Erectile dysfunction (ED) is a common condition with a reported overall prevalence of 18-49% in men, which increases with age and cardiovascular risk factors 1.
Venogenic erectile dysfunction (ED) occurs when inadequate relaxation of the cavernosal smooth muscle during arterial inflow results in the failure to block penile venous outflow tracts.
Etiology
The exact cause of venogenic erectile dysfunction (ED) is not fully understood.
Symptoms
Symptoms of venous leak may include short-lived, and soft erections causing unsatisfactory sexual relations, consequently negatively impacting quality of life and self-confidence.
Treatment
- Surgery
Surgical treatment is quite invasive and typically needs to be done in an operating room under general anesthesia. Furthermore, the long-term success rates of surgical ligation of the deep dorsal vein and its collaterals were reported to be approximately 25%.
- Endovasculary therapy
The aim of endovascular therapy is to achieve sufficient embolization of efferent pelvic veins, such as periprostatic, internal, or external pudendal veins, making it a minimally invasive, pain-free procedure without leaving a scar.
Procedure duration
Venous leak embolization is done as an outpatient procedure. Patients can typically go home the same day after a brief observation period. On average, the procedure takes between one to two hours based on the complexity of each case 2.
Embolization procedure in details
Preparation: before the procedure, answer the patient's questions and provide detailed instructions on how to prepare.
Locale anesthesia: local subcutaneous administration of 2% lidocaine for painless catheter insertion at the base of the penis.
Insertion of the catheter: the penile deep dorsal vein was punctured using real-time fluoroscopy image guidance and an ultrasound-guided technique. A stiff 20-gauge micropuncture set and a 0.018-inch guide wire were used to perform the puncture, followed by the insertion of a 4-French introducer with a stiff 3-French inner dilator. The stiff 3-French inner dilator was then introduced through the penile fascia (Buck's fascia) into the deep dorsal penile vein, and the catheter was carefully guided to the veins responsible for the venous leak.
Embolization: Afterwards, all materials were washed using a 5% glucose solution.Then, venous embolization was performed with a slow but steady injection of a liquid embolic agent, modified cyanoacrylate-based glue (n-butyl 2 cyanoacrylate or NBCA) monomer, and ethiodized oil (Lipiodol) mixed in ratios of 1:1–1:3. This was done under Valsalva maneuver and continuous fluoroscopic monitoring. The injection was stopped in time to prevent inadvertent distribution of embolization material from internal pudendal or periprostatic veins to the iliohypogastric veins, external pudendal veins to femoral veins, or dorsal penile veins. The total amount of the liquid embolic agent used ranged from 1 to 3 ml. These substances selectively block the veins to restore sufficient blood pressure to the corpora cavernosa in the penis, improving erectile function. After finishing the procdure, the catheter will be taken out, and the incision will be carefully sealed 1.
Post-operative follow-up
Patients can resume their regular activities within a few days following embolization. Most experience a significant improvement in erectile function and quality of life post-procedure.
Outcomes
Recent studies have shown that venous leak embolization holds promise as a treatment for associated symptoms and can lead to significant improvement in erectile function. This procedure could potentially offer a minimally invasive alternative to commonly performed surgical interventions 2-4.
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