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Outpatient Surgery for Penile Venous Patch With the Patient Under Local Anesthesia

HAN-SUN CHIANG

From the ^* Department of Urology, Taiwan Adventist Hospital, College of Medicine, Fu-Jen Catholic University; and Taipei Medical University Hospital, Taipei, Taiwan, Republic of China.

Correspondence to: Dr Geng-Long Hsu, Department of Urology, Taiwan Adventist Hospital, 424 Pa Te Road, Section 2, Taipei, Taiwan 10558, Republic of China.

Received for publication May 23, 2002; accepted for publication August 9, 2002.

	Abstract

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Although local anesthesia for penile surgery has been widely reported, its application for penile venous patch, however, has not been published. We evaluated an anesthetic and surgical technique on an outpatient basis. From March 1993 to September 2001, a total of 29 men with penile deformity, aged 27 to 77 years (mean 55 years) received a penile venous patch for morphologic correction. They received autologous grafting of the deep dorsal vein under local anesthesia as an outpatient procedure. The anesthetic effect and postoperative results were satisfactory. The average available area of the deep dorsal vein was 5.7 x 2.5 cm². The common immediate side effects included puncture of the vessels, subcutaneous ecchymosis, and transient palpitation, but there were no significant late complications. All patients returned home uneventfully. This has been proven to be a cost-effective, simple, and safe method with fewer complications. It offers the advantages of lower morbidity, protection of privacy, fewer adverse effects of anesthesia, and a more rapid return to activity with minimal complications.

     Key words: Penile curvature, impotence, topical block, venous grafting, epinephrine

	Materials and Methods

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From March 1993 to March 2001, a total of 29 patients with Peyronie disease aged 27 to 77 years (mean 55 years) with penile deviation of from 30° to 90°, which prevented them from performing normal coitus, received a penile venous patch that was derived from an autologous deep dorsal vein after its feasibility had been assessed via an cavernosogram in the flaccid state (Figure 1). These operations were performed under local anesthesia as an outpatient procedure.

View larger version (115K): [in this window] [in a new window]   Figure 1. Cavernosogram of a patient with Peyronie disease. The horizontal arrow denotes the area of a Peyronie plaque. In between the vertical arrows, the venous trunk was good for patching if it was taken and detubularized.

Anesthesia of the Penis

A 23-gauge x 1.5-inch disposable needle was used to inject the local anesthetic of a 0.8% 50-mL lidocaine solution prepared in an aseptic steel bowl that was prefilled with 0.1 mL of a 1:200 000 epinephrine solution (Hsu, 1999). The needle, with its bevel parallel to the direction of the body axis, was inserted in between the suspensory ligament along the public angle with two fingers holding the penile shaft (Figure 2A) away from the body axis. The solution was injected in three directions to cover the bilateral proximal dorsal nerves (Figure 2B). Peripenile infiltration was subsequently made with finger-guided manipulation. Ventral infiltration (Figure 2C) was performed, including a meticulous injection to the junction between the corpus spongiosum and the corpora cavernosa. The injection had to be sufficiently encircled in order to cover the entire penile shaft (Figure 2D). Aspiration was performed immediately before any attempt at injection, so that an inadvertent entering of a vessel was avoided.

View larger version (104K): [in this window] [in a new window]   Figure 2. Photographs of local anesthesia. (A) Finger-guided manipulation in which the index finger of the assistant's hand is used to confirm the precise position of the injection. The infrapubic space was first injected in three directions to cover the bilateral dorsal nerves. (B) Illustration of the precise positions injected. The needle was inserted 0.5 to 1.0 cm cranial to the penopubic fold, with its bevel parallel to the direction of the body axis, in between the suspensory ligament along the public symphysis until the infrapubic angle was met. It was injected in three directions: the penile hilum medially and 15° obliquely and bilaterally. (C) Ventral infiltration was meticulously performed in between Bucks fascia and its overlying layer via finger-guided manipulation. (D) The precise injection (incomplete circle) had to be sufficient to block the entire penile shaft, then extra infiltration (arrows) was performed in the junction of the corpus spongiosum and the corpora cavernosa bilaterally.

Operation of the Deep Dorsal Vein

A circumferential incision was made and then a degloving procedure was performed to expose the deep dorsal vein that was readily seen by a milking manipulation 0.5 cm proximal to the retrocoronal sulcus. The venous trunk served as a guide for the thorough stripping, and it was kept moist throughout the entire procedure. Any tributary had to be double ligated with two ties in order to apply a scissors to cut them apart. The vein was moved until the level of the infrapublic angle was met. The removed vein was immersed in saline solution for at least 30 minutes, then it was sutured side by side with a 6-0 nylon suture (Figure 3B) after it was detubularized (Figure 3A).

View larger version (122K): [in this window] [in a new window]   Figure 3. (A) Detubularized deep dorsal vein. The vein was kept moist throughout the entire procedure. It was stripped from the retrocoronal sulcus to the subpubic angle, then it was detubularized and sutured (B) with 6-0 nylon with its serosal side outward after it had been immersed in saline solution for 30 minutes.

Operation of the Venous Patch

The penile shape was assessed by creating an artificial erection using saline infusion via a #19 or #21 scalp needle. The neurovascular bundle was freed with hydropressure dissection in which the normal saline solution was injected into the most curvilinear area in between the tunica albuginea and its overlying tissue in order to expand and separate them, and it was tagged with a Penrose drain. After dorsal or ventral exposure of the tunica, the inelasticity of the plaque was evident. An incision was made transversely on the Peyronie plaque, and the corporotomy defect was patched with the venous graft, which was placed with the serosal side outward, spliced together if necessary, and continuously fashioned with a 6-0 nylon suture. Enhanced sutures were made 1-cm intervals apart. The artificial erection was repeated to ensure that the penis was straight. If curvature persisted, further modifications by way of incisions and grafting combined with a contralateral modified Nesbit procedure were undertaken whenever necessary. The overlying fascia layers and skin were closed layer by layer with 5-0 chromic sutures.

A postanesthesia questionnaire was administered, and the answers were recorded. Subsequently, each patient was followed-up to determine his satisfaction with the penile morphology as evaluated using the abridged five-item version of the International Index of Erectile Function (IIEF-5) scoring for erectile capability.

	Results

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The available area of detubularized deep dorsal vein was 5.7 x 2.5 cm² on average. In all patients, the available area was larger than the corporotomy tunical defect that was measured at from 2.5 x 0.8 cm² to 2.8 x 1.0 cm².

One venous patch was required in 13 patients, and the remaining 16 men needed two pieces. In 11 patients, a small ellipse of a modified Nesbit procedure was made on the contralateral tunica to obtain a more satisfactory shape. Among them, the excised tunica was patched to the contralateral side in five patients. Among patients who underwent venous patch with or without the Nesbit procedure, or venous patch with tunical graft, there was no preference of treatment.

The lidocaine dosage was from 280 to 400 mg with an average of 352.2 ± 57.7 mg. This quantity was sufficient to cover the average operation time (205.5 ± 31.3 minutes), however, 11 of 29 (38%) patients required a booster injection. The side effects included puncture of vessels in four (13.7%) patients, transient palpitation in two (6.9%) patients, and subcutaneous ecchymosis in six (20.7%) patients. One patient contracted an infection that manifested as a preputial ulceration, and was cured after treatment for 1 month with no microorganism isolated.

Overall, the postoperative penile shape was satisfactory in 27 (93.1%) patients whose postoperative penile deviation was less than 10°, but mild penile deviation of less than 15° was reported in 2 (6.9%) patients without further surgery. Erectile function has been good in 26 patients for whom the mean preoperative IIEF-5 score of 20.9 ± 3.2 was increased to a mean postoperative IIEF-5 score of 22.7 ± 1.5. Unfortunately, a satisfactory erection could not be attained until 10 months after the operation in two patients. One patient subsequently received a penile implant. Three patients had undergone an unsuccessful first surgery somewhere else and experienced an uneventful course, even though their tissues were fibrotic.

	Discussion

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Many potential patch materials can serve as a patch graft for the treatment of Peyronie disease (Lowsley and Gentile, 1947; Devine and Horton, 1974; Bruschini and Mitre, 1979; Dad and Amar, 1982; Lowe et al, 1982; Collins, 1988; Gelbard and Hayden, 1991; Krishnamurti, 1994; Ganabathi et al, 1995). However, the optimal patch material for covering a corporotomy defect is a venous patch for the sake of its histological identity (Fournier et al, 1993; Moriel et al, 1994; Kim and McVary, 1995; Brannigan et al, 1998; Lue et al, 1998; Montorsi et al, 2000). An overwhelming surplus of the deep dorsal vein is available if it is stripped from the retrocoronal sulcus distally to the infrapubic angle, where its circumference is as large as 1.5 cm. This encourages the application of local anesthesia because of what is found in the anatomical vicinity. Thus, complete removal of the vein favors its availability as patching material, particularly if it is spliced together. During the procedure, the removed vein should be immersed for at least a half-hour before it is detubularized, otherwise a dry and contracted vein might be difficult to manage and is readily underestimated. In our practice, no patient required another vein, which might require a further type of anesthesia.

Assessing the precise position and length of the tunical incision largely depends on the principle of trial and error with repeated artificial erections. The decision of the surgeon is paramount in avoiding inadequate as well as over-correction. Precise correction is preferable through a modified Nesbit procedure. This explains why 11 of 29 patients required tunica plication procedures, albeit a small ellipse, to accomplish satisfactory straightening. The suture material is an important consideration in this operation. We used fine 6-0 nylon, which is sufficiently tenacious and biocompatible, rather than an absorbable kind.

Finger-guided manipulation using the index finger of the assistant's hand is helpful to confirm the precise position of the injection throughout the anesthetic procedure, as the tissue is palpable because of the paucity of adipose tissue and the nature of the layered penile tissue. This in turn enables the technique to be easily endured. The bevel of the injection needle is preferably parallel to the long axis of the body avoiding the possibility of needle severance of a nerve. A peripenile injection is recommended to puncture the needle in the 12 and 6 o'clock positions to avoid unnecessary pain if puncture more.

We generally use lidocaine as a local anesthetic as advocated for retention in the corpora cavernosa (Light and Scott, 1985); however, we caution against needle puncture of the sinusoid through the tunica, particularly if an implant is in situ and a booster injection is necessary when the patient registers some intraoperative pain. Likewise, this avoids the possible complications of headache, dizziness, palpitations, nausea, and vomiting that result from epinephrine because the corporeal drainage is always substantial. Whereas application of marcaine, which is more durable than lidocaine might be advocated, its potential toxicity has prevented us from experimenting with its use.

It is generally agreed that adrenaline is contraindicated for use as a local anesthetic (Auletta and Grekin, 1985; Scott, 1989; Berens and Pontus, 1990), however, there is a paucity of possible ischemia in our series. Under careful manipulation, this drug is good for prolonging the anesthesia time up to 5 hours (Bernards and Kopacz, 1999). We believe that postoperative ischemia of the human penis should be ascribed to iatrogenic damage, not to the drug.

Painful injections may be expected, but in reality a slow injection as well a quick puncture through the skin is acceptable (Serour et al, 1998). Creating a wheal as a result of a subcutaneous injection should be avoided, otherwise intolerable injection pain might scare the patient.

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