Surgery for sexual dysfunctions Khaled Dabees, MD, PhD Egypt

Vascular E.D arterial surgery venous surgery Priapism Penile fracture Peyronie’s disease Penile prosthesis

Arterial and venous structure Dorsal artery of penis

Superficial vein Prostate Circumflex vein Penile arteries

Deep dorsal vein

Deep dorsal vein Superficial vein

Deep artery of penis Emissary vein

Cavernosal artery Tunica albuginea

Three key aetiologies in ED

Vascular causes

Aging

Psychological and other causes

Atherosclerosis A multifactorial disease

Role of Oxygen on Erection Low oxygen tension

→

TGF – BETA1 ↓ Collagen synthesis ↓ Fibrosis

O2-Induced Acetylcholine Smooth Muscle Relaxation 0 10 20 Percent Relaxation

30 40

3% 02 (n = 6)* 4% 02 (n = 9)* 6% 02 (n = 9)* Normoxia (n = 9)

50 60 9

8

7

6

5

4

-log [Acetylcholine] (M) Kim et al. J Clin Invest. 1993

Penile Arterial Revascularization

• Artery to artery – 0% art. insuff. – 30% traumatic – 54% Ë 81% traumatic – 82% non atheriosclerotic

Sharlip 1984

Goldstein and Padma-Nathan 1990 Jarow 1996

• Artery to vein (Virag) – 42% – 55% – 93%

Virag 1982 Grano 1994 Furlow 1988

• Artery to vein-artery (Hauri) – 89% – 30%

Hauri 1986 Melman-Ricardi 1993

Venous Surgery

Outcomes studies of venous leak surgery

Wespes, J Urol 1985 Williams, J Urol 1988 Lewis, Urol Clin 1988 Treiber, Urol 1989 Freedman, J Urol 1993 Montague, J Urol 1993 Huang, Eur Urol 1994

2 pat. 11 pat. 39 pat. 69 pat.

traumatic arterial lesions resection deep dorsal vein deep dorsal vein art. penile implant

Success > 4 y. 100% 14% 12% 93%

The synergism of penile venous surgery and oral Sildenafil in treating patients with erectile dysfunction

Wen H et al, Intern J Androl 2005; 28: 297-303

Priapism

Ischemic priapism Surgical treatment

Ischemic priapism Surgical treatment

Ischemic priapism Surgical treatment

Ischemic priapism Surgical treatment • Distal shunt: – corporaglandular shunt (Winter) (Ebbehoj) – Al-Ghorab procedure

Results 66% 73% 74%

• Proximal shunt: – caverno-spongiosal shunt (Quackels) – cavernosa-saphenous shunt (Grayhack)

• Immediate penile implant (Rees, BJ Int 2002)

77% 76%

High flow priapism • Embolization • Surgery

Penile Fracture

Penile fracture Diagnosis • History • Physical examination • Doppler • Cavernosography

Penile fracture Treatment • Conservative (10-53% complications) – ED – deviation – plaque – fistula – urethral stenosis

• Surgical (0% complications) – evacuation of the subcutaneous haematoma – suture of the TA Grima et al, Progrès en Urol 2006; 16: 12-18

Peyronie's Disease

Peyronie’s disease Pathophysiology Disorganisation of the circular or longitudinal layers in the tunica as well as disruption of elastin or a decrease in elastin content - Mechanical stress - Microvascular trauma (Subtunical bleeding)

Treatment options: Recommendations Reassurance and watchful waiting if the condition is painless, the deformity is minimal and erectile function is satisfactory Medical treatment drugs: vitamin E, potaba, tamoxifen, colchicine and intralesional verapamil efficacy: unpredictable, effective in less than 50% Reconstructive surgery reserved for potent patients with stable disabling deformity. ED patients who respond well to nonsurgical ED treatment can also be candidates International Consultation on Erectile Dysfunction, 1999

Indications for surgery A. Deformity

B. Erectile dysfunction

• when makes penetration difficult

in men with organic ED not

• In young men may be necessary to correct deformities as little as 20-30 degrees

responding to non-surgical therapy, penile prosthesis implantation is the choice

• Older men in a stable relationship and with a partner who has had several children may be able to cope with • A ventral deformity causes more difficulty than a dorsal or lateral one

• Improvement of function may occur postoperatively by reducing the volume of the corpora or by ligating a prominent dorsal penile vein

• Disease process has stabilized (a year after the onset of the disease and the bend has been stable for three months) International Consultation on Erectile Dysfunction, 1999

Choosing surgical technique: Recommendations • For less experienced surgeon, the Nesbit wedge resection, plication surgery or one of the modifications offers the best overall results • Grafting procedures should be performed by more experienced surgeons because more advanced skills are required in dissection of neurovascular bundles and grafting • In those with disabling penile deformity and ED not satisfied with non-surgical treatment, penile prosthesis implantation gives the best outcome International Consultation on Erectile Dysfunction, 1999

Nesbit

Plicature

Grafts Autologous tissue • dermis • temporalis fascia • dura mater • tunica vaginalis and • dorsal or saphenous vein Synthetic material • Dacron • Goretex

• No graft material that is perfect for replacing tunica albuginea • The synthetic material, dura and fascia provide strong covering but they don't stretch and curvature may recur • Synthetic material has risks of foreign body reaction and infection • Dermis tends to contract after several months and cause recurrence unless a larger graft (1/3 larger than the defect) is placed to allow contraction • Saphenous vein graft regains blood supply within minutes, the endothelium limit permeation of blood and its smooth muscle coat reacts to high pressure

Penile prosthesis

Thank You