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Venoligation Revascularization Prosthesis

Surgical Treatment for Impotence / Erectile Dysfunction

[Penile Prosthesis / Penile Implants / Venoligation / Re-vascularization]

 

Erection has a mechanism that relies on pumping blood into the corpus cavernosum of the penis, and closing the outlets so that blood pressure increases inside the penis to the extent of rigidity. This mechanism may fail due to many reasons, including leakage from the outlets (venous leak), occlusion of the inlets (arterial occlusion) and otherwise.

If this mechanism fails, and if medical treatment is not effective, a trial at restoring the mechanism can be performed surgically by venoligation or re-vascularization, with a limited success rate. If this too fails, the mechanism can be replaced totally, by penile prosthesis implantation surgery, with a very high success rate.

 

Venoligation

If impotence is caused by venous leak, the leaking veins can be individually occluded (ligated) to repair the faulty mechanism of erection.

This requires accurate studying of the veins prior to surgery, in terms of site and number, accomplished by cavernosography.

The best results with venoligation surgery are obtained in cases where leakage is through a one or two veins at most, rather than many veins, patients less than 45 years age, non-smokers, with impotence dating since puberty.

The incision is 1-3 cm long on the upper surface of the base of the penis. Surgery takes 30-45 minutes, and patients are discharged from the hospital on the same day.

The incision for venoligation, showing the vein (blue) right in the middle, surrounded on either side by an artery and a vein.

Success rate is within 60%. Some of the cases that fail surgery respond better to medical treatment contrary to the lack of response before surgery. Other failed cases require implantation of a penile prosthesis.

 

Vein arterialization:

Venous leak can be stopped by an alternative surgical method where an artery obtained from the anterior abdominal wall is connected to the vein to pump blood in a direction against the leaking blood, stopping the leak.

The incision is much longer than that of venous leak, and the results are not higher.

Revascularization

Re-vascularization a surgical technique used in case impotence is caused by arterial occlusion, aiming at repairing the faulty mechanism of erection.

Re-vascularization means connecting a new fresh artery to the corpus cavernosum or to the artery that feeds the corpus cavernosum to pump blood into the penis, since the original artery is obstructed.

The artery is usually obtained from the anterior wall of the abdomen (inferior epigastric artery) by a 15-25 cm long vertical incision from the umbilicus to the pubic fat.

Again, success rate is around 60% in well selected cases who should preferably be non-smokers, non-atherosclerotic, non-diabetics, non-hypertensive, with age around 35 years.

If surgery fails, penile prosthesis can be implanted.

Penile Prosthesis / Implant

 

 

If medical treatment fails, and the previously mentioned surgeries fail or do not have good expectations, penile prosthesis can be implanted to replace the normal mechanism of erection with one that error-proof, while not interfering with natural shape and form of the penis, natural feeling, natural pleasure, natural ejaculation, fertility and urination, all of which are preserved. It only addresses rigidity that is completely restored. When one desires erection, he induces rigidity in the penis by manipulating it in a special way that varies according to the type of prosthesis implanted. When the penis is made rigid, it stays that way for any length of time required, until one undoes rigidity by another manipulation. Even after ejaculation, the penis can be left rigid and intercourse can proceed for any length of time. Intercourse can thus be possible for any number of sessions, every day, and for any desired length of time. However, the penis will not turn rigid on its own. One must make it rigid with the hand manipulation that varies from one type of implant to the other. For example, the inflatable prosthesis  (see later) is made rigid by pressing a small sphere that is placed next to the testis inside the scrotal skin. Needless say that the penis retains the normal shape and form, that is, it is very difficult to tell that there is a prosthesis implanted.

 

The prosthesis is a silicon-made cylinder that is inserted into each corpus cavernosum, to grant complete rigidity whenever needed. This is performed through a small incision that is concealed and does not usually appear.

 

After the skin incision, the corpus cavernosum is incised for a length of 1cm, a metal rod is inserted into the corpus cavernosum to dilate it, and the prosthesis follows.

The corpus cavernosum is closed, and so is the skin.

 

 

This usually takes an average of 60 minutes of surgery, and does not usually require any length of hospital stay.

Two types of prosthesis exist, depending on the mechanism of rigidity: the inflatable, and malleable/semirigid.

The inflatable prosthesis is made of two soft, long cylinders that are connected to a small fluid-filled pump. The two cylinders are placed inside the two corpora cavernosa. The pump is placed inside the scrotum next to the testis. When the pump is pressed, fluid leaves the pump and fills the cylinders expanding them and rendering them rigid. The cylinders occupy the whole length of the corpora cavernosa, thus result in rigid erection of the penis when filled.

When one desires to undo erection in case an inflatable prosthesis is implanted, he presses the top of the pump or the penis itself (according to the model of the inflatable prosthesis). Fluid flows out of the cylinders making them soft again, and the penis shrinks back to normal.

The inflatable prosthesis allows for erection and shrinkage

The semirigid / malleable is different. It is composed of a long silver wire that can be bent and straightened. The silver wire is surrounded by a firm cylinder of silicon that has the feeling of a rigid penis. The cylinder can be bent or straightened as desired. When straightened, it stays straight and rigid.

Two cylinders are inserted, one in each corpus cavernosum, in the same way an inflatable prosthesis is implanted (see before). When one has a semirigid / malleable prosthesis implanted and he desires erection, he straightens the penis with his hand, and it stays erect as long as he needs. When he is done, he bends the penis downwards so that it does not show underneath his pants, but it stays rigid (though bent).

The semirigid /  malleable prosthesis can be straightened and bent as desired

To sum up, the major difference between the inflatable and the semirigid / malleable prosthesis is that the inflatable can erect and shrink back, while the semirigid / malleable can be erect or bent. This has major health implications. For example, men with diabetes mellitus should preferably implant and inflatable prosthesis rather than a semirigid / malleable prosthesis because the inflatable is less likely to press on the tissues since it is not always rigid. When one needs to have endoscopy performed for prostatic problems, the inflatable permits endoscopy while the semirigid / malleable prosthesis makes it more difficult. On the other hand, when one has fibrosis of the penis, a semirigid / malleable prosthesis may sometimes be better as the firm fibrous tissue cannot harm it, contrary to the inflatable prosthesis.

Possible complications of this surgery include wound infection, which can be prevented by strict sterilization, antibiotics and perfect surgical technique. Other very unlikely complications are over-sizing and under-sizing of the prosthesis, both of which result from poor surgical technique. Over sizing can result in perforation and extrusion of the prosthesis especially in diabetics.

Implanting a prosthesis in case of fibrosis

In cases of extreme fibrosis of the penis, insertion of a penile prosthesis in such conditions is very difficult and risky since the rigid fibrous tissue occupies the corpora cavernosa, where the prosthesis should be inserted. The corpora cavernosa are closed cylinders. Removal of fibrous tissue out of them is usually done by excavation in blind fashion ( being closed cylinders), unless a very long incision is performed spanning the whole length of the penis. Blind excavation results in  severe injuries. Long incisions result in infections. Again, the author of this website; Dr.Shaeer, has designed an innovative surgical technique where an endoscope is inserted into the corpora cavernosa, allowing easy excavation under vision. This technique is internationally published under the name of "Shaeer's Technique":

Corporoscopic Excavation of the Fibrosed Corpora Cavernosa for Penile Prosethesis Implantation: Optical Corporotomy and Trans-Corporeal Resection, Shaeer’s Technique.
Osama Shaeer and Ahmed Shaeer. DOI:10.1111/j.17436109.2006.00348.x

 

 

     

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