(439) Penile Revascularization Utilizing The Lateral Femoral Circumflex Artery After Pelvic Fracture Urethral Injury

Abstract

Abstract Introduction Pelvic fracture urethral injury (PFUI) is associated with erectile dysfunction (ED) in up to 62% of patients, often due to decreased arterial inflow. For select healthy patients with isolated arterial insufficiency, penile revascularization utilizing the inferior epigastric artery to either the cavernosal or dorsal penile artery has been shown to be an effective treatment ED. The patient originally presented with a PFUI after a motor vehicle collision. He underwent suprapubic tube placement and selective embolization of a right internal pudendal artery pseudoaneurysm. Four months later, he underwent a posterior urethroplasty with corporal splitting and inferior pubectomy. During follow-up, he reported no erectile function following his initial trauma with no prior history of erectile dysfunction. He was trialed on PDE5is which were ineffective and ICI which was discontinued due to pain and minimal efficacy. Penile Doppler ultrasound with ICI showed bilateral arterial insufficiency with peak systolic velocities of 11.3 and 18.8 cm/second and no evidence of veno-occlusive dysfunction with end-diastolic flows of 2.85 and 4.66 cm/second of the cavernosal arteries (Figure 1). Bilateral inferior epigastric arteriography demonstrated 20-30% ostial stenosis with left traumatic occlusion of the internal pudendal and complete occlusion of the right internal pudendal artery post-embolization. The dorsal penile arteries filled in a delayed fashion via small-caliber collaterals. Objective We present this case to demonstrate use of an alternative arterial donor vessel for penile revascularization. Methods An infrapubic incision was made to expose the right dorsal penile artery. Another incision was made from the right anterior superior iliac spine to just above the patella tendon. The rectus femoris and vastus lateralis were atraumatically split and the descending branch of the lateral femoral circumflex artery was exposed. Small branches were clipped (Figure 2). The most distal branch to the rectus femoris was divided to become the donor vessel, leaving the proximal branch to maintain muscular perfusion. The donor branch was mobilized and passed via a subcutaneous tunnel into the infrapubic incision (Figure 3). Using an operating microscope the dorsal penile artery was ligated and the distal end was anastomosed to the donor artery and an end-to-end fashion using 8-0 nylon interrupted sutures. A drain was placed in the thigh wound, and both wounds were closed in two layers. Results The patient was started on 325mg of daily aspirin and remained on bed rest for two days. He was discharged on postoperative day two and his thigh drain remained in place for two weeks. He was restricted to less than 30-degree abduction of the right thigh for four weeks. Four months postoperatively the patient was achieving erections with 7/10 rigidity using only 5mg of tadalafil as needed. His SHIM was 17. At six months postoperatively he had increased his tadalafil dose to 20mg and was achieving erections with 8/10 rigidity from his pre-injury baseline. Conclusions This case demonstrates an excellent result from penile revascularization utilizing the lateral femoral circumflex artery. This artery can be considered an alternate donor for penile revascularization procedures following pelvic fracture urethral injury when there is a contraindication to the use of the inferior epigastric artery. Disclosure No