the technical complexity of the surgery, few men are actually candidates for it. The ideal candidate is a healthy man with a discrete arterial narrowing and who has no known medical conditions (e.g., diabetes mellitus, hypertension, elevated cholesterol level, and cardiovascular disease) that could complicate future arterial function.
The aim of the surgery is to provide an alternate arterial pathway that does not rely on the obstructed artery.
Who performs penile bypass surgery and how is it done?
The surgery is typically performed by a urologist specializing in the treatment of erectile dysfunction. The urologist may also involve a vascular surgeon, that is, a surgeon who performs bypass procedures for blood flow problems throughout the body. This is a highly technical procedure that should be performed by surgeons who are experienced with this type of surgery. Your local urologist may refer you to the appropriately trained surgeon in your area. The procedure may be performed under general or spinal anesthesia. Often, two incisions are made, one in the lower abdomen to provide access for the donor artery, the artery that will bring blood into the penis, and one in the opposite groin area to provide access for the recipient artery, the artery to which the donor artery will be sewn (Figure 13).
What is the success rate of penile bypass surgery?
The reported success rates for penile bypass surgery range from 30% to 84%. Careful patient selection helps to optimize the long-term results.
What are the risks of penile bypass surgery?
The risks of penile bypass surgery include the routine risks of any surgical procedure, such as anesthetic-related risks, wound infection, bleeding, incisional pain, and swelling. Additional risks related to the bypass surgery include:
- Disruption of the anastomosis and subsequent bleeding. The patient must refrain from intercourse, masturbation, or heavy activity for 6 weeks to minimize the risk of injury to the anastomosis.
- Penile pain.
- Loss of penile sensation. This occurs as a result of trauma to the nerve that supplies sensation to the penis.
- Glans hyperemia-increased blood flow to the glans (tip) of the penis. This occurs in 7% to 13% of patients.
- Groin hernia.
- Thrombosis (obstruction) of the graft. If the blood flow through the graft is not adequate, then thrombosis (the formation of a clot) may occur in the graft.
What is venous ligation surgery?
Venous ligation surgery is a surgical procedure in which the veins that are responsible for the venous leak are identified and ligated (tied off). Cavernosometry (see Question 23) and cavernosography (see Question 24) are required before surgery to confirm the presence of a venous leak and to identify the site(s) of venous leak.
Who is a candidate for venous ligation surgery?
Men whose erectile dysfunction is caused by a venous leak are candidates for venous ligation surgery. It is important to rule out other arterial disease that may be occurring along with the venous leak; therefore, these individuals should undergo an arterial assessment by color-flow Doppler ultrasonography. In addition, there should be no medical contraindications to surgery. Men who are interested in pursuing venous ligation surgery should be aware of the risks, benefits, success rates, and alternatives to the procedure.
What are the success rate and risks of the venous ligation surgery?
Most patients who undergo venous ligation surgery for erectile dysfunction caused by venous leaks will notice immediate improvements in their erectile function after surgery. However, this effect appears to be lost over time, and the long-term success rate is only about 50%. In men who do not respond over the long-term, repeat cavernosography demonstrates new sites of venous leak in many. Complications and risks of the procedure include the routine risks of any surgical procedure, including anesthetic risks, infection, and bleeding, as well as those related to the procedure, including prolonged penile swelling and failure to restore erectile function.
Who performs penile ligation surgery and how is it done?
There are select institutions throughout the country that perform venous ligation surgery. Most local urologists do not perform this surgery but would be able to give you the name and location of the closest urologist who does perform this procedure. Institutions that perform the surgery are also capable of performing the specialized tests needed to confirm and localize the site(s) of venous leak, the cavernosometry and cavernosography tests. These tests must be performed before venous ligation surgery is considered, and it is best to undergo these tests at the institution where you plan to have the surgery.
The venous ligation procedure may be performed under spinal or general anesthesia. The surgery is often performed through an inguinoscrotal incision (an incision that starts in your groin and extends down into your scrotum) and requires an extensive dissection of the veins, both the superficial and the deep penile veins. During the surgery, the veins responsible for the venous leak are tied off. Intraoperative studies can help delineate the sites of the leakage, and at the conclusion of the procedure, they can confirm that a rigid erection can be obtained and that there are no residual sites of venous leak.