Vascular (Arterial and Venous) Surgery for Erectile Dysfunction

  • Geng-Long HsuEmail author
  • Cheng-Hsing Hsieh
  • Eric Allaire


The use of penile vascular intervention to restore erection quality has been studied since 1873. Although it is not recommended by the medical community at large – particularly in the present era, in which the preferred treatment option is PDE-5 inhibitors like Viagra – nascent developments both in surgical techniques and in understanding of the penile anatomy promote a more favorable view of vascular reconstructive surgery as a treatment modality. The tunica albuginea of the corpora cavernosa is a bi-layered structure with a 360° complete inner circular layer and a 300° incomplete outer longitudinal coat upon which penile erection-related vasculature interacts. Meanwhile, the erection-related veins are composed of not only a conventional deep dorsal vein, but also two cavernosal veins and four para-arterial veins which drain the cavernosal sinusoids via emissary veins between Buck’s fascia and the tunica albuginea. Apagogical hemodynamic studies on defrosted cadavers substantiate the veno-occlusive mechanism occurring at the tunica albuginea; accordingly, a surgeon seeking to restore a patient’s erectile capability must treat each emissary vein. Thus, all venous routes leaking sinusoidal bloods must be treated – but carefully so, to avoid damaging nearby tissues such as artery and nerve. Overall reports on penile arterial reconstructive surgery support its adequacy in young men who have sustained arterial trauma and in older men with a localized arterial occlusive disease. Penile venous stripping surgery has been shown to be effective in correcting corporal veno-occlusive dysfunction, with outstanding results, since 1986. The conventional complications such as irreversible penile numbness and permanent deformity have been virtually negated with the use of new venous ligation techniques rather than electro-cautery. However, penile vascular reconstructive surgery is viable if and only if the surgical handling is done properly and soundly. With dissemination of the correct training, it ought to be procurable in practice worldwide.


Angioplasty Electrocautery Erectile dysfunction Penile arterial insufficiency Penile arterial reconstruction Penile venous ligation Penile venous stripping Revascularization Penile venous sclerotherapy Penile venous embolization Veno-occlusive dysfunction 



We would like to thank Nicholas Bagnall for English editing, and Director Chih-Chung Lu, Ms. Hsiu-Chen Lu, Ying-Hui Chen for preparing the illustration and photos in this manuscript.


  1. 1.
    Melman A, Gingell JC. The epidemiology and pathophysiology of erectile dysfunction. J Urol. 1999;161:5–11.CrossRefGoogle Scholar
  2. 2.
    FDA approves oral therapy for erectile dysfunction. Am J Health Syst Pharm. 1998;55:981–4.Google Scholar
  3. 3.
    Chen KK, Jiann BP, Lin JSN, et al. Efficacy and safety of on-demand oral tadalafil in the treatment of men with erectile dysfunction in Taiwan: a randomized, double-blind, parallel, placebo-controlled clinical study. J Sex Med. 2004;1:201–8.CrossRefGoogle Scholar
  4. 4.
    Capogrosso P, Colicchia M, Ventimiglia E, et al. One patient out of four with newly diagnosed erectile dysfunction is a young man – worrisome picture from the everyday clinical practice. J Sex Med. 2013;10:1833–41.CrossRefGoogle Scholar
  5. 5.
    Hublin JJ, et al. New fossils from Jebel Irhoud, Morocco and the pan-African origin of Homo sapiens. Nature. 2017;546:289–92.CrossRefGoogle Scholar
  6. 6.
    Gratzke C, et al. Anatomy, physiology, and pathophysiology of erectile dysfunction. J Sex Med. 2005;7(1 Pt 2):445–75.Google Scholar
  7. 7.
    Hsu GL, et al. The three-dimensional structure of the human tunica albuginea: anatomical and ultrastructural level. Int J Impot Res. 1992;4:117–29.Google Scholar
  8. 8.
    Hsu GL, Hsieh CH, Wen HS, Hsu WL, Chen CW. Anatomy of the human penis: the relationship of the architecture between skeletal and smooth muscles. J Androl. 2004;25(3):426–31.CrossRefGoogle Scholar
  9. 9.
    Hsu G-L, Lu H-C. Penis structure – erection. In: Skinner MK, editor. Encyclopedia of reproduction, vol. 1. Elsevier: Academic; 2018. p. 367–75. Scholar
  10. 10.
    Hsu GL, et al. Distal ligament in human glans: a comparative study of penile architecture. J Androl. 2005;26(5):624–8.CrossRefGoogle Scholar
  11. 11.
    Hsu GL. The hypothesis of human penile anatomy, erection hemodynamic and their clinical applications. Asian J Androl. 2006;8(2):225–34.Google Scholar
  12. 12.
    Hsu G-L, Liu S-P. Penis structure. In: Skinner MK, editor. Encyclopedia of reproduction, vol. 1. Elsevier: Academic Press; 2018. p. 357–66. Scholar
  13. 13.
    Molodysky E, Liu SP, Huang SJ, Hsu GL. Penile vascular surgery for treatment of erectile dysfunction: current role and future direction. Arab J Urol. 2013;11:254–66.CrossRefGoogle Scholar
  14. 14.
    Hsu GL, et al. Penile venous anatomy: an additional description and its clinical implication. J Androl. 2003;24(6):921–7.CrossRefGoogle Scholar
  15. 15.
    Hsu GL, Hung YP, Tsai MH, Hsieh CH, Chen HS, Molodysky E, Huynh CC, Yu HJ. Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers. J Androl. 2012;33:1176–85. SCI, IF: 2.427CrossRefGoogle Scholar
  16. 16.
    Hsu GL, Molodysky E, Liu SP, Chang HC, Hsieh CH, Hsu CY. Reconstructive surgery for idealizing penile shape and erectile functional restoration on patients with penile dysmorphology and erectile dysfunction. Arab J Urol. 2013;11(4):375–83.CrossRefGoogle Scholar
  17. 17.
    Gazzaruso C, Giordanetti S, De Amici E, Bertone G, Falcone C, Geroldi D, Fratino P, Solerte SB, Garzaniti A. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation. 2004;110:22–6.CrossRefGoogle Scholar
  18. 18.
    Hsu GL, Hsieh CH. Veno-occlusive dysfunction in young patients resulting from jelqing maneuver: long-term results of penile venous stripping surgery. Proceedings from 13th biennial meeting of the asia pacific society for sexual medicine, Kaohsiung, Taiwan, P132, 2011.Google Scholar
  19. 19.
    Lue TF, Hricak H, Marich KW, Tanagho EA. Vaculogenic impotence evaluated by high-resolution ultrasonography and pulsed Doppler spectrum analysis. Radiology. 1985;155:777–81.CrossRefGoogle Scholar
  20. 20.
    Aschenbach R, Steiner T, Kerl MJ, et al. Endovascular embolization therapy in men with erectile impotence due to veno-occlusive dysfunction. Eur J Radiol. 2013;82:504–7.CrossRefGoogle Scholar
  21. 21.
    Michal V, et al. [Direct arterial anastomosis on corpora cavernosa penis in the therapy of erective impotence]. Rozhl Chir. 1973;52(9):587–590.Google Scholar
  22. 22.
    Virag R. [Unstable erection due to venous insufficiency. Diagnosis and surgical correction. 10 cases with a mean follow-up 12 months (author’s transl)]. J Mal Vasc. 1981;6(2):121–124.Google Scholar
  23. 23.
    Hauri D. A new operative technique in vasculogenic erectile impotence. World J Urol. 1986;4(4):237–49.CrossRefGoogle Scholar
  24. 24.
    Furlow WL, Fisher J. Deep dorsal vein arterialization: clinical experience with a new technique for penile revascularization. J Urol. 1988;139:298A.CrossRefGoogle Scholar
  25. 25.
    Kawanishi Y, Kimura K, Nakanishi R, Kojima K, Numata A. Penile revascularization surgery for arteriogenic erectile dysfunction: the long-term efficacy rate calculated by survival analysis. BJU Int. 2004;94(3):361–8.CrossRefGoogle Scholar
  26. 26.
    Kayigil O, et al. Penile revascularization in vasculogenic erectile dysfunction (ED): long-term follow-up. BJU Int. 2012;109(1):109–15.CrossRefGoogle Scholar
  27. 27.
    Bleustein CB, Melman A. Hypervascularity of the glans penis diagnosed with cutaneous temperature measurements. Int J Impot Res. 2002;14(6):543–4.CrossRefGoogle Scholar
  28. 28.
    Lukkarinen O, et al. Non-prosthetic surgery in the treatment of erectile dysfunction. A retrospective study of 45 impotent patients in the University of Oulu. Scand J Urol Nephrol. 1998;32(1):42–6.CrossRefGoogle Scholar
  29. 29.
    Munarriz R. Penile microvascular arterial bypass surgery: indications, outcomes, and complications. Sci World J. 2010;10:1556–65.CrossRefGoogle Scholar
  30. 30.
    Manning M, et al. Long-term follow-up and selection criteria for penile revascularization in erectile failure. J Urol. 1998;160(5):1680–4.CrossRefGoogle Scholar
  31. 31.
    Kim ED, Owen RC, White GS, Elkelany OO, Rahnema CD. Endovascular treatment of vasculogenic erectile dysfunction. Asian J Androl. 2015;17:40–3.CrossRefGoogle Scholar
  32. 32.
    Michal V, Ruzbarsky V. Histological changes in the penile arterial bed with aging and diabetes. In: Zorgniotti AW, Rossi G, editors. Vasculogenic impotence: proceedings of the first international conference on corpus cavernosum revascularization. Springfield: Thomas; 1980. p. 113–9.Google Scholar
  33. 33.
    King SB 3rd, Marshall JJ, Tummala PE. Revascularization for coronary artery disease: stents versus bypass surgery. Annu Rev Med. 2010;61:199–213.CrossRefGoogle Scholar
  34. 34.
    Parona F. Imperfect penile erection due to varicosity of the dorsal vein: observation. Giornale Italiano Delle Malattie Veneree E Della Pelle. 1873;14:71–6.Google Scholar
  35. 35.
    Wooten JS. Ligation of the dorsal vein of the penis as a cure foratonic impotence. Texas Med J. 1902;18:325–9.Google Scholar
  36. 36.
    Lowsley OS, Rueda A. Further experience with an operation for the cure of certain types of impotence. J Int Coll Surg. 1953;19:69–77.PubMedGoogle Scholar
  37. 37.
    Wespes E, Schulman CC. Venous leakage: surgical treatment of a curable cause of impotence. J Urol. 1985;133:796–8.CrossRefGoogle Scholar
  38. 38.
    Fuchs AM, Mehringer CM, Rajfer J. Anatomy of penile venous drainage in potent and impotent men during cavernosography. J Urol. 1989;141:1353–6.CrossRefGoogle Scholar
  39. 39.
    Elhanbly S, Abdel-Gaber S, Fathy H, et al. Erectile dysfunction in smoker: a penile dynamic and vascular study. J Androl. 2004;25:991–5.CrossRefGoogle Scholar
  40. 40.
    Hsieh CH, Huang YP, Tsai MH, Chen HS, Huang PC, Lin CW, Hsu GL. Tunical outer layer plays an essential role in penile veno-occlusive mechanism evidenced from electrocautery effects to the corpora cavernosa in defrosted human cadavers. Urology. 2015;86(6):1129–36.CrossRefGoogle Scholar
  41. 41.
    Hsu GL, Chen HS, Hsieh CH, Lee WY, Chen KL, Chang CH. Clinical experience of a refined penile venous surgery procedure for patients with erectile dysfunction: is it a viable option? J Androl. 2010;31(3):271–80.CrossRefGoogle Scholar
  42. 42.
    Hsieh CH, Chen CW, Huang HM, Johnson H, Teng R-J, Hsu GL. Penile venous stripping surgery is a viable option for erectile dysfunction after unsuccessful vascular interventions. Clin Pract. 2017;14(1):86–94.Google Scholar
  43. 43.
    Montague DK, et al. Clinical guidelines panel on erectile dysfunction: summary report on the treatment of organic erectile dysfunction. J Urol. 1996;156:2007–11.CrossRefGoogle Scholar
  44. 44.
    Munarriz R, Uberoi J, Fantini G, Martinez D, Lee C. Microvascular arterial bypass surgery: long-term outcomes using validated instruments. J Urol. 2009;182(8):643–8.CrossRefGoogle Scholar
  45. 45.
    Vardi Y, et al. Evaluation of penile revascularization for erectile dysfunction: a 10-year follow-up. Int J Impot Res. 2004;16(2):181–6.CrossRefGoogle Scholar
  46. 46.
    Huang P-C, Hsu G-L. Vascular surgery for erectile dysfunction. In: Skinner MK, editor. Encyclopedia of reproduction, vol. 4. Elsevier: Academic; 2018. p. 427–36. Scholar
  47. 47.
    Hsu GL, et al. Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadavers. J Androl. 2012;33(6):1176–85.CrossRefGoogle Scholar
  48. 48.
    Hsu GL. Physiological approach to penile venous stripping surgical procedure for patients with erectile dysfunction. 2012. Google Patents; Patent No: US 8,240,313 B2,

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Geng-Long Hsu
    • 1
    Email author
  • Cheng-Hsing Hsieh
    • 2
  • Eric Allaire
    • 3
  1. 1.Microsurgical Potency Reconstruction and Research CenterHsu’s Andrology and Yin Shu-Tien Memorial Hospital Shu-Tien Urology Ophthalmology ClinicTaipeiTaiwan
  2. 2.Department of Urology, Taippei Tazuchi Hospital, The Buddhist Tzuchi Medical Foundation, School of MedicineBuddhist Tzu Chi UniversityHualienTaiwan
  3. 3.Clinique Geoffroy Saint HilaireParisFrance

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