(100) Cavernovenous Leakage: A New Surgical Treatment in 171 Consecutive Patients with Severe, Drug-Resistant Erectile Dysfunction

Abstract

Abstract Introduction Cavernovenous leakage (CVL) is a frequent cause of erectile dysfunction (ED) in which blood entering corpora cavernosa escapes too early due to abnormal venous network, for erections to develop or maintain. When PDE5Is are ineffective to compensate for leakage, CVL is a devastating condition, affecting millions worldwide for whom no specific treatment is currently proposed. Objective Evaluate results of a new method of treatment combining open surgery and embolization simultaneously during the same procedure, in patients with CVL resistant to PDE5Is. Methods 171 consecutive patients with severe ED for more than six months, with CVL diagnosed by pharmacologically-challenge penile duplex sonography (PC-PDS) using intracavernous injection of Prostaglandin E1 and Papaverine, were operated-on. Leaks were imaged by caverno-computed tomography. Patient with other cause of ED were excluded, all had refused a penile implant, signed an informed consent, had a control PC-PDS three months after surgery, and were clinically evaluated during follow-up. A retrospective analysis was performed on prospectively collected data. Comparisons of variables before and after surgery used a paired t-test. Results Mean age was 43.8±13.6 years, range 18–76. ED had started at the beginning of sexual life (30) in 47.4%. Mean ED duration before surgery was 11.1±9.1 years (range 0.5–30). All patients had two clinical signs of organic ED: 1. no phase of erection improvement in the past six months, 2. erection alterations during masturbation (Erection Hardness Score (EHS)<3 and/or erection instability). Signs suggesting CVL were 1. variation of erection hardness according to position during masturbations or intercourses in 59.1%, 2. erections instability during masturbation or intercourse in all patients. At three-month evaluation, mean pharmacologic EHS had increased from 2.56±.66 before surgery, to 3.40±.56 (p<.0001). All CVL hemodynamic parameters at PC-PDS had decreased compared to pre-surgery: mean End Diastolic Velocity (from 16.6±9.5 to 9.3±7.7 cm/s, p<.0001), mean leakage speed on Deep Dorsal Vein (from 12.8±13.4 to .8±3.2 cm/s, p<.0001), mean speed on any superficial vein (from 11.2±10.1 to 3.9±6.3 cm/s, p<.0001). Patients unable to perform penetrations despite ICC injection of Prostaglandin E1 20 micg plus Papaverine 40 mg (EHS<3) decreased from 66.9 to 11.6% (p<.001). At the end of the 29.8±20.4-month follow-up, IIEF-5 score had increased from 9.7±5.1 to 15.5±6.0 (p<.0001), clinical EHS during sexual intercourse from 2.0±.7 to 3.3±.7 (p<.0001), penetration success rate from 22.3±31,7 to 70.1±37.2% (p<.0001), mean EHS during masturbation from 2.11±.67 to 3.04±.75 (p<.0001), EHS at morning erection from .95±1.24 to 2.1±1.37 (p<.0001), before and after surgery, respectively. 30.4% did not take any medication for erection. Success rate defined by post-operative EHS>3 and/or EHS increase >0.5 and erection stability was 80.7%. 78.9% recognized sexual support by a sexual medicine specialist is necessary for sexual recovery after surgery. Conclusions Simultaneous open surgery and embolization is a new procedure that offers unprecedented documented results in CVL resistant to PDE5Is. Clinical screening of CVL in ED patients is simple and should be evaluated in sexual medicine practice. Disclosure No.