Venous Stripping Surgery Research Articles

(535) A Novel Approach for Penile Venous Stripping Surgery and Bilateral Varicocelectomy on an Ambulatory Basis

Abstract Introduction There are varied approaches for conducting varicocelectomy and penile venous surgery, which are not unified or conspicuously, being not above controversy in the later type either in methodology or routes for accessibility thus far. Objective We sought to present this innovative method in a novel combination of a physiological penile venous stripping and bilateral varicocelectomy via a single longitudinal pubic wound on an ambulatory basis. Methods From July 2012 to December 2021, 63 consecutive patients underwent this combined surgery. Primary diagnosis tools are dual cavernosography and doppler sonography. A 4-5cm longitudinal pubic incision is two-thirds above the penile pubic fold. A blunt dissection maneuver using a hemostat or finger creates a space between the Colles' and Buck's fascia. The entire penis is then released with an inside-out maneuver resulting in Buck's fascia being exposed exclusively, followed by firmed ligation of every emissary vein of the corpora cavernosa via 6-7 open-to-open schemes on Buck's fascia, subsequently stripping of the deep dorsal vein (DDV) and paired cavernosal veins (CVs). In contrast, the para-arterial veins are just ligated segmentally. Reduction of the penis is made after Buck's openings are repaired with not too tight square knots with 6-0 nylon. The stripping of the DDV and CVs is completed after 125-137 ligatures until the infra-pubic angle. Finally, the spermatic cord is hooked below the inguinal canal outlet level. On each side of the varicocele, ligation of 8-11 spermatic veins is macroscopically performed at no expense of ruining all other tissues, even the fragile lymphatic vessel. Then meticulous repair is obtained layer by layer. This novel approach is likely the most appropriate method for making a milking maneuver which is helpful in vascular differentiation on both corpora cavernosa and pampiniform plexus during the entire procedure to prevent residual veins from offensive. Results The average follow-up period is 5.3±0.5 years. There is a significant (9.6±2.7 vs. 20.9±2.3; P<0.01) between the preoperative and postoperative IIEF-5 scores. So does the EHS scale (1.6±0.3 vs. 2.9±0.3; P<0.01) between the preoperative and postoperative status. The radiopacity was unexceptionally enhanced postoperatively. Although the intracorporeal retention and erection quality improvement were unexceptional, the satisfaction rate is just 71.4% (45/63). Penile length resumed 3.5 months postoperatively, although two patients initially complained about 1-2 cm postoperative shortage. Conclusions From the physiology viewpoint, we would like to recommend this promising method with which the shortcut to express. Disclosure No

(533) Penile Venous Stripping for Treating Patients with Erectile Dysfunction Secondary to a Minimally Invasive Prostatectomy

Abstract Introduction A minimally invasive prostatectomy becomes a treatment of choice in patients with operable prostate cancer. However, it is not uncommon to encounter patients with erectile dysfunction (ED) secondary to this procedure. Objective Although there are many ED treatment strategies, we want to report a physiological penile venous stripping surgery to those patients whose ED was secondary to prostatectomy and refractory to all medical treatments in the recent decade. Methods From 2012 to 2021, 15 consecutive patients, aged 62 to 79, sustained erectile dysfunction (ED) following a minimally invasive prostatectomy for treating prostate cancer. Meanwhile, their ED was refractory to contemporary varied treatment strategies, including one 70-year-old patient non-responsive to 800 mg sildenafil. All patients received dual cavernosography in which the penile venous anatomy was shown by a pilot cavernosograpy, PGE-1 test in-between, and a veno-occlusive dysfunction (VOD) was documented by pharmaco-cavernosography. Eventually, they underwent a physiologically penile venous stripping surgery (PVSS) for erection restoration from VOD. The ambulatory basis was unexceptionally conducted under acupuncture-assisted local anesthesia. PVSS begins with a circumferential approach, followed by degloving those tissues superficial to the Colles' fascia until the penile base. Next, it entailed stripping a deep dorsal vein and two cavernosal veins while fixing every emissary's vein with 6-0 nylon closest to the outer tunica. In contrast, the two pairs of para-arterial veins were only segmentally ligated. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and corporeal radio-opacity assessed erection restoration. Additionally, the erection hardness scale (EHS) confirmed improvement. Results The prostatectomy was performed in laparoscopic (n=7) and Da Vinci surgical system (n=8) elsewhere. The average follow-up period was 5.3±0.4 years. It was unexceptionally pronounced on the radiopacity of the corpora cavernosa to the femoral cortex, denoting the intracorporeal retention established in the corpora cavernosa after PVSS. It was statistically significant between the preoperative and postoperative IIEF-5 scores (5.9±1.8 vs. 11.8±2.6, P<0.01). The EHS improved at least one scale. Surprisingly, two patients reported gratifying outcomes although they were committed to Parkinsonism. Overall, just 42.9% (9/21) of patients reported unaided sex. The remaining patients required medication aid every five men depending on 20 mg sildenafil and 5 mg vardenafil, respectively. Eventually, four resorted to malleable penile implants, which firmly declined preoperatively. Conclusions PVSS is beneficial in managing some groups of males whose ED is secondary to a minimally invasive prostatectomy, although the sample size is limited. Disclosure No

P57 - A novel approach for penile venous stripping surgery and bilateral varicocelectomy

P57 - A novel approach for penile venous stripping surgery and bilateral varicocelectomy

Penile venous stripping surgery is a viable option for erectile dysfunction after unsuccessful vascular interventions

To study whether penile venous stripping can improve erectile function after unsuccessful prior vascular interventions. Methods: This study is a retrospective review of the 49 consecutive patients that sought our assistance between 1999 and 2016 after receiving unsatisfactory vascular interventions elsewhere. Patients were evaluated by the abridged 5-item version of the International Index of Erectile Function (IIEF-5) and pharmaco-cavernosography. After the evaluation, the 36 patients without cardiovascular problems underwent a salvaging penile venous stripping and while the 13 remaining patients did not undergo the procedure. A circumferential incision was first made to strip the erection-related veins with 6-0 nylon sutures. A median longitudinal pubic incision was used to complete the stripping proximally until the infrapubic angle was reached. Finally, the wound was closed with 5-0 chromic sutures. Results: The follow-up period ranged between 1.0 and 16.5 years. Patients reported adequate and acceptable penile morphology postoperatively. Though there was no significant difference in IIEF-5 scores between the two groups preoperatively (n=13, 7.3 ± 1.9 vs. n=36, 7.6 ± 2.3, p=0.11), there was a statistically significant difference between treatment (n=36, 7.6 ± 2.1 vs. 17.4 ± 4.1, p<0.001) and control groups (ni¼13, 5.9 ± 1.8 vs. n=29, 18.7 ± 3.4, p<0.001). Postoperative cavernosograms confirmed that the paired corpora cavernosa are an ideal chamber for intracorporeal fluid retention in all patients, particularly, the penile crura displayed a stronger radiopaque than that of femoral cortex. Furthermore, we identified certain unexpected complications, such as embolization coils lodged in the cardiopulmonary avenues and electrocautery-induced fibrosis from prior interventions. Conclusions: Penile venous stripping appears to be a viable option for those who have undergone unsatisfactory prior vascular interventions for erectile dysfunction.

Salvaging Penile Venous Stripping Surgery

Disappointing functional outcome and penile deformity are major concerns of penile venous surgery. Consequently, it has been abandoned by most urologists. To explore whether penile deformity is correctable and erectile function can be improved, we report our experience in patients who had undergone surgery elsewhere. From 1986 to 2008, 16 consecutive patients sought our assistance because of poorer erectile capability or/and penile deformity from previous venous surgery elsewhere. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) was used to score the patients when it became available in 1998. Accordingly, 3 and 13 patients were categorized into the non-IIEF and IIEF groups, respectively. A median longitudinal pubic incision and a circumferential or semicircumcision were made to relieve the fibrotic tissues for accessing the deep dorsal veins, which were stripped thoroughly and ligated with 6-0 nylon sutures. The cavernosal veins were managed in a similar manner. The paraarterial veins were ligated only segmentally. Finally, the wound was approximated while an assistant consistently stretched the penile shaft. The operation time was 5.2 to 8.5 hours. The follow-up period ranged from 0.6 to 23.0 years. Overall, all patients reported satisfactory penile morphology postoperatively. In the IIEF group, the difference in preoperative and postoperative scores was significant (P < .001). In the non-IIEF group, 2 of the 3 patients reported natural coitus. This series of salvaging venous surgeries, although technically challenging, are helpful in correcting penile deformity and restoring erectile function in some patients who had poorer outcomes from prior venous surgeries.

Editorial Commentary

Editorial Commentary

Clinical Experience of a Refined Penile Venous Stripping Surgery Procedure for Patients With Erectile Dysfunction: Is It a Viable Option?

Penile venous surgery might not be considered an appropriate treatment for erectile dysfunction (ED) because of disappointing functional outcomes and unacceptable, seemly unavoidable, penile deformity. We report results of a refined penile venous stripping method in patients with veno-occlusive dysfunction (VOD). From 2000 to 2003, 341 of 467 men with ED were diagnosed with VOD via cavernosography and Doppler sonography. Patients were excluded from undertaking cavernosography if they had an untreated chronic systemic disease. Patients who had undergone the first penile venous surgery in other institutes were also excluded from this study because of the protracted surgical time and unpredictable functional outcomes, because severe fibrosis may prevent patients from completing penile venous removal. Of these 341 men, 178 were treated with a refined venous stripping surgical method (surgery group) and 163 patients were treated without this surgery (control group). In the surgery group, 167 were available for long-term follow-up using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system. The operative time ranged from 2.1 to 5.0 hours. The follow-up period ranged from 5.1 to 8.2 years, with an average of 7.7 +/- 1.4 years. The difference between the preoperative (9.7 +/- 3.9) and postoperative (21.6 +/- 2.8) IIEF-5 scores was significant (P < .001). Overall, 90.4% of the surgery group (151 of 167) reported improvements after surgery. A significant decrease in IIEF-5 scores (10.4 +/- 3.8 vs 7.9 +/- 3.2, P < .001, n = 121) during the same period of follow-up was, however, noted in the control group. This refined penile venous stripping surgery delivered favorable results and is a viable alternative for treating VOD.

Insufficient Response to Venous Stripping Surgery: Is the Penile Vein Recurrent or Residual?

There is currently controversy on whether the insufficient response to penile venous surgery done in an attempt to restore erectile function is due to recurrent or residual veins. In order to elucidate this issue, we report a study on those patients who failed to respond to the first venous surgery and subsequently underwent or declined a second operation. From July 1996 to July 2003, a total of 83 patients, aged 25 to 83, who were dissatisfied with their first venous surgery and were later diagnosed with a persistent veno-occlusive dysfunction via our dual cavernosography, were recruited into our study. Subsequently, 45 men underwent penile venous stripping surgery for a second time and were assigned to the surgery group, whereas the remaining 38 men were subject to follow-up and routine management and were assigned to the control group. All were evaluated with the abridged 5-item version of the international index of erectile function (IIEF-5) every 6 months for 1 to 5 years and cavernosogram, if necessary. In the surgery group their preoperative IIEF-5 score was 10.1 +/- 3.7, which increased to 17.1 +/- 3.2 (P < .001) after the first surgery and further increased to 20.7 +/- 3.1 (P < .001) after a second venous stripping of the cavernosal vein that was consistently demonstrated on the cavernosogram. Overall, 41 men (91.1%) reported a positive response to further venous surgery, with more satisfactory coitus, after the residual veins were stripped thoroughly, although eventually 4, 3, and 3 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. The follow-up period ranged from 12 months to 72 months, with an average of 37.0 +/- 11.5 months. In the control group, however, their corresponding IIEF-5 score changed from 17.4 +/- 2.9 to 16.9 +/- 3.2 (P > .05). Finally, 11, 7, and 8 men required additional oral sildenafil, penile implant, and intracavernosal injection, respectively. Although there was no statistical significance between the 2 groups in the first postoperative IIEF-5 scores, there was a significant difference in their IIEF-5 after further venous surgery. In this study, we propose that the clinical relapse of erectile dysfunction is a result of "residual" veins rather than "recurrent" ones.

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

A possible synergistic effect between penile venous surgery and oral sildenafil was inadvertently found in treating patients with erectile dysfunction in our clinic. We therefore sought to elucidate the possible synergic effect between venous surgery and sildenafil through studying patients who were non-responders preoperatively. From July 1998 to July 2003, 128 patients were diagnosed with veno-occlusive dysfunction. Subsequently, 65 of them underwent penile venous surgery and were assigned to the surgical treatment group. The remaining 63 men were assigned to the control group, and were subject to a simple re-exposure of oral sildenafil. All patients were evaluated with the international index of erectile function (IIEF-5) scoring. Sildenafil (12.5-100 mg) was prescribed postoperatively to all surgical patients as venous surgery alone was unsatisfactory and similarly, 100 mg preparation was prescribed for patients in the control group. The IIEF-5 scoring in the control group changed from a preoperative mean IIEF-5 score of 9.4 +/- 3.9 to 10.7 +/- 3.5 postoperatively. In surgical patients, however, the mean preoperative IIEF-5 score of 9.2 +/- 5.0, which increased to 15.1 +/- 5.0 (p < 0.001) postoperatively, further increased to 20.1 +/- 5.4 (p < 0.0001) after the addition of sildenafil. Although there was no significant difference between the two groups characteristics, there was a statistically significant difference between treatment results (p < 0.001). Overall, 61 men (93.8%) reported a positive response to sildenafil after venous stripping surgery. In contrast, only eight patients (12.7%) felt a beneficial response in the control group (p < 0.001). Forty-one of 65 patients had scores of > or =22, and 19 of these had a score of 25. No response was found in three (4.6%), and a decrease of 7 was seen in one (1.5%). In summary, patients in whom sildenafil was not effective preoperatively can become excellent responders after careful penile venous surgery. It appears that together, oral sildenafil and penile venous surgery may provide an encouraging solution to impotent patients with veno-occlusive dysfunction who are non-responders to sildenafil.

Penile venous anatomy: an additional description and its clinical implication.

The human penile venous system has been well studied and described but the demonstration of extra venous channels in imaging films prompted us to seek refinement of our anatomical knowledge of this venous system. Cavernosography in 37 patients who had venous stripping surgery and now suffered recurrent erectile dysfunction consistently showed an independent vein, smaller than the deep dorsal vein, running almost in the same position of the deep dorsal vein even though the latter had been removed unequivocally in previous surgery. Cavernosography in 9 patients who underwent intraoperative films also demonstrated the presence of this cavernosal vein in addition to the deep dorsal vein. Meticulous dissection of the penis under the microscope was then performed in 21 male cadavers and we found a cavernosal vein coursing along each corpus cavernosum all the way distally to the glans and draining directly into the Santorini's plexus in 19 subjects. This is in contrast to the previous description that this cavernosal vein was a short vein in the penile hilum. Two sets of para-arterial veins, which have not been reported in the literature, were found to accompany each dorsal artery in all 21 subjects. This more extensive and extra venous drainage might have important implication for venous stripping surgery in the treatment of erectile dysfunction.