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 .
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.