Venogenic Erectile Dysfunction Research Articles

Прямая перкутанная рентгенэндоваскулярная окклюзия вен простатического сплетения

In this work, we developed and introduced into clinical practice direct percutaneous X-ray endovascular occlusion of the veins of the prostatic plexus. Indications for this operation were a decrease in the quality of life associated with erectile dysfunction, the presence of proximal pathological venous drainage from the corpora cavernosa of the penis, lack of sufficient effect from taking of inhibitors phosphodiesterase type 5, refusal to use intracavernosal injections, refusal to undergo penile prosthetics, absence or low quality of visualization of the deep dorsal vein of the penis when using antegrade approaches to the prostatic plexus (transdorsal) as well as the complex anatomy of the pelvic veins when using retrograde approaches to the prostatic plexus (transfemoral and transcubital). The advantage of this technique was safety, extremely low morbidity and minimal hospitalization time. Keywords: venogenic erectile dysfunction, x-ray endovascular occlusion of the veins of the prostatic plexus

Can the parameters of penile duplex assessment predict the success of urethroplasty?

BackgroundThis work aimed to study the role of penile duplex in predicting the outcome of anastomotic urethroplasty.MethodsBetween March 2022 and February 2023, all patients presented with posterior urethral distraction defect (PUDD) underwent anastomotic end to end urethroplasty. Preoperative evaluation of sexual function was performed using international index of erectile function (IIEF-5) and penile doppler parameters (the response E1 to E5, peak systolic velocity (PSV), end diastolic velocity (EDV) and resistivity index (RI)). Each patient was, routinely, evaluated through 12 month-follow up using IIEF-5, penile doppler parameters, uroflowmetry for Qmax and pelvic ultrasound for postvoid residual urine (PVR). The procedure was considered successful if Qmax > 15 ml/s and PVR < 50 cc at the end of follow up. The correlation between the success rate of anastomotic urethroplasty and pre-operative penile Doppler parameters was the primary outcome.ResultsThirty patients with a mean age of 29.47 ± 9.79 years were evaluated. Twenty patients (66.7%) had previous orthopedic surgery. The stricture site was membranous in 6 patients (20.0%) and bubo-membranous in 24 (80.0%). The mean stricture length was 2.52 ± 0.98 cm. There was a statistically significant increase in mean end-diastolic velocity (P < 0.001) with a subsequent significant decrease in mean resistance index (P < 0.001). 14.3% of pre-operatively potent patients developed venous leakage (P < 0.001), while there was no change of arteriogenic or venogenic erectile dysfunction. In addition, of the patients who have arteriogenic erectile dysfunction, 37.5% did not require surgery, 25% had a urethrocystoscopy, and 37.5% required a repeat end to end urethroplasty. There is a significant association between pre-operative peak systolic velocity and the need for re-operation (P = 0.005).ConclusionPenile duplex may anticipate anastomotic urethroplasty efficacy in the case of PUDD.

Nosological concept and classification of venogenous erectile dysfunction

Various forms of proximal and distal types of pathological venous drainage from the cavernous bodies in patients with venogenic erectile dysfunction were studied and described using 3D computed cavernosography. The operation of targeted ligation of the veins of the penis based on the results of 3D computed cavernosography was developed and put into practice. A nosological concept and classification of venogenic erectile dysfunction (kind – type – form) has been developed and proposed.

(118) The Atherosclerotic Cardiovascular Disease Risk Score is a Reliable Tool to Identify Patients with Arteriogenic Erectile Dysfunction at Dynamic Penile Color Doppler Duplex Ultrasound – Findings From a Real-life Cross-sectional Study

Abstract Introduction The ASCVD (Atherosclerotic Cardiovascular Disease) risk score is a validated and standardised algorithm predicting the individual 10-year risk of developing acute cardiovascular events (CVs). Patients with erectile dysfunction (ED) are at greater risk of CVs; Objective we aimed to i) apply the ASCVD score at a homogenous cohort of men undergoing dynamic penile color doppler duplex ultrasound (CDDU) for ED, and ii) explore its predictive ability to identify patients with arteriogenic and venogenic ED at CDDU. Methods Complete data of 188 consecutive patients undergoing CDDU for ED were analysed. Health-significant comorbidities were scored using the Charlson comorbidity index. All patients completed the International Index of Erectile Function (IIEF) at baseline. Serum hormones (total testosterone (tT) and luteinising hormone (LH)) were dosed for every patient. The ASCVD score was applied to the entire cohort. According to the ASCVD, patients were segregated into low (≤7.5%) vs. intermediate/high risk (&amp;gt; 7.5%). Descriptive statistics was used to explore differences between the two groups. Logistic regression models tested the potential predictive role of ASCVD scores to predict pathological CDDU parameters (peak systolic velocity (PSV) &amp;lt; 35 cm/s and/or resistance index (RI) ≤ 0.70). Local polynomial smoothing models graphically displayed the probability of pathological CDDU parameters at different ASCVD scores. Results Overall, median (IQR) age was 54 (43-60) yr. Of all, 52 (27.7%) patients reported severe ED, as for IIEF-EF ≤ 11. Overall, 80 (42.6%) showed a pure arteriogenic ED and 15 (8%) pure venogenic ED at CDDU. Intermediate/high-risk patients (52.7%) were found to have lower IIEF-EF scores, higher BMI, higher CCI and presented with a greater rate of PDE5i non-responders compared to those with low-risk (47.3%) according to ASCVD (all p&amp;lt;0.005). Conversely, the two groups did not significantly differ in terms of CDDU parameters. At logistic regression analysis, the ASCVD risk score was identified as a strong predictor for arteriogenic ED at CDDU (OR: 1.07, 95% CI: 1.03-1.13, p = 0.007) after adjusting for BMI. Conversely, the ASCVD score was not identified as a predictor of pure venogenic ED (OR: 1.04, 95% CI: 0.98-1.1, p = 0.22). Figure 1 displays the probability of pathological findings at CDDU (PSV &amp;lt; 35 cm/sec vs. RI &amp;lt; 0.7) at different ASCVD scores. Conclusions The ASCVD risk score can be used as a valuable tool to identify patients with arteriogenic ED at CDDU in real-life settings. Since vasculogenic ED may anticipate CVs even by some years, the accurate identification of patients with deficient cavernosal arterial flow would certainly allow earlier and more effective cardiovascular prevention in this subset of patients. Disclosure No

The atherosclerotic cardiovascular disease risk score is a reliable tool to identify patients with arteriogenic erectile dysfunction.

The atherosclerotic cardiovascular disease risk score is a validated algorithm predicting an individual's 10-year risk of developing acute cardiovascular events (cardiovascular disease). Patients who suffer from arteriogenic erectile dysfunction are susceptible to developing cardiovascular disease in the future. To apply the atherosclerotic cardiovascular disease score at a homogenous cohort of men with erectile dysfunction undergoing a dynamic penile colour Doppler duplex ultrasound and explore its predictive ability to identify patients with vasculogenic erectile dysfunction at colour Doppler duplex ultrasound. Complete data of 219 patients undergoing colour Doppler duplex ultrasound were analysed. All patients completed the International Index of Erectile Function. The atherosclerotic cardiovascular disease score and Charlson comorbidity index were applied to the entire cohort. Patients were divided into those with normal vs. pathological parameters at colour Doppler duplex ultrasound. Descriptive statistics were used to explore differences between the two groups. Logistic regression models tested the potential role of atherosclerotic cardiovascular disease to predict arteriogenic and/or venogenic erectile dysfunction. Local polynomial smoothing models graphically displayed the probability of pathological colour Doppler duplex ultrasound parameters at different atherosclerotic cardiovascular disease scores. Overall, arteriogenic erectile dysfunction and venous leakage were diagnosed in 88 (40.2%) and 28 (12.8%) patients respectively. The median (interquartile range) atherosclerotic cardiovascular disease score was 7.7 (3.9-14). Patients with pathologic colour Doppler duplex ultrasound were older (59vs. 54 years, p<0.001), had higher Body Mass Index (26.5vs. 25.6kg/m2 , p=0.04), more comorbidities (Charlson comorbidity index ≥ 1) (76.5%vs. 54.4%, p=0.002) and higher median atherosclerotic cardiovascular disease scores (9.95vs. 7, p=0.005), respectively. At logistic regression analysis, a higher atherosclerotic cardiovascular disease risk score was independently associated with arteriogenic erectile dysfunction at colour Doppler duplex ultrasound (odds ratio: 1.03, 95% confidence interval: 1.01-1.08, p=0.02) after adjusting for Body Mass Index, physical activity, alcohol consumption and severe erectile dysfunction. As vasculogenic erectile dysfunction may precede bysome years the onset of acute cardiovascular diseases, the rigorous identification of patients with deficient cavernosal arterial blood flow, would definitely allow the implementation ofearlier and more effective cardiovascular prevention strategies in men with erectile dysfunction. The atherosclerotic cardiovascular disease risk score represents a reliable tool to identify patients with arteriogenic erectile dysfunction in everyday clinical practice.

Venous Leak Embolization in Patients with Venogenic Erectile Dysfunction via Deep Dorsal Penile Vein Access: Safety and Early Efficacy

PurposeThis all-comers registry aimed to assess safety and early efficacy of venous embolization in patients with venogenic erectile dysfunction due to venous leak in an unselected cohort.MethodsBetween October 2019 and September 2022, patients with venogenic erectile dysfunction resistant to phosphodiesterase-5-inhibitors were treated with venous embolization using ultrasound-guided anterograde access via a deep dorsal penile vein in a single center. A mix of ethiodized oil and modified cyanoacrylate-based glue n-butyl 2 cyanoacrylate (NBCA) monomer plus methacryloxy-sulpholane monomer (Glubran-2, GEM, Italy) was used as liquid embolic agent. Prior to embolization, venous leak had been verified based on penile duplex sonography and computed tomography cavernosography. Procedural success was defined as technically successful and complete target vein embolization. The primary safety outcome measure was any major adverse event 6 weeks after the procedure. The primary feasibility outcome measure was IIEF-15 (International Index of Erectile Function-15) score improvement ≥ 4 points in ≥ 50% of subjects on 6 weeks follow-up post intervention.ResultsFifty consecutive patients (mean age 61.8 ± 10.0 years) with severe erectile dysfunction due to venous leak underwent venous embolization. Procedural success was achieved in 49/50 (98%) of patients with no major adverse events on follow-up. The primary feasibility outcome measure at 6 weeks was reached by 34/50 (68%) of patients.ConclusionVenous leak embolization via deep dorsal penile vein access using a liquid embolic agent was safe for all and efficacious in the majority of patients with severe venogenic erectile dysfunction on 6 weeks follow-up.

Venogenic erectile dysfunction: diagnosis on computed tomography cavernosography and endovascular treatment using an anterograde access via deep dorsal penile vein

BackgroundThe underlying etiologies of erectile dysfunction may be manifold. Among them, vasculogenic etiologies are of increasing relevance and are not strictly limited to the elderly population. According to recent study, venogenic erectile dysfunction appears to be even more relevant than arteriogenic erectile dysfunction. Venogenic erectile dysfunction due to venous leakage causes insufficient penile blood retention. Proper diagnosis of venous leakage should include both color Doppler flow analysis and computed tomography cavernosography for adequate patient selection and treatment planning. Besides surgical ligation of penile draining veins, endovascular treatment methods may demonstrate more promising results. Especially endovascular embolization of venous leakage using an anterograde access via deep dorsal penile veins appears to be more beneficial for patients’ clinical outcome and awareness of this technique should be raised among endovascular interventionalists.Case presentationA 47-year-old man was diagnosed with venogenic erectile dysfunction due to venous leakage on color Doppler flow analysis and computed tomography cavernosography. He did not respond to PDE-5-inhibitors. This patient demonstrated major venous leakage of paired deep dorsal penile veins via periprostatic veins and internal pudendal veins draining into both iliohypogastric veins. This patient’s venous leak was treated with endovascular embolization using an anterograde access via deep dorsal penile veins.ConclusionThis patient’s erectile dysfunction due to venous leakage, based on findings in color Doppler flow analysis and computed tomography cavernosography, was embolized using an anterograde access via deep dorsal penile veins as a minimally-invasive endovascular treatment option.

PIVET-ED: A Prospective, Randomised, Single-Blinded, Sham Controlled Study of Pelvic Vein Embolisation for Treatment of Erectile Dysfunction.

Erectile Dysfunction (ED) is defined as the inability to obtain or maintain an erection firm enough for satisfactory sexual performance and affects the quality of life of over 50% of men aged over 40years. Venogenic ED is elucidated as a cause in a subgroup of patients. The study aims to investigate the clinical success, technical success, safety and durability of venous embolisation for management of venogenic ED. After providing informed consent, and subsequent to confirmation of venogenic ED by Doppler ultrasound (dUS) and cavernosography, 80 men referred for cavernosography and pelvic vein embolisation, will undergo randomisation by a computer system either to treatment or sham groups. Efficacy will be assessed using dUS and a validated questionnaire, the International Index of Erectile Function (IIEF). Pharmacologic agents used during the trial will be recorded. The primary outcome of PiVET-ED is to establish clinical success at 3 and 6months post venous embolisation, as defined by end diastolic velocity in the cavernosal artery < 5cm/s with dUS and by a > 4-point improvement in IIEF. Durability of the embolisation procedurewill be assessed annually to 5years. Quality of life will be assessedat all study time points using the 36-Item Short Form Survey (SF-36). The PiVET-ED trial is a prospective, randomised, single-blinded, single centre, sham controlled study, which aims to establish the safety, efficacy and durability of pelvic vein embolisation for the treatment of venogenic erectile dysfunction. Australian New Zealand Clinical Trials Registry ACTRN12620001023943, 08/10/2020.

Комплексная профилактика кавернозного фиброза после перенесенной радикальной нервосберегающей простатэктомии

Advances in laboratory and radiation diagnostics have improved the detection of early prostate cancer in patients aged 45 to 60 years who are sexually active and interested in preserving their erectile function after surgery. Objective: to improve sexual rehabilitation of patients after nerve-sparing robot-assisted radical prostatectomy (NS-RARP). Patients and methods. This study was conducted at the Medical Research and Educational Center of Lomonosov Moscow State University and included 32 patients who had undergone NS-RARP. Their mean age was 58 ± 6.4 years. Mean PSA level at diagnosis was 7.07 ± 2.9 ng/mL. The stages of prostate cancer were distributed as follows: 3 cases of T1bN0M0 (9%), 17 cases of T1cN0M0 (53%), 7 cases of T2aN0M0 (22%), and 5 cases of T2bN0M0 (16%). All patients were operated on by the same surgeon; neurovascular bundles were preserved using the intrafascial technique. Conclusion. Implementation of the robot-assisted technique reduced the frequency of postoperative erectile dysfunction. It is well known that even a successful standard prostatectomy is likely to result in erectile dysfunction due to partial denervation and ischemia of the cavernous bodies in the early postoperative period and cavernous fibrosis in the late postoperative period causing venogenic erectile dysfunction. Prophylaxis of cavernous fibrosis with phosphodiesterase type 5 inhibitors does not always ensure normal erection: 75% of patients have complaints of erectile dysfunction one year postoperatively. Comprehensive prevention (pharmacotherapy plus physiotherapy) of cavernous fibrosis in the early postoperative period significantly improved erectile function as demonstrated by the International Index of Erectile Function (IIEF). It was also confirmed by better hemodynamic parameters and increased stiffness of cavernous tissue in the patients studied.

Choice of X-ray surgical tactics for the treatment of venogenic erectile dysfunction in patients with pelvic varicose veins

The aim of the study was to develop an interventional approach for X-ray endovascular occlusion of the periprostatic plexus veins in patients with venogenic erectile dysfunction by systematizing X-ray phlebographic images obtained by standard dynamic pharmacocavernosography and dynamic multispiral computed cavernosography.Materials and methods. A comprehensive examination was carried out in 192 patients with venous erectile dysfunction. The age of the patients ranged from 19 to 66 (36.5 ± 0.73) years. The indication for occlusion of the veins of the periprostatic plexus was a combination of erectile dysfunctions on the IIEF-5 scale from 5 to 20 points and pathological venous drainage from the proximal cavernous bodies of the penis.Results. According to the Doppler ultrasound of the scrotum organs, TRUS of the prostate and the veins of the periprostatic plexus, all patients were diagnosed with pelvic varicose disease as a simultaneous combination of varicose veins of the gonadal veins and veins of the pelvic organs. Standard dynamic pharmacocavernosography was performed in 96 patients with erectile dysfunction. Pathological venous drainage was detected in 79 patients: proximal type - in 68 (86.0 %) of cases, distal type - in 4 (5.1 %) of cases and mixed type - in 7 (8.9 %) of cases. Periprostatic plexus vein occlusion was performed in 20 patients with venogenic erectile dysfunction with proximal pathological venous drainage. Complete disappearance of complaints of erectile dysfunction 6 months after X-ray surgical occlusion of the periprostatic plexus veins was noted in 81.0 % of cases (an increase in the index on the IIEF-5 scale from 12.7 ± 0.9 to 19.8 ± 0.9 points). The discrepancy between the data on the presence of venous leakage according to the results of standard pharmaco-Doppler sonography and the data on its absence according to the results of dynamic pharmacocavernosography in 19 patients determined the indications for dynamic multispiral computed pharmacocavernosography. The implementation of dynamic multispiral computed pharmacocavernosography made it possible to improve the visualization of variants of pathological venous outflow into the periprostatic venous plexus and the veins of the small pelvis from the cavernous bodies of the penis and to offer our own X-ray anatomical classification.Conclusion. The most common type of pathological venous drainage is its proximal type (86.0 % of cases). X-ray surgical occlusion of the veins of the periprostatic plexus is an effective method for the treatment of venogenic erectile dysfunction. Visualization of X-ray phlebographic images of the small pelvis during dynamic multispiral computed cavernosography with 3D reconstruction surpasses the results of standard dynamic pharmacocavernosography in the diagnosis of proximal, distal and mixed types of pathological venous drainage from the corpora cavernosa of the penis. Dynamic multispiral computed pharmacocavernosography with 3D reconstruction allows to determine the shape of the pathological venous drainage of the proximal type and determines the choice of antegrade or retrograde method of X-ray endovascular occlusion of the peripheryprostatic plexus veins in patients with venogenic erectile dysfunction.

Serum lipocalin-2 and carotid artery intima-media thickness in relation to obesity in eugonadal males over forty with venogenic erectile dysfunction.

Obesity is a risk factor for erectile dysfunction and atherosclerosis. Lipocalin-2 is an adipocytokine with proinflammatory properties involved in several disorders with metabolic alterations. Our aim was to study the relation of serum lipocalin-2 and carotid artery intima-media thickness (CIMT) to obesity in erectile dysfunction. Serum lipocalin-2 and CIMT were measured in 25 obese and 25 nonobese eugonadal patients over forty with venogenic erectile dysfunction and 25 healthy controls. Their relation to different patient- and disease-related parameters was studied. Results revealed lipocalin-2 to be significantly higher in obese compared with nonobese patients and with controls, and in nonobese patients compared with controls. CIMT was lower in controls compared with both obese and nonobese patients. In obese and nonobese patients, lipocalin-2 was positively correlated with disease duration, body mass index, waist circumference and end-diastolic velocity. Lipocalin-2 was negatively correlated with the short form of the international index of erectile function scores in both groups. In conclusion, the elevated lipocalin-2 in obese and to a lesser extent in nonobese patients and its association with disease severity points to its potential value as a diagnostic marker and a possible therapeutic target that could ameliorate the metabolic derangement associated with erectile dysfunction.

Role of RigiScan parameters in differentiation of vascular erectile dysfunction.

Male nocturnal penile tumescence and rigidity assessed by RigiScan monitoring device (GOTOP Inc.) is a noninvasive tool to differentiate organic from psychogenic erectile dysfunction (ED). This study aimed to determine the diagnostic value of RigiScan parameters in differentiating arterial ED from veno-occlusive ED. We recruited 102 male patients (mean±SD, 32.3±6.7years old) presented with an overall score <21 in the 5-item version of the International Index of Erectile Function scoring system. Baseline data of the included subjects were collected, and the patients were then subjected to RigiScan monitoring, penile colour Doppler ultrasound, and dynamic infusion cavernosometry and cavernosography examination. These patients were allocated into psychogenic, arterial and venous ED group based on the results of these specific examinations. At last, psychogenic ED was identified in 56 out of 102 men, while arteriogenic ED was identified in 31 cases and venogenic ED in 15 out of the overall 102 cases. The erection episodes per night (1.6±0.5 vs. 2.5±0.9 for venogenic vs. arterial ED respectively) and the duration of tip erections ≥60% in the venogenic ED group (21.5±10.5min) were significantly lower than cases in arteriogenic ED individuals (34.5±17.0min). Besides, receiver operating characteristic analysis showed that the duration of tip erections with a cut-off value of 12.5min had 81.4% sensitivity and 100% specificity for predicting a venogenic ED in cases with organic impotence. In conclusion, the duration of tip erection of RigiScan parameters was used to distinguish venogenic from arterial ED.

Diagnostic categorization of erectile dysfunction using duplex color doppler ultrasonography and significance of phentolamine redosing in abolishing false diagnosis of venous leak impotence: A single center experience.

Background and Aims:Erectile dysfunction (ED) is an inability to achieve and maintain erectile rigidity sufficient for satisfactory sexual performance. It is either organic or psychogenic in origin. This study was aimed at establishing vasculogenic causes among patients being evaluated for ED using Penile Doppler Ultrasound.Methods:Fifty-two consecutive patients with the clinical diagnosis of ED were evaluated with color Doppler ultrasound scan using a 7.5 MHz high-frequency linear transducer between July 2016 and June 2019. The examination was commenced 3 min after an intracavernosal injection with 10-20 μg of PGE1 and continued for 30 min. The measurements were obtained alternately from both deep penile arteries. The variables analyzed were the peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistive index (RI), calculated as (PSV-EDV)/PSV. Erection Hardness was evaluated subjectively using the EH Score (EHS), a 5-point response score denoting how the patient would rate his erection. ED was subjectively assessed using the International Index of Erectile Function (IIEF-5) questionnaire. In patients with a diagnosis of vasculogenic ED, intracavernosal PGE1 injection was started with a 5 μg dose and then increased in 5 μg increments until the final dose of 20 μg was reached.Results:PSV of cavernosal arteries (CA) varied between 19.2 and 106.2 cm/s (mean: 43.8 ± 18.2) among the entire patients and between 19.7 and 80.2 cm/s (mean: 42.6 ± 11.3) among patients with arteriogenic ED. Arteriogenic ED was found in 8 patients (15.3%), while venogenic ED was observed in 12 patients, which constituted 23% of the entire study population and mixed arteriogenic-venogenic ED was found in 6 patients (11.5%) of the study population. DICC performed on patients diagnosed with venogenic ED on color Doppler ultrasonography revealed venous leakage and no statistically significant differences between results of DICC and color Doppler ultrasonography were found in EDV, RI, and PI measurements (P< 0.005). Among patients with venogenic ED and mixed arteriogenic-venogenic ED,2 patients had a normal erectile response and the remaining 16 received 2 mg phentolamine. A significant increase in PSV between baseline and 20 mg PGE1 (P < 0.001) was observed in all cases. Following phentolamine, there was a significant increase in grade of erection (P = 0.0001) and a significant reduction in the EDV (P = 0.0001). A reduction of the EDV to below 0.0 cm/s was observed in 12 patients. In patients with arteriogenic erectile dysfunction, mean (±standard deviation) duration of erection for consecutive doses of PGE15 μg, 10 μg, 15 μg, and 20 μg were 42.2±18.4, 55.4±24.1, 66.1 ± 31.1, and 83.3±36.7 minutes, respectively, with significant increase for each dose. In patients with veno-occlusive dysfunction, mean durations of erection significantly increased from 9.1±8.0 minutes at 10 μg to 19.2±9.8 minutes at 20 μg.Conclusion:In the current study, 50% of patients had vasculogenic ED and “false-positive’’ diagnosis of venous leakage was unmasked by phentolamine re-dosing. It is therefore imperative that patients with ED benefit from duplex color Doppler ultrasonography which is safe, cheap and non-ionizing diagnostic modality before initiating therapy as ED treatment is cause specific.

Endovascular correction of venogenic erectile dysfunction in May–Thurner syndrome (clinical case)

Introduction. Secondary varicose small pelvic veins with the development of chronic venous insufficiency due to obstruction of the magistral venous vessels, in particular, the left common iliac vein and the right common iliac artery (May–Thurner syndrome), occupy a special place in the structure of the causes of venogenic erectile dysfunction (ED).The study objective is to present the clinical case of arteriovenous conflict (May–Thurner syndrome), leading to the development of secondary varicose small pelvic veins in men and venogenic ED, as well as modern methods of its verification and endovascular surgical repair.Clinical case. A clinical case of successful endovascular correction of venogenic ED is presented. The patient is diagnosed with: May– Thurner syndrome. Pelvic varicose disease С3 (according to CEAP Classification). Condition after endovascular balloon angioplasty and stenting of the left common iliac vein. Bilateral varicocele. Condition after bilateral varicocelectomy in 2018. Severe venogenic ED (pathological venous drainage, proximal type, International Index of Erectile Function (v. 5) – 12 points; Er3 according to the Unem Scale) in accordance with the Comprehensive Classification System for Chronic Venous Disorders. On July 24, 2019 endovascular occlusion of the Santorini’s plexus veins was performed with the installation of occlusion spirals in their lumen according to Gianturco. In order to provide visualization of the veins in the Santorini’s plexus, given the impossibility of cannulation of the deep vein of the penis, bilateral symmetrical cannulation of the cavernous bodies of the penis was carried out to perform cavernosophlebography. The left common iliac vein was catheterized according to the Crossover technique. Under phlebography control we ensured that the stent in the common iliac vein passed without signs of loss of its lumen. The internal pudental vein on the left was selectively catheterized. Hydrophilic guidewire was introduced through the veins of the periprostatic plexus into the right internal pudental vein. Selective catheterization of the periprostatic venous plexus was not possible due to pronounced tortuosity, valve flaps of the veins and small diameter of the catheterized veins. It was decided to pass the guidewire further through the right iliac vein system with access to the inferior vena cava. Further, the guidewire was again transferred to the left common iliac vein (double crossover). The left common femoral vein was punctured followed by the placement of 5 Fr introducer sheath according to Seldinger. The guidewire tip was fixed by the loop in the left common iliac vein, then captured and brought out through the introducer in the left common femoral vein. A catheter Сobra15 Fr was inserted through a crossover guide from the left common femoral vein into the right internal iliac vein and further into the periostatic venous plexus. Gradually veins of the Santorini’s plexus were selectively catheterized followed by Gianturco coils embolization.Conclusion. The first choice surgery for verified proximal type ED is endovascular occlusion of the veins in the Santorini’s plexus through the deep vein of the penis, which allows to change the hemodynamics in the penis and provide sufficient erection without resorting to endofalloprosthesis of the penis. Single or double-sided transfemoral access is suggested for patients when access through the deep vein of the penis is rather challenging or absent.

Vascular conflicts in andrology. Part 2. Lower level arteryovenous conflicts

This paper presents a review of the literature on the prevalence, classification, symptoms, diagnosis and treatment of lower level arteriovenous conflicts. New approaches in the treatment of both arteriovenous conflicts and comorbid diseases such as varicocele, varicose veins of the pelvic organs, venogenic erectile dysfunction, chronic pelvic pain syndrome are presented. The data of the literature review can form the basis for the revision of approaches to the management of patients with varicocele, erectile dysfunction and chronic recurrent prostatitis. It is shown that x-ray surgical embolization of prostatic plexus veins alone or in combination with testicular vein embolization, angioplasty and iliac vein stenting is possible only at the junction of urology, andrology and x-ray surgery.

PS-07-014 The repair of abnormalities in the Penile Suspensory Ligament

The function of the penile suspensory ligament (PSL) is to provide support to the erect penis to and maintain an appropriate angle for sexual intercourse, This paper describes the management of congenital and aquired abnormalities of the PSL. A total of 124 patients that presented with a variety suspensory ligament abnormalities necessitating repair are included. The aetiology included: subsequent to sexual trauma (n=68), congenital penile curvature/ torsion (n=33), absence/laxity of the ligament (n=6), Peyronie’s Disease (n=8), venogenic erectile dysfunction (n=7) and penile dysmorphic disorder (n=2). The diagnosis was made clinically via a history and examination, instability on artificial erection testing and the presence of a palpable gap between the pubis symphysis and penis. Psychogenic ED was excluded using nocturnal rigiscan monitoring. The surgical repair involved placement of non-absorbable sutures between the tunica albuginea of the penis in the midline and the symphysis pubis. Ancillary proceedures of plication/grafting or venous ligation was also performed in 41 patients.

Repair of the penile suspensory ligament for congenital and acquired pathology.

To review the mechanisms and patient outcomes for men presenting with abnormalities of the penile suspensory ligament (PSL) and their correction. We conducted a retrospective review of a total of 118 patients who presented with a variety of PSL abnormalities that necessitated surgical repair from 1993 to 2018. The patients mean (range) age at presentation was 29 (12-60) years with a mean (range) follow up of 8 months (3 months-12 years). The diagnosis was made clinically, often with a history of penile instability, pain or curvature/torsion, which was confirmed on artificial erection testing. Nocturnal tumescent testing and magnetic resonance imaging were used where necessary. The surgical repair was performed by placing non-absorbable sutures between the tunica albuginea of the penis and the symphysis pubis. Postoperative outcomes were reported in the clinic by direct questioning and a repeat of the investigations above when patients were unsatisfied with the result. The aetiologies and surgical indications in the 118 patients included: abnormality subsequent to sexual trauma (n = 66); congenital curvature of penis and/or congenital absence/laxity of the ligament (n = 37); Peyronie's disease (n = 8); and venogenic erectile dysfunction (ED; n = 7). A good surgical result, as defined by stabilization and straightening of the penis and a return to normal sexual function, was achieved in 85% of the patients and 82% were very satisfied with the outcome. Complications included long-term ED in four patients. Abnormalities of the PSL are uncommon and often subtle, but with the appropriate diagnosis, a good cosmetic and functional result is usually achievable.

Carotid artery intima-media thickness can predict the response of patients with erectile dysfunction to phosphodiesterase 5 inhibitors.

This study investigated the role of carotid artery intima-media thickness (IMT) as a morphological marker of the response of vasculogenic erectile dysfunction (ED) patients to tadalafil, one of the phosphodiesterase 5 inhibitor (PDE5-I). Through March-December 2016, 51 men with vasculogenic ED aged over 30 years were enrolled in this prospective study. Vasculogenic ED was accepted as a normal testosterone level, with penile colour Doppler ultrasonography showing arteriogenic ED, venogenic ED or mixed arteriogenic and venogenic ED. All patients underwent biochemical and hormonal blood tests, ultrasonographic evaluation of the common carotid artery (CCA) IMT and penile colour Doppler ultrasonography. On-demand tadalafil (10 mg or 20 mg in cases of a non-response to 10 mg) was administered to each patient for 2 months. ED was assessed using the short form of International Index of Erectile Function (IIEF-5) before and after the drug therapy. According to the patients' responses to the medication, they were grouped as non-responders or responders. Thirty-one of the 51 patients responded to tadalafil. The mean CCA IMT of the non-responders and responders was 0.9 ± 0.2 mm and 0.6 ± 0.2 mm, respectively (P = 0.000). The IMT of 90% of the non-responders was >0.67 mm, whereas it was >0.67 mm in 40% of the responders. The data were analysed using the Kolmogorov-Smirnov test, Chi-square test, t-test, Mann-Whitney U test and receiver operator characteristic (ROC) curves. Measurement of CCA IMT may offer an alternative and simple method to predict the response of vasculogenic ED patients to PDE5-Is.

The role of shear wave elastography on evaluation of the rigidity changes of corpus cavernosum penis in venogenic erectile dysfunction

ObjectiveThe goal of this study was to evaluate the effect of shear wave elastography (SWE) on the measurement of rigidity changes of penile erection in venogenic erectile dysfunction (ED) and in rigidity alterations of corpus cavernosum penis with age in normal population. MethodsThe study was a prospective analysis of 81 patients referred to the department of urology with complaints of ED as well as 35 healthy volunteers. SWE was performed on the corpus cavernosum penis (CCP) in the flaccid state of healthy group. The patients were divided into venogenic ED (31 patients) and non-vascular ED (neither arterial insufficiency nor venogenic dysfunction) (36 patients) by performing color doppler ultrasonography in association with intracavernous injection (ICI). SWE measurements were performed in CCP in the flaccid state, after 15–20 min and 25–30 min of ICI in both patients groups. Differences between groups were compared. ResultsAge was significantly negatively associated with SWE values of CCP among three groups (healthy group: r = −0.584, p < 0.05; venogenic ED group: r = −0.468, p < 0.05; non-vascular ED group: r = −0.539, p < 0.05). There was no significant difference between the SWE values of three groups in the flaccid state (p > 0.05). The mean SWE values of CCP were significantly lower in the erectile state (15–20 min after ICI) compared with the flaccid state in two patients groups (p < 0.05). The mean SWE values of CCP after ICI increased with time (from 15–20 min to 25–30 min) in patients with venogenic ED (p < 0.05), while the SWE values of CCP after ICI did not statistically significantly differ with time in patients with non-vascular ED (p > 0.05). ConclusionSWE is expected to be a promising approach in terms of the etiological diagnosis of ED and the quantitative evaluation of alternations of penile structures with age.

Применение рентгенологического метода исследования в предоперационном планировании пациентов с веногенной эректильной дисфункцией

Purpose: To study the effectiveness of dynamic computer cavernosography at the stage of preoperative examination of patients with venogenic erectile dysfunction (ED).&#x0D; Material and methods: 92 patients with venogenic erectile dysfunction were operated. Patients were divided into two groups depending on preoperative planning. Patients in group 1, pharma doppler sonography of the penis was used for preoperative planning. In group 2 – pharma doppler sonography of the penis and dynamic computer cavernosography were used. Resection of the deep dorsal vein of the penis was undergone in patients with proven distal type of shunt. A survey of patients was carried out before surgery and 12 months after surgical treatment according to the validated international rating scales of the erectile function.&#x0D; Results: After preoperative planning and surgical treatment scores of erectile function in both groups changed. In both groups the proportion of patients with a severe degree of ED significantly decreased. The level of assessment of the quality of erection in group 1 remained almost the same, but 26 % of patients recorded a maximum score of 4. In group 2 the majority of patients (56 %) described their condition with a maximum score of 4 points. The assessment of quality of life using a scale of “QOL” after surgical treatment was described by patients in the following way: “excellent”: in group 1 and 3 %, in group 2 and 7 %; “good”: in group 1 – 34 %, group 2 – 63 %; “satisfactory”: 3 % in both groups; “poor”: in group 1 – 50 %, group 2 – 15 %. These data confirm that resection of the deep dorsal vein of the penis statistically significantly (p &lt; 0.0001) improves the quality of life of patients with vein-occlusive mechanism of erectile dysfunction. However, in group 2 due to the proposed preoperative planning and pathophysiologically due to the definition of specific indications for surgical intervention we achieved the best estimates of quality of life (p = 0.0108).&#x0D; Conclusion: Preoperative planning based on the application of dynamic computer cavernosography, provides a statistically significant (p = 0.0061) improvement of the results of resection of the deep dorsal vein of the penis in patients with vein-occlusive mechanism of ED.