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Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications¹

¹ From the Departments of Radiology (M.B., L.C., C.G., R.P.M.) and Urology (G. Savoca, G.L.), University of Trieste, Trieste, Italy, and the Department of Radiology, A.O. Santa Corona, Pietra Ligure, Italy (G. Serafini). Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received May 5, 2004; revision requested June 14 and received December 8; accepted December 13. All authors have no financial relationships to disclose. Address correspondence to M.B., Dipartimento di Scienze Cliniche, Morfologiche e Tecnologiche, U.C.O. di Radiologia, Ospedale di Cattinara, Strada di Fiume, 34149 Trieste, Italy (e-mail: bertolot{at}univ.trieste.it).

	Abstract

Top Abstract LEARNING OBJECTIVES Introduction Normal Penile Anatomy Surgical Procedures Conclusions References

 
A number of surgical procedures that significantly change the penile anatomy and vasculature can be used to manage pathologic conditions of the penis (eg, congenital and acquired deformities, erectile dysfunction, priapism). Phallic reconstruction surgery can be used for sex reassignment and after penile amputation or for correction of congenital malformations. Color Doppler ultrasonography (US) clearly depicts the normal penile anatomy and postoperative changes (eg, changes of the tunica albuginea, extraalbugineal pathologic fluid collections, cavernosal tissue changes produced by scars and fibrosis). It is also effective in evaluating surgery-related complications and determining the causes of erectile dysfunction and other unsatisfactory long-term results. Moreover, color Doppler US of the penile vessels and vascular anastomoses following revascularization allows direct evaluation of flow characteristics, shunt patency, and venous engorgement. Color Doppler US is the imaging modality of choice in evaluating patients who have undergone penile surgery.

© RSNA, 2005

	LEARNING OBJECTIVES

Top Abstract LEARNING OBJECTIVES Introduction Normal Penile Anatomy Surgical Procedures Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Discuss the main penile surgical procedures.
  
• Recognize the typical US features of the postoperative penis.
  
• Describe the US appearance of various postoperative complications.
  

	Introduction

Top Abstract LEARNING OBJECTIVES Introduction Normal Penile Anatomy Surgical Procedures Conclusions References

 
Color Doppler ultrasonography (US) is the imaging modality of choice in patients with penile diseases because it allows full evaluation of the penile vasculature and excellent depiction of both the normal penile anatomy and pathologic conditions affecting the penis. US has a well-established role in evaluating erectile dysfunction as well as penile trauma, scarring, deformity, and tumors. The penile urethra can be evaluated after distention with fluid.

A variety of surgical procedures have been developed to manage various penile diseases and malformations. The normal postoperative anatomy and the pathologic changes that can occur in cases of surgical complications can be successfully investigated with US. However, little has been written about color Doppler US of the postoperative penis. In this article, we review the normal penile anatomy and discuss a variety of penile surgical procedures (urethral surgery, correction of penile malformations, prosthesis implantation, vascular surgery for impotence, surgical management of priapism, phallic reconstruction). We also discuss and illustrate the gray-scale and color Doppler US appearance of the normal penis as well as postsurgical US findings.

	Normal Penile Anatomy

Top Abstract LEARNING OBJECTIVES Introduction Normal Penile Anatomy Surgical Procedures Conclusions References

 
The penis is composed of three cylindric bodies consisting of endothelium-lined cavernous spaces: two corpora cavernosa and the corpus spongiosum (Fig 1). The corpora cavernosa are the main erectile bodies, and the corpus spongiosum contains the urethra.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Normal penile anatomy. Drawings illustrate a transverse section through the penile shaft (a) and a sagittal view of the penis (b). The tunica albuginea (gray line) is seen enveloping the two corpora cavernosa (CC) and the corpus spongiosum (CS). Two other fascial layers, one deep (Buck fascia [green line]) and one superficial (Colles fascia) [blue line]), surround the tunica albuginea. The deep dorsal vessels (DDV), the superficial dorsal vein (SDV), and the cavernosal arteries (CA) are also seen. The urethra (U) is divided into a prostatic portion, which passes through the prostate gland (Pr); a membranous portion, which passes through the urogenital diaphragm (UD); a bulbar portion, which extends to the suspensory ligament of the penis (S); and a pendulous portion, which extends to the external urethral meatus.

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Normal penile anatomy. Drawings illustrate a transverse section through the penile shaft (a) and a sagittal view of the penis (b). The tunica albuginea (gray line) is seen enveloping the two corpora cavernosa (CC) and the corpus spongiosum (CS). Two other fascial layers, one deep (Buck fascia [green line]) and one superficial (Colles fascia) [blue line]), surround the tunica albuginea. The deep dorsal vessels (DDV), the superficial dorsal vein (SDV), and the cavernosal arteries (CA) are also seen. The urethra (U) is divided into a prostatic portion, which passes through the prostate gland (Pr); a membranous portion, which passes through the urogenital diaphragm (UD); a bulbar portion, which extends to the suspensory ligament of the penis (S); and a pendulous portion, which extends to the external urethral meatus.

The male urethra is subdivided into prostatic, membranous, bulbar, and penile portions. The prostatic urethra begins at the bladder neck and passes through the prostate gland up to the prostatic apex. The membranous urethra passes through the urogenital diaphragm. The bulbar urethra is surrounded by the bulb of the corpus spongiosum and extends from the perineal area to the suspensory ligament, which anchors the penis to the symphysis pubis. The penile or pendulous portion of the urethra extends from the suspensory ligament to the external urethral meatus. Just before the meatus, there is an ampullar dilatation called the fossa navicularis.

The blood flow to the penis is supplied by the cavernosal, dorsal, and urethral arteries, which are branches of the internal pudendal artery. There are many anatomic variations of all the penile vessels, and various arterial anastomoses can occur.

In most patients, one cavernosal artery penetrates each corpus cavernosum and runs through it in a central position; numerous small vessels with a tortuous course, the helicine arteries, branch from the cavernosal arteries and split into arterioles that communicate directly with the corporeal sinusoidal spaces. The helicine arteries constitute the functional circulation of the penis. Venous drainage from the corpora cavernosa is through small emissary veins, which drain into the corpus spongiosum and the dorsal, cavernosal, and crural veins.

The glans penis and the corpus spongiosum are mostly supplied by the dorsal penile arteries, which lie above the tunica albuginea and below the Buck fascia, and by the urethral arteries. Superficial arteries and veins lying above the Buck fascia supply the penile skin.

Among the anatomic variations of the arterial supply to the penis, the following are commonly seen and can be of interest to the surgeon: (a) more than one cavernosal artery within a corpus cavernosum, (b) both cavernosal arteries originating from a common arterial branch, and (c) a size difference between a well-developed dorsal artery and a hypotrophic contralateral artery. Arterial communications occur between the two cavernosal arteries in the majority of patients. In addition, communications between the cavernosal and urethral arteries are common at the base of the penis; communications between the dorsal and cavernosal arteries occur less frequently.

The corpora cavernosa and the corpus spongiosum manifest at US as homogeneous cylindric structures (Fig 2a). The urethra can be evaluated at US after distending it with fluid. The tunica albuginea and the Buck fascia are stuck together and appear as a thin echogenic line surrounding the three corpora. The Colles fascia is barely visible in healthy patients. On transverse US images, the cavernosal arteries appear as a pair of dots, whereas on longitudinal images they manifest as linear or narrow tubular structures. The dorsal vessels are visible as anechoic structures in the dorsal aspect of the penile shaft.

View larger version (192K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Normal penile anatomy. (a) Transverse US image obtained on the ventral aspect of the penis shows the paired corpora cavernosa (CC) and the corpus spongiosum (CS). The tunica albuginea (arrowheads) appears as a thin echogenic line surrounding the penile bodies. The Buck fascia is stuck to the tunica albuginea and cannot be distinguished from it. The cavernosal arteries (white arrows) are appreciable as a pair of dots located slightly medially within the corpora cavernosa. The dorsal vessels (black arrows) are visible in the dorsal aspect of the penis beyond the tunica albuginea. (b) Transverse color Doppler US image shows the cavernosal arteries (solid arrows), the dorsal penile vessels (open arrows), and the helicine arteries branching from the cavernosal arteries.

View larger version (205K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Normal penile anatomy. (a) Transverse US image obtained on the ventral aspect of the penis shows the paired corpora cavernosa (CC) and the corpus spongiosum (CS). The tunica albuginea (arrowheads) appears as a thin echogenic line surrounding the penile bodies. The Buck fascia is stuck to the tunica albuginea and cannot be distinguished from it. The cavernosal arteries (white arrows) are appreciable as a pair of dots located slightly medially within the corpora cavernosa. The dorsal vessels (black arrows) are visible in the dorsal aspect of the penis beyond the tunica albuginea. (b) Transverse color Doppler US image shows the cavernosal arteries (solid arrows), the dorsal penile vessels (open arrows), and the helicine arteries branching from the cavernosal arteries.

View larger version (42K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).

View larger version (60K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).

View larger version (45K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 3d.  Normal Doppler waveform changes in the cavernosal arteries during the onset of erection. Images of the Doppler spectrum show the monophasic flow with minimal or no diastolic flow that occurs in the flaccid state (a), increased systolic and diastolic flow (b), absence of end diastolic flow (c), and holodiastolic flow reversal (d).

	Surgical Procedures

Top Abstract LEARNING OBJECTIVES Introduction Normal Penile Anatomy Surgical Procedures Conclusions References

Curative management of urethral stricture requires urethroplasty. The best success rate is achieved by excising the stricture and creating an end-to-end anastomosis of the two ends of the urethra on either side of the excision. Unfortunately, this approach is not practicable in strictures of the penile portion of the urethra because urethral shortening would interfere with erection. Tissue transfer with flaps of local genital skin or free grafts is required in these patients. With use of tissue transfer urethroplasty, an 85% curative success rate can be achieved (3).

The major early complications of urethroplasty are infection with formation of fistulas, acquired pseudodiverticula, and necrosis of the grafted tissue. Flaps of insufficient width may predispose to restricture, whereas inappropriately wide flaps may cause sacculation in the reconstructed urethral segment.

A common late complication of scrotal flap urethroplasty, the surgical technique most commonly used in the past, is hair growth with urine stagnation and a tendency to obstruction. A number of surgical variants have been proposed to avoid this inconvenience, including depilation with electrocoagulation of the scrotal skin flap, the use of a penile or vesical skin flap, and even the use of synthetic materials. At present, the surgical procedure of choice for the construction of the urethral pouch is a buccal mucosal free graft.

The male urethra can be accurately studied with US either preoperatively or intraoperatively (5,6). The posterior tract can be investigated during patient voiding with high-frequency linear endorectal probes; the anterior tract can be explored with high-frequency linear transducers placed on the ventral aspect of the penis, scrotum, and perineum during voiding or after distention of the urethral lumen with saline solution or jelly. After urethral surgery, US is effective in evaluating restricture and other complications (Fig 4).

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Complications after urethral surgery. US of the urethra was performed through the scrotum following retrograde distention with saline solution. (a) Longitudinal US image obtained after urethral dilation in a 60-year-old man with recurrent postinflammatory stenosis shows the bulb of the corpus spongiosum (*) and a bulbar urethral restricture (arrowheads) with mucosal thickening. (b) Longitudinal US image obtained in a 23-year-old man with a history of bladder exstrophy and urethral duplication, with the ectopic urethra opening onto the anal canal and atresia of the proximal orthotopic urethra, shows a hair-bearing ectatic neourethra. The urethral malformation had been corrected during childhood by closing the ectopic urethral orifice and connecting the ectopic urethra to the bulbar portion of the orthotopic urethra proximal to the atresic portion using a scrotal skin flap.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Complications after urethral surgery. US of the urethra was performed through the scrotum following retrograde distention with saline solution. (a) Longitudinal US image obtained after urethral dilation in a 60-year-old man with recurrent postinflammatory stenosis shows the bulb of the corpus spongiosum (*) and a bulbar urethral restricture (arrowheads) with mucosal thickening. (b) Longitudinal US image obtained in a 23-year-old man with a history of bladder exstrophy and urethral duplication, with the ectopic urethra opening onto the anal canal and atresia of the proximal orthotopic urethra, shows a hair-bearing ectatic neourethra. The urethral malformation had been corrected during childhood by closing the ectopic urethral orifice and connecting the ectopic urethra to the bulbar portion of the orthotopic urethra proximal to the atresic portion using a scrotal skin flap.

Peyronie disease is the most frequent cause of acquired penile curvature; less common causes are penile fracture or other pathologic conditions resulting in localized corporeal fibrosis or scarring. In patients with Peyronie disease, penile deformity is caused by plaques of the tunica albuginea. The underlying cause remains unclear, but clinical data and histologic findings implicate local inflammation and fibrosis from repeat trauma as an initiation factor (7).

The indications for surgical correction of penile bending include (a) severe curvature, narrowing, or indentation of more than 1 year’s duration with sexual difficulty or partner discomfort because of deformity, and (b) severe penile shortening (8–10). Surgical correction can take the form of either shortening or lengthening procedures.

Shortening procedures provide excellent results in terms of preservation of erectile function but result in loss of penile length because curvature is corrected with excisions or plications of the tunica albuginea at the opposite aspect of the corpora cavernosa. Lengthening procedures have a higher prevalence of erectile dysfunction. They are performed on the concave, diseased side of the penis and require plaque excision or incision with grafting.

A shortening procedure to correct congenital penile curvature was first described by Nesbit in 1965 (11) and was subsequently used in patients with Peyronie disease (9,12). The Nesbit operation is performed by excising one or more ellipsoid wedge resections of tunica albuginea on the side opposite the curvature and closing the albugineal defects with running absorbable sutures (Fig 5). The overall results are satisfactory, with a success rate of 82% (9). A modification of the Nesbit operation was described by Yachia (8) in which, instead of removing an ellipse of tunica albuginea, a long longitudinal incision or multiple smaller longitudinal incisions are made in the area of maximum curvature of the corpora cavernosa and closed horizontally to straighten the penis, providing equal clinical success with less morbidity. Wedge resection or incision of the tunica albuginea requires extensive dissection of the neurovascular bundle or corpus spongiosum. A simplified approach for correcting penile curvature is corporeal plication, in which two or three pairs of nonabsorbable longitudinal plication sutures are placed through the full thickness of the tunica albuginea on the side opposite the curvature. The plication technique avoids dissection of the neurovascular bundle with its potential complications. Excision or incision of the tunica albuginea is not necessary, preventing damage to the erectile tissue (13,14).

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 5.  Drawings illustrate the Nesbit operation. After dissection of the neurovascular bundle, one or more ellipses of the tunica albuginea are excised on the side opposite the curvature and the edges of the albugineal defects are approximated to correct the curvature and closed with running absorbable sutures.

US allows visualization of albugineal sutures (Fig 6) and albugineal plications protruding into the cavernosal tissue. These features are better visualized in the early postoperative period, at which time the absorbable sutures are still intact and a small amount of fluid is often present that makes identification easier. The albugineal patches are usually identified as interruptions of the normally appreciable hyperechoic interface of the tunica albuginea. The dermal grafts are generally hyperechoic and thickened relative to the normal tunica albuginea, whereas the saphenous grafts appear less echogenic (Fig 7). In our experience, these findings are well appreciated soon after surgery and disappear progressively within 4–6 months.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 6.  Albugineal sutures in a 63-year-old man with Peyronie disease who had undergone a Nesbit operation 15 days earlier. Longitudinal US image obtained on the side opposite the curvature shows that the penis is straight. The albugineal sutures are visible as hyperechogenic dots (arrowheads).

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Albugineal patches in patients with Peyronie disease who had undergone penis lengthening operations. The grafts are identified as interruptions of the normally appreciable hyperechoic interface of the tunica albuginea. (a) Axial US image shows a dermal graft that appears as a thick, echogenic interface (arrows). (b) Axial US image obtained in a different patient shows a saphenous vein graft (arrows) that appears less echogenic than the adjacent tunica albuginea. Sutures are visible as hyperechogenic dots.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Albugineal patches in patients with Peyronie disease who had undergone penis lengthening operations. The grafts are identified as interruptions of the normally appreciable hyperechoic interface of the tunica albuginea. (a) Axial US image shows a dermal graft that appears as a thick, echogenic interface (arrows). (b) Axial US image obtained in a different patient shows a saphenous vein graft (arrows) that appears less echogenic than the adjacent tunica albuginea. Sutures are visible as hyperechogenic dots.

View larger version (186K): [in this window] [in a new window] [Download PPT slide]   Figure 8.  Penile hematoma in a 24-year-old man who developed penile, scrotal, and perineal ecchymosis following corporeal plication for congenital penile curvature. Axial US image shows a large, organized extraalbugineal hematoma on the dorsal aspect of the penis (*).

View larger version (199K): [in this window] [in a new window] [Download PPT slide]   Figure 9.  Recurrent penile curvature in a 64-year-old man who had undergone plaque excision with grafting 1 year earlier. Axial US image shows deformation of the left corpus cavernosum (arrowheads) due to contracture of the graft.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 10.  Graft bulking in a 51-year-old man with a dermal graft complicated with veno-occlusive dysfunction. Longitudinal US image shows bulking of the graft (arrowheads) with herniation of the cavernosal tissue (*).

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Epidermoid cyst in a 61-year-old man with Peyronie disease who had undergone plaque excision with dermal grafting 7 years earlier. (a) Photograph shows an elastic, mobile, painless tumescence that had developed at the site of the graft on the dorsum of the penis. (b) Axial US image shows a well-circumscribed echogenic lesion with acoustic enhancement (*). At histologic analysis, the lesion proved to be an epidermoid cyst arising from the graft, probably originating from accidental inclusion of surface epithelium.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Epidermoid cyst in a 61-year-old man with Peyronie disease who had undergone plaque excision with dermal grafting 7 years earlier. (a) Photograph shows an elastic, mobile, painless tumescence that had developed at the site of the graft on the dorsum of the penis. (b) Axial US image shows a well-circumscribed echogenic lesion with acoustic enhancement (*). At histologic analysis, the lesion proved to be an epidermoid cyst arising from the graft, probably originating from accidental inclusion of surface epithelium.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 12.  Iatrogenic high-flow priapism in a 23-year-old man who developed the priapism in the early postoperative period following corporeal plication for congenital penile curvature. Axial color duplex US image of the distal portion of the penile shaft shows an arterial-lacunar fistula of the right cavernosal artery with characteristically high systolic velocity and turbulent flow. It is conceivable that the cavernosal artery tear was produced during surgery by the needle used to create the artificial erection.

Both malleable and inflatable prostheses have their advantages and disadvantages. Inflatable penile prostheses produce suitable erection and excellent patient satisfaction in the majority of men. Implant reliability is excellent, and postoperative morbidity is low (22). Although these prostheses have had a history of mechanical failure, improved design and materials have markedly reduced this problem. Malleable prostheses are less expensive than inflatable devices and are easier to implant surgically, with a lower prevalence of mechanical failure; however, they are not as esthetically pleasing or as sexually satisfying to both partners as inflatable devices. Nevertheless, malleable prostheses are more economical and can be considered in (for instance) elderly patients or tetraplegic patients who are not able to use the scrotal pump because of motion difficulties.

US provides good visualization of the corporeal cylinders (Fig 13 ) and scrotal pump of inflatable devices. Tubing is also visualized, although not in its entirety. Visualization of the abdominal reservoir is variable and depends on patient habitus, deep or superficial position, and refilling. During routine US of the pelvis, an abdominal reservoir that is adjacent to the bladder can be mistaken for a large bladder diverticulum or a pelvic fluid collection. Inflating the prosthesis can be useful in removing this doubt, since doing so changes the shape of the reservoir and reduces its volume (Fig 14). The visibility of the abdominal reservoir is usually better when the penis is flaccid, at which time a greater amount of fluid is collected within the reservoir.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Corporeal cylinders in a 37-year-old impotent man who had undergone prosthesis implantation. Axial US images of the penile shaft obtained before (a) and after (b) inflation of the corporeal cylinders show the cylinders as anechoic structures replacing the cavernosal tissue.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Corporeal cylinders in a 37-year-old impotent man who had undergone prosthesis implantation. Axial US images of the penile shaft obtained before (a) and after (b) inflation of the corporeal cylinders show the cylinders as anechoic structures replacing the cavernosal tissue.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 14a.  Abdominal reservoir in a 60-year-old impotent man who had undergone prosthesis implantation. US images of the pelvis obtained before (a) and after (b) inflation of the corporeal cylinders show the abdominal reservoir of the prosthesis (*) adjacent to the bladder (B). The shape of the reservoir changes and its volume is reduced when the corporeal cylinders are inflated.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 14b.  Abdominal reservoir in a 60-year-old impotent man who had undergone prosthesis implantation. US images of the pelvis obtained before (a) and after (b) inflation of the corporeal cylinders show the abdominal reservoir of the prosthesis (*) adjacent to the bladder (B). The shape of the reservoir changes and its volume is reduced when the corporeal cylinders are inflated.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 15a.  Complications after penile prosthesis implantation. (a) Corporeal fibrosis in a 60-year-old diabetic man with severe penile shortening who had undergone removal of an infected penile prosthesis 2 years earlier. Axial US image shows diffuse fibrosis appearing as echogenic areas within the corpora cavernosa. (b) Penile deformation in a 40-year-old man with an inflatable prosthesis that had suddenly deflated during sexual intercourse. Longitudinal US image shows deformation of a cylinder along with fluid extravasation, findings that helped confirm the clinical diagnosis of tear.

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 15b.  Complications after penile prosthesis implantation. (a) Corporeal fibrosis in a 60-year-old diabetic man with severe penile shortening who had undergone removal of an infected penile prosthesis 2 years earlier. Axial US image shows diffuse fibrosis appearing as echogenic areas within the corpora cavernosa. (b) Penile deformation in a 40-year-old man with an inflatable prosthesis that had suddenly deflated during sexual intercourse. Longitudinal US image shows deformation of a cylinder along with fluid extravasation, findings that helped confirm the clinical diagnosis of tear.

Vascular Surgery for Impotence
Erectile dysfunction can have psychogenic or organic causes; in many patients, however, the disorder is of mixed etiology, with both psychogenic and organic factors present. Among the organic causes, a variety of pathologic conditions can account for impotence of vascular origin (24). Arteriogenic causes include atherosclerotic or traumatic arterioocclusive disease. Inadequate venous occlusion may result from a variety of pathophysiologic processes, such as the presence or development of large venous channels draining the corpora cavernosa, degenerative changes or traumatic injury to the tunica albuginea, and structural alterations in the fibroelastic components of the trabeculae, cavernous smooth muscle, and endothelium.

The integrity of the arterial supply to the penis can be assessed with Doppler US of the cavernosal arteries after intracavernous injection of vasoactive drugs. A peak systolic velocity of less than 25 cm/sec is considered suggestive of arterial insufficiency; patients with high peak systolic velocity (>35 cm/sec) and incomplete erectile response or who achieve an erection that is sufficient for penetration for only 5 minutes or less are considered to have veno-occlusive dysfunction (25).

A series of surgical procedures have been developed to restore penile vascular supply in patients with arterial insufficiency or to increase penile engorgement by reducing venous outflow in patients with venous leakage. Venous ligation, either alone or in association with other surgical procedures, and deep dorsal vein arterialization can be performed in patients with veno-occlusive dysfunction, whether isolated or associated with decreased arterial inflow. Arterial revascularization can be performed in patients with purely arteriogenic dysfunction. The widespread use of oral pharmacotherapy with efficacious drugs has dramatically reduced the number of indications for these procedures, a number that decreased even further because of poor long-term clinical results. Moreover, a growing body of experimental and clinical evidence shows that, in most cases, veno-occlusive dysfunction is predominantly due to disease of the cavernous tissue that makes the tissue unable to relax (26,27), rather than to pathologic blood leakage through the outflow vascular pathways. Consequently, penile vascular surgery can now be considered only in selected cases. The best results are obtained in young men with trauma-associated vascular disease; impotent patients in whom oral pharmacotherapy is not successful are generally considered as candidates for implantation of a penile prosthesis.

Several types of venous ligation surgery have been proposed that attempt to create a venous stasis during erection that may compensate for the inability to store blood in the corpora cavernosa (28). The least invasive type of surgery is dissection of the superficial dorsal vein and ligation or dissection of the deep dorsal vein, with occlusion of the circumflex veins. Other more invasive procedures also require ligation of the crural veins by means of perineal incision and dissection of the ischiocavernous muscles or ligation of the crural portions of the corpora cavernosa. Closure of distal venous shunts between the corpora cavernosa and the corpus spongiosum requires spongiosolysis (28), in which the dorsal portion of the corpus spongiosum is dissected and the tips of the corpora cavernosa are isolated from the glans. Ligation of the crural veins and spongiosolysis have largely been abandoned because of unacceptably high risk of major complications and poor clinical outcome. Despite unsatisfactory long-term results, ligation or dissection of the deep dorsal vein can be offered to selected patients with mild degrees of veno-occlusive dysfunction who do not wish to pursue other treatment options (29). No anatomic changes are usually appreciated at US except disappearance of the dorsal veins.

Arterial revascularization of the penis can be performed by connecting the inferior epigastric artery to the dorsal artery (Fig 16). This procedure can be considered in young patients with arteriogenic impotence following pelvic trauma (30) who have at least one well-developed dorsal artery. Because intracavernosal anastomoses occur frequently but connections between the dorsal and cavernosal arteries are rare, preoperative color Doppler US is needed to check for the presence of these arteries. Different surgical techniques are used depending on whether communications between the dorsal and cavernosal arteries are identified. If such communications have been identified, revascularization is performed in keeping with the physiologic direction of blood flow; if they have not been identified, arterialization of the deep dorsal vein can be considered, or perhaps a retrograde arterial anastomosis in which the blood flows from the epigastric artery to the dorsal artery with inverted flow toward the origin of the cavernosal artery. In patients with arterial revascularization, US allows evaluation of the anastomosis between the inferior epigastric and dorsal arteries (Fig 17). Retrograde or anterograde arterial flow is recorded in the dorsal artery, depending on the surgical procedure. Abnormal enlargement of the corpus spongiosum can be appreciated due to increased vascular supply via the dorsal artery and, retrogradely, via the urethral arteries.

View larger version (49K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.

View larger version (47K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.

View larger version (49K): [in this window] [in a new window] [Download PPT slide]   Figure 16c.  Drawings illustrate surgical revascularization procedures for patients with erectile dysfunction. (a, b) Penile arterial revascularization is performed with anastomosis of the inferior epigastric artery to the dorsal artery that either retains the normal direction of blood flow (ie, from the epigastric artery to the proximal and distal portions of the dorsal artery) (a) or creates flow in the opposite direction (ie, from the epigastric artery to the proximal portion of the dorsal artery with inverted flow toward the origin of the cavernosal artery) (b). (c) In deep dorsal vein arterialization, the inferior epigastric artery is anastomosed end-to-side to the deep dorsal vein without ligation of the emissary veins. The deep dorsal vein is then ligated proximal to the retrocoronal plexus.

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 17a.  Epigastric artery–dorsal artery anastomosis in a 32-year-old impotent man who had undergone penile arterial revascularization. (a) Longitudinal color Doppler US image obtained on the dorsal aspect of the base of the penis shows retrograde revascularization of the dorsal artery (arrowhead) with the epigastric artery (arrow). (b) Axial US image of the penile shaft shows abnormal enlargement of the corpus spongiosum (*).

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 17b.  Epigastric artery–dorsal artery anastomosis in a 32-year-old impotent man who had undergone penile arterial revascularization. (a) Longitudinal color Doppler US image obtained on the dorsal aspect of the base of the penis shows retrograde revascularization of the dorsal artery (arrowhead) with the epigastric artery (arrow). (b) Axial US image of the penile shaft shows abnormal enlargement of the corpus spongiosum (*).

In patients with dorsal vein arterialization, the anastomosis between the inferior epigastric artery and the dorsal vein can be identified with color Doppler US. The inferior epigastric artery used to create the anastomosis is larger and has a higher-velocity flow than the contralateral artery. The wall of the deep dorsal vein is thickened and has a stratified appearance as a consequence of arterialization changes. The corpus spongiosum and the glans enlarge markedly with dilated sinusoidal spaces, whereas only mild engorgement of the corpora cavernosa is observed. Dilatation of the perispongiosal veins can be detected as a consequence of the increased pressure in the entire penile venous system (Fig 18).

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 18a.  Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 18b.  Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 18c.  Physiologic changes in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier. Postoperative US was performed after intracavernous administration of vasoactive drugs. (a) Axial US image demonstrates engorgement of the corpus spongiosum (*), which appears larger than the corpora cavernosa. (b) Longitudinal US image of the distal portion of the corpora cavernosa demonstrates enlargement of the corpus spongiosum (*) and dilatation of the perispongiosal veins (arrowheads). (c) Axial US image shows the deep dorsal vein with a thick, stratified wall as a consequence of arterialization (arrows).

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  Aneurysmal dilatation of an anastomosis in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier and had developed a slowly enlarging lump on the dorsal aspect of the penile base. (a) Photograph shows the clinical appearance of the tumescence. (b) Sagittal color Doppler US image demonstrates an aneurysm originating at the anastomosis between the inferior epigastric artery and the deep penile dorsal vein.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  Aneurysmal dilatation of an anastomosis in a 36-year-old man who had undergone arterialization of the deep dorsal vein 8 years earlier and had developed a slowly enlarging lump on the dorsal aspect of the penile base. (a) Photograph shows the clinical appearance of the tumescence. (b) Sagittal color Doppler US image demonstrates an aneurysm originating at the anastomosis between the inferior epigastric artery and the deep penile dorsal vein.

In patients with nonischemic priapism, the penis is usually painless and not fully rigid. Erection develops as a consequence of unregulated arterial blood flow into the corpora cavernosa through a tear of a cavernosal artery. The lacunar endothelium adjacent to the fistula is exposed to oxygenated blood with high-velocity turbulent flow, which creates a shear stress and stimulates the release of nitric oxide, resulting in dilatation of the cavernosal arteries and distention of the cavernous spaces (32).

In patients with ischemic priapism, the penis is fully erect and painful. Erection results from inadequate venous outflow, leading to hypoxia, acidosis, and tissue ischemia (32,33). Ischemic priapism is usually seen after intrapenile injection of vasoactive drugs, drug abuse, or insect bites or in men with sickle cell disease and disseminated malignancies (33). About one-third of cases are idiopathic (34).

Differentiation between ischemic and nonischemic priapism is based on history and clinical appearance. A history of trauma and incomplete, painless rigidity are suggestive of the nonischemic type. Corporeal aspiration of oxygenated blood is confirmatory. In doubtful cases, duplex US can be very helpful in formulating the differential diagnosis.

In patients with nonischemic priapism, color Doppler US is currently considered the imaging modality of choice (35,36). The cavernosal artery tear is identified as a characteristic arterial color blush, a finding that is consistent with extravasation of blood from the lacerated vessel. Doppler US of the fistula displays high-velocity turbulent flows (Fig 20). In patients with ischemic priapism, color Doppler US shows absent or markedly reduced flow in the cavernosal arteries (Fig 21).

View larger version (196K): [in this window] [in a new window] [Download PPT slide]   Figure 20a.  High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.

View larger version (203K): [in this window] [in a new window] [Download PPT slide]   Figure 20b.  High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.

View larger version (178K): [in this window] [in a new window] [Download PPT slide]   Figure 20c.  High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.

View larger version (177K): [in this window] [in a new window] [Download PPT slide]   Figure 20d.  High-velocity blood flow in a 27-year-old man with nonischemic priapism. The base of the penile shaft had been crushed against the gas tank of the patient’s motorcycle during a road accident. (a) Sagittal color Doppler US image of the left corpus cavernosum shows the cavernosal artery (arrowheads) and a color blush in the area of the cavernosal artery tear (*). (b) Color duplex US image of the fistula shows high-velocity turbulent flows. (c) Angiogram shows extravasation of contrast material from the torn vessel (arrowhead), a finding that indicates arterial laceration. (d) Angiogram obtained after embolization shows occlusion of the fistula.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 21a.  Idiopathic ischemic priapism. (a) Sagittal color Doppler US image of the right corpus cavernosum obtained in a 32-year-old man shows no flow in the cavernosal artery (arrowheads). In addition, no flow was appreciated in the contralateral cavernosal artery. (b) Sagittal color duplex US image of the right corpus cavernosum obtained in a 45-year-old man shows very low-velocity high-resistance flows. Similar findings were appreciated in the left corpus cavernosum.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 21b.  Idiopathic ischemic priapism. (a) Sagittal color Doppler US image of the right corpus cavernosum obtained in a 32-year-old man shows no flow in the cavernosal artery (arrowheads). In addition, no flow was appreciated in the contralateral cavernosal artery. (b) Sagittal color duplex US image of the right corpus cavernosum obtained in a 45-year-old man shows very low-velocity high-resistance flows. Similar findings were appreciated in the left corpus cavernosum.