Penile Arterial Revascularization
Penile arterial revascularization is a microsurgical bypass procedure that restores arterial inflow to the penis in men with pure arteriogenic erectile dysfunction caused by focal arterial occlusive disease, most commonly after blunt pelvic, perineal or penile trauma. Vaclav Michal first described it in 1973. It is a potentially curative surgical treatment for selected young men with focal arteriogenic ED and is reserved for a highly selected patient population.[1][2] The inferior epigastric artery (IEA) is the usual donor to the dorsal penile artery. Michal II uses an end-to-side anastomosis, while a contemporary IEA-to-dorsal bypass description uses end-to-end anastomosis.[6][1] Saphenous vein is not the usual donor.
Outcomes in the published series vary with patient selection. In Dabaja's 2014 series of 45 men referred for a second opinion on candidacy, 49% had a significant discrepancy between erectile hemodynamic testing and selective internal pudendal arteriography (SIPA).[3] Repeat testing was normal in 73% of those discrepant cases, so those men were no longer candidates for surgery.[3] The best outcomes have been reported in young (< 55 years), non-smoking, non-diabetic men with pure arteriogenic ED, fewer than 2 vascular risk factors, and a history of focal pelvic, perineal or penile trauma.[4][5][10]
The AUA 2018 guideline gives a conditional recommendation, Grade C for penile arterial reconstruction in young men with focal pelvic or penile arterial occlusion who lack generalized vascular disease or veno-occlusive dysfunction; it limits the procedure to a highly skilled surgeon at a center of excellence and advises counseling that long-term success is not well established.[7] The ICSM standard-operating-procedures statement (Sohn 2013) limits recommendations to Grade D given the absence of RCTs.[8]
Pathophysiology and rationale
Arteriogenic ED in this context results from focal endothelial injury and stenosis or occlusion of the distal internal pudendal, common penile, or proximal cavernosal artery, distinct from generalized atherosclerotic disease.[2][1] Decreased arterial inflow lowers corporal oxygen tension, reduces cavernosal smooth-muscle volume and is followed by corporoveno-occlusive dysfunction, which current studies regard as an effect rather than the cause of the erectile failure.[2]
The surgical goal is to bypass the occlusion and restore perfusion pressure to the cavernosal bodies via communicating branches between the dorsal and cavernosal arteries.[1][9]
Patient-selection criteria (locked)
| Criterion | Threshold |
|---|---|
| Age | Dicks describes an otherwise healthy index patient aged ≤55 years[1]; Kayıgil enrolled men aged 23–69 years[10]; Manning reported 69% success at age ≤50 versus 39% above 50[4] |
| Etiology | Pure arteriogenic; typically focal post-traumatic occlusion |
| Vascular risk factors | Manning reported 58% success among men with <2 vascular risk factors (smoking, diabetes, hypertension, hyperlipidemia, atherosclerosis) and proposed additional selection criteria of no recent diabetes and nicotine cessation; the ICSM SOP similarly favors nonsmokers and nondiabetics.[4][8] |
| Atherosclerosis | Absent for AUA consideration of arterial reconstruction: the guideline limits candidacy to men without documented generalized vascular disease[7] |
| Veno-occlusive function | Intact on DICC; absent corporal-fibrosis evidence[11][12] |
| Focal arterial lesion | Confirmed on selective internal pudendal arteriography (SIPA); concordant with duplex Doppler findings[3][13] |
Preoperative workup
Before vascular testing, document trauma and erectile history, a baseline validated erectile-function score, metabolic and hormonal factors, and genital sensory findings.[1][21]
| Step | Purpose |
|---|---|
| Duplex Doppler penile ultrasound (DUS) | Screens for arterial and veno-occlusive abnormalities after adequate pharmacologic erection. Anxiety or inadequate vasoactive dosing can yield false-positive vascular findings; optimize stimulation or repeat inconclusive testing before assigning a surgical vascular diagnosis.[3][21] In Wegner's 325 men, peak systolic velocity below 20 cm/s occurred only in arteriogenic ED and end-diastolic velocity above 5 cm/s indicated veno-occlusive dysfunction. Only 14% had at least one hemodynamically relevant dorsal-to-cavernosal connection, which the bypass relies on.[9] A methodology review of 86 published DUS protocols found no consensus threshold: 39% of studies defined a normal PSV as 30 cm/s or higher (not 20 cm/s), and 57% used an EDV of 5 cm/s or lower as normal, matching Wegner's venous cutoff; treat Wegner's 20 cm/s arterial threshold as one of several cutoffs in use.[22] Variant arterial anatomy limits duplex accuracy (sensitivity 77%, specificity 85% against arteriography in 42 men).[14] |
| Dynamic infusion cavernosometry / cavernosography (DICC) | Excludes corporoveno-occlusive dysfunction.[11][12] |
| Selective internal pudendal arteriography (SIPA) | Defines focal arterial anatomy and the occlusion site; pudendal arteriography is described as the current gold standard for penile arterial evaluation.[13] For bypass planning, also evaluate both inferior epigastric donor arteries, the dorsal recipient arteries, cavernosal arteries, and dorsal-to-cavernosal communicating branches.[1] Arteriography is needed before arterial surgery because variant penile arterial anatomy was present in 83% of 42 men in one series.[14] |
| Concordance check | DUS and DICC findings should agree with SIPA. Discrepancies prompt repeat testing.[3] |
Surgical techniques
The techniques below use the inferior epigastric artery (IEA) as the donor. For IEA-to-dorsal arterial bypass, Dicks and Kawanishi describe preserving the fundiform ligament, dorsal nerves, and dorsal-to-cavernosal communicating branches during recipient dissection.[1][26]
| Technique | Description | Use |
|---|---|---|
| Michal I | Direct IEA → cavernosal artery anastomosis | Largely abandoned because of poor results[1] |
| Michal II | End-to-side IEA → dorsal penile artery; perfusion communicated to cavernosal artery via perforating branches | Described for focal post-traumatic occlusion in young men; comparative data are limited (see Outcomes)[1][5] |
| Hauri | IEA → dorsal penile artery with an additional arteriovenous shunt to the deep dorsal vein, which Hauri describes as lowering the risk of anastomotic thrombosis | Used when communicating branches between the dorsal and cavernosal arteries are present[11][16] |
| Furlow-Fisher modification of Virag V (FFV5) | IEA end-to-side to deep dorsal vein only, which arterializes venous drainage | Used when no communicating branches are identified or the proximal common penile artery is obstructed[11][6] |
| Mannheim triple anastomosis | IEA anastomosed to the dorsal artery and dorsal vein in sequence (modified by the Mannheim group) | Used in the German Mannheim series[4][15] |
Villalta and Lue describe a laparoscopic extraperitoneal IEA harvest through an infraumbilical access with a 10-mm balloon trocar and two 5-mm ports, dissecting the bundle from its external iliac origin toward the umbilical bifurcation and transferring the divided bundle through Hesselbach's triangle under direct vision to avoid torsion; an open harvest is described as an alternative when adequate length and branch control can be achieved. For the anastomosis, they describe trimming the adventitia, an arteriotomy of about 1 mm, an end-to-side interrupted 9-0 polypropylene anastomosis under the operating microscope, and confirming pulsatile flow or Doppler patency after unclamping. This is the chapter authors' described operative sequence, not evidence that one harvest or anastomotic approach outperforms another.[23] When the IEA is unavailable because of early branching or previous ligation, a reversed saphenous-vein graft connected to the superficial femoral artery, tunneled to the penile base and anastomosed end-to-side to the dorsal penile artery has been described as a historical alternative, without an outcome comparison against the standard IEA procedure.[24]
Outcomes
| Series | n | Technique | Follow-up | Success | Notes |
|---|---|---|---|---|---|
| Cookson 1993[12] | 50 | Microsurgical bypass ± venous | 24 mo (median) | 88% excellent or improved (48% excellent); 67% excellent in pure arterial ED vs 42% in mixed | Pure-arterial etiology significantly better than mixed |
| Manning 1998[4] | 62 | Virag (7) / Hauri (13) / modified Mannheim (42) | 41 mo (mean) | 54% overall (34% spontaneous, 20% pharmacologically induced erections); 69% at age ≤ 50; 58% with < 2 risk factors; 43% in diabetics; 39% at age > 50 | Age, diabetes and risk factors predicted outcome |
| Sarramon 1997[6] | 114 | Michal II (44) / modified Furlow-Fisher DDVA (70) | 17 mo (mean) | Good 47.8%, improved 14.6%, failed 37.4% | Deep dorsal vein arterialization did better than arterial bypass regardless of etiology; pure arteriogenic ED treated with Michal II did worst |
| Kawanishi 2004[11] | 49 | Hauri / FFV5 | 5 yr | 67.5% subjective / 65.5% objective (Kaplan-Meier) | No difference between techniques; strict selection |
| Kayıgil 2012[10] | 110/125 completed follow-up | Modified Furlow-Fisher | 73.2 mo (mean) | 63.6% at 5 yr reached a score >26 of 30 on the six-item erectile-function domain of the IIEF-15[28]; 92.8% success was reported in men without risk factors | Mean IIEF-5 rose from 7.3 to 16.8; a rise of at least 5 IIEF-5 points was a separate improvement definition |
| Zuckerman 2012[5] | 17 | IEA → dorsal artery | 3.1 yr (mean) | 14/17 overall: 11/13 treated for ED and 3/4 treated to protect urethral perfusion achieved erections sufficient for intercourse | PFUI cohort; success allowed erections with or without pharmacologic assistance |
The series above are retrospective and use different definitions of success. Results are better in young men without risk factors.[4][10][11]
Complications
| Complication | Rate | Notes |
|---|---|---|
| Glans hyperemia / hypervascularization | 4–13% in the cited mixed shunt or venous-arterialization series (2/49 Kawanishi; 6.4% Kayıgil; 13% Manning) | Dicks et al. reported none in their isolated-bypass experience.[1][4][10][11] |
| Shunt / anastomosis thrombosis | 8% | Mixed 62-patient series: Virag (7), Hauri (13), modified Mannheim (42)[4] |
| Inguinal hernia | 6.5% | Mixed 62-patient series: Virag (7), Hauri (13), modified Mannheim (42)[4] |
| Penile edema | 2 of 17 men | Early postoperative, after pelvic fracture urethral injury[5] |
| Abdominal wall hematoma requiring evacuation | 1 of 17 men | Early postoperative, in the PFUI series[5] |
| Superficial surgical-site infection | 1 of 17 men | Early postoperative, in the same PFUI series[5] |
| Anastomotic hemorrhage | 1 of 49 | Kawanishi[11] |
| Scar contracture | 1 of 49 | Kawanishi[11] |
Other described operative risks include dorsal nerve injury with reduced penile sensation or pain and fundiform-ligament injury or scarring with penile shortening. Dicks and colleagues estimated shortening in approximately 5% of their own experience without giving a denominator.[1] In a separate single-institution retrospective series of 71 men without vascular risk factors (mean follow-up 34.5 months), 20/71 (28.2%) reported loss of penile length and 18/71 (25.4%) reported decreased sensation.[29]
Endovascular alternatives
Older men with atherosclerotic arteriogenic ED are not candidates for microsurgical bypass. Endovascular revascularization with drug-eluting stents has been described for this group.
- Schönhofen 2021 reported a single-center registry of 100 men (mean age 61.8 years) treated with a sirolimus-eluting stent. At 1 year, 55 of 97 (56.7%) improved by at least 4 IIEF-6 points. In a selected angiographic substudy of 24 men imaged during secondary contralateral revascularization, 46 of 52 stented lesions (88.5%) were patent at a mean of 9.6 months.[17]
- Mohan 2025 extended this registry to 147 men (mean age 63.5 years) with PDE5i-refractory ED. Of the 68 men (46%) who completed follow-up at a mean of 30 months, 54% (37/68) reached the 4-point IIEF-6 improvement.[18]
- SwissPower 2026 reported arterial interventions in 524 men; among 402 with available IIEF-6 follow-up, 175 (43.5%) improved by at least 4 points at about 30 months. Participants partly overlap earlier reports.[27] Puncture complications occurred in 110/492 men (22.4%; mostly conservatively managed hematomas), and 49/399 (12.3%) underwent repeat arterial intervention during median 24-month follow-up.[27]
- Doppalapudi 2019 pooled 16 heterogeneous arterial and venous case series. Among 162 arterial patients, 65 (40.1%) received internal pudendal stents; pooled clinical success was 63.2%, and complications occurred in 8/162 (4.9%), including four classified as severe.[19] Success definitions varied.[19]
- Diehm 2019 reported a 50-patient registry using balloon angioplasty, drug-coated balloons and drug-eluting stents. At 12 months, 30 of 46 (65%) improved by at least 4 IIEF-6 points. Older men and men with hypertension improved less.[20]
These reports are uncontrolled registries and case series, mostly from one center, in men who had not responded to PDE5 inhibitors.[18][20]
Guideline position
| Body | Position |
|---|---|
| AUA 2018[7] | Conditional Recommendation, Grade C — penile arterial reconstruction may be considered for young men with focal pelvic / penile arterial occlusion without generalized vascular disease or veno-occlusive dysfunction |
| ICSM SOP 2013 (Sohn)[8] | Grade D ; no RCTs available |
| AFU/SFMS 2025[25] | Revascularization may be offered after pelvic trauma for isolated arterial insufficiency in patients without comorbidities (R58: expert agreement in this guideline) |
| EAU 2026[21] | Text only, with no graded recommendation: in young patients with pelvic or perineal trauma, surgical revascularization has a reported 60-70% long-term success rate; stenosis must be confirmed by penile pharmaco-arteriography and corporeal veno-occlusive dysfunction excluded by dynamic infusion cavernosometry or cavernosography. Venous ligation for veno-occlusive dysfunction is no longer recommended because of poor long-term results |
Guidelines do not treat penile arterial revascularization as a standard therapy. It may be offered in specialized centers to carefully selected patients.[2][8]
When to refer / when not to operate
- Refer. Consider specialist vascular evaluation for a young man (<55) with suspected post-traumatic arteriogenic ED and no generalized vascular disease; response to PDE5 inhibitors does not exclude referral. Confirm intact veno-occlusive function and concordant focal arterial disease before offering bypass.[1][3][7]
- PFUI reconstruction. In one 17-man post-PFUI series with bilateral deep pudendal obstruction, four underwent bypass before urethroplasty because of concern for ischemic repair.[5]
- Do not operate. Generalized vascular disease, confirmed corporeal veno-occlusive dysfunction, or mixed-etiology ED excludes focal arterial bypass.[7][4] Older age, diabetes, smoking and multiple vascular risk factors lower expected success and commonly make a patient a poor candidate.[7][4]
- Endovascular alternative. Consider referral at an experienced center for selected older men with atherosclerotic ED refractory to PDE5 inhibitors. Stenting of erection-related arteries has been described in uncontrolled registries; latest follow-up was available for 68/147 men in the 2025 series, so comparative efficacy and durability remain uncertain.[17][18]
Postoperative management
Protocols vary by center.
- Activity restriction. Dicks and colleagues advise avoiding intercourse and masturbation for six weeks after bypass; restrict cycling and strenuous exercise during early healing according to the operating team's protocol.[1] Kawanishi et al. reported one anastomotic rupture after accidental trauma at postoperative week five requiring emergency repair.[26]
- Postoperative duplex Doppler at 4–6 weeks to confirm patency.
- Anticoagulation / antiplatelet protocol per local microvascular service.
- PDE5 inhibitors. Dicks and colleagues describe nightly low-dose use for six months to support confidence and recovery.[1]
- Patient-reported outcomes. Record IIEF erectile-function-domain or IIEF-5 scores at baseline, 3, 6, and 12 months, then annually to assess function. Do not infer graft patency from these scores; evaluate suspected occlusion with vascular testing.[1][26]
- Smoking cessation is a selection criterion in the Mannheim series, and success was highest in men without risk factors in the Kayıgil series.[4][10]
See Also
- Erectile Dysfunction Atlas (04j ED database)
- Erectile Dysfunction (clinical condition)
- Pelvic Fracture Urethral Injury (PFUI): the trauma context that produces most candidates
- PDE5 Inhibitors (pharmacology hub)
- Psychosexual Therapy
References
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18. Mohan V, Schönhofen J, Hoppe H, et al. Long-term outcomes of drug-eluting stent implantation for patients with atherosclerotic erectile dysfunction not responding to PDE-5 inhibitors. J Endovasc Ther. 2025;32(3):720–729. doi:10.1177/15266028231183775
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