Endovascular
Treatment
Vasculogenic
disease is one of the most common etiologies of ED. Microsurgical vascular
reconstruction for penile artery insufficiency as a treatment for ED was first
attempted in 1973. Various vascular conduits were used for reestablishment of
arterial inflow, but given the limited studies and wide range of complications,
the American Urological Association (AUA) advised against such procedures.
Today, our surgical armamentarium has improved with more sophisticated image
guided procedures and techniques. The Zen Trial (Zotarolimus-Eluting Peripheral
Stent System for the Treatment of ED in Males with Sub-Optimal Response to PDE5
Inhibitors) was launched in 2009 and was the first trial to investigate the use
of the drug eluting stent in patients with ED caused by internal pudendal
artery stenosis refractory to PDE5-I. Results of the study revealed a fourpoint
improvement in erectile function according to the International Index of Erectile
Function (IIEF) in greater than 50% of patients [Goldstein and Koehler, 2012].
No adverse events or complications were encountered. Given the study's low
cohort of only 30 patients and short follow-up period of 30 days, larger scale
controlled trials are needed before stents could be introduced as an option for
patients with arteriogenic ED.
Other
interventional modalities currently being performed include balloon dilation of
internal pudendal artery secondary to peripheral arterial disease. A case series
published by Babaev and Jhaveri reported significant improvement in erectile
function after balloon dilation of the internal pudendal artery after selective
angiography demonstrated decreased pudendal arterial patency [Babaev and
Jhaveri, 2012]. Various sized drugeluding coronary stents were additionally
deployed within the pudendal artery to maintain patency. Figure 6 demonstrates
the findings on selective angiography and postpudendal artery dilation. All
patients were discharged the same day and upon follow up reported increased
erectile function.
Figure 6: Selective angiographies of the right internal iliac artery show
stenosis in the proximal internal pudendal artery, balloon angioplasty and
stenting. Final angiographic image demonstrates good distal runoff after
revascularization. Source: Babaev and Jhaveri [2012].
For patients with a veno-occlusive dysfunction,
endovascular treatment with selective embolization therapy has shown to be a
safe and effective method of treatment for ED. A recent study by Aschenbach and
colleagues published data on embolization of the dorsal penile vein with a
mixture of N-butyl-2-cyanoacrylate tissue adhesive and
LIPIODOL ULTRA. Results of this study revealed an 88% success rate of 24/27
patients recovering from poor tumescence and rigidity [Aschenbach et al. 2013].
The author reported a 0% complication rate. However, given the low cohort of
participants and retrospective nature of the larger scale study, prospective
data are needed to approve and validate the procedure.
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