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Penile Venous Ligation Surgery

Penile venous ligation surgery treats corporeal veno-occlusive dysfunction (CVOD), also called venous leak, in which inadequate trapping of blood within the corpora cavernosa prevents the achievement or maintenance of erection. The classic operation resects the deep dorsal vein and ligates pathologic drainage pathways. The AUA 2018 guideline does not recommend penile venous surgery for ED because long-term results are inconsistent.[1] A 2020 review discussed a surgical niche; later selected cohorts reported combined ligation and embolization or standalone embolization, with limited long-term comparative evidence.[2][3][4][15]

The AUA 2018 guideline states: "For men with ED, penile venous surgery is not recommended ." The guideline adds that venous ligation is unlikely to result in long-term success for the overwhelming majority of men and delays treatment with more reliable options such as penile prosthesis surgery.[1]

A 1999 series restricted surgery to 23 men meeting at least three study-specific criteria: age <50 years, mild leak on cavernosometry, >30% cavernosal smooth muscle, normal cavernous electromyography, or cavernosal oxygen tension >65 mm Hg.[5] At long-term follow-up, 6/12 assessed men had spontaneous erections.[5] Prospectively collected series describe combined ligation plus embolization in selected men with drug-resistant ED and CVL confirmed on imaging; standalone embolization has also been reported. The Allaire and Hoppe reports had no randomized comparator.[3][4][15] A 2024 PiVET-ED conference abstract reported interim six-month sham-controlled embolization results for 31 participants.[23]

Pathophysiology and rationale​

Normal erection requires arterial inflow, sinusoidal smooth-muscle relaxation, and compression of subtunical venules against the tunica albuginea (the veno-occlusive mechanism). In CVOD, blood drains prematurely through incompetent veins, most commonly the deep dorsal vein, cavernous veins, and crural veins. Surgery aims to eliminate these pathologic drainage pathways.[6][2]

Conceptual caveat. Contemporary understanding suggests that CVOD is often an effect rather than a primary cause of ED, secondary to smooth-muscle degeneration, fibrosis, or arterial insufficiency. This may partly explain the variable surgical outcomes.[2]

Preoperative diagnosis and patient selection​

Diagnosis of venous leak requires hemodynamic confirmation:

TestFinding
Pharmacologically challenged penile duplex sonography (PC-PDS)EDV ≥5 cm/s can support suspected veno-occlusive dysfunction after adequate pharmacologic stimulation and rigidity-based assessment; redose or reassess when the erectile response is inadequate. Assess arterial inflow separately: Flores et al. classify PSV 30–35 cm/s as a gray zone and ≥35 cm/s as normal in their protocol.[7][21]
Dynamic infusion cavernosometry / cavernosography (DICC)Maintenance flow rates and identification of leak sites[5][9]
CT cavernosographyAnatomic mapping of leak sites, used in contemporary series[3][4]

Selection features proposed in individual series[5][9][10]:

  • Young age and primary venous leak were favored in Cayan’s selected cohort, whereas Stief found no age association and poor results in his small primary-ED subgroup.[9][10]
  • Normal arterial inflow on PC-PDS. Selective internal pudendal arteriography (SIPA) was used in some older studies but is not routine work-up for venous ligation.[18]
  • Mild-to-moderate leak on cavernosometry.
  • Normal cavernous electromyography (SPACE). Abnormal results predict poor outcomes (full spontaneous erections in 28 of 41 men with normal single-potential analysis of cavernous electrical activity, SPACE, versus 3 of 36 with abnormal results).[10]
  • No significant atherosclerosis, diabetes, or smoking.
  • Smooth-muscle content preserved on biopsy where assessed.

Surgical technique​

StepDetail
1. IncisionInfrapubic or inguinoscrotal approach.
2. Dorsal-vein treatmentHwang resected the deep dorsal vein from the coronal sulcus to the pubic arch; Cayan also resected the superficial dorsal vein, while Stief ligated and divided superficial dorsal and lateral veins before deep dorsal-vein resection. Wespes reported slightly better results with resection than simple ligation.[9][10][11][13]
3. Ligation of cavernous veinsAt the penile hilum.
4. Crural ligationBanding of the crura proximal to the entrance of the cavernous artery using umbilical tapes (in more extensive procedures, e.g. Cayan 2008).
5. PreservationPreserve dorsal arteries and dorsal nerves bilaterally.

Technique and safety pearls. These are described operative and safety practices:[19]

  • Protect the urethra before passing crural tapes. A Foley catheter is placed before the umbilical tape is passed between the crus and the bulbar corpus spongiosum, to help identify and avoid injury to the urethra.
  • Identify the cavernous artery before ligating. The cavernous artery's entrance into the corpus cavernosum is traced (with intraoperative Doppler ultrasound to confirm it), and crural ligation is performed proximal to that point to avoid ligating the artery itself.
  • Use polyester, not cotton, umbilical tapes, with at least two tapes placed separately around each crus, to reduce the foreign-body and infection reaction associated with cotton tape.
  • Reattach the dorsal tunica to the pubic periosteum after the fundiform and suspensory ligaments are divided, to substitute for the severed ligament and limit penile shortening.

Outcomes — variable response and uncertain long-term durability​

Results are highly variable and depend heavily on patient selection, technique, and follow-up duration.

SeriesnFollow-upSuccessNotes
Wespes 1985[6]20Not stated16/20 (80%) improved enough for satisfactory intercourseThe 4 failures had serious arterial lesions
Wespes 1992[11]67Long-term31/67 (46%) potent7 relapses from deeper vein leakage; 11 failures from arterial disease
Freedman 1993[12]46> 12 mo11/46 (24%) sustained potency74% initial improvement with high relapse; sustained function in 43% of distal leaks and 16% of proximal leaks
Hwang 1994[13]35 (30 followed)27.5 mo (mean)12/30 (40%) sustained spontaneous erection93% initial success; inadequate elimination of leaking veins, especially crural veins, was the likely cause of recurrence
Stief 1994[10]776 mo (77/77); later mean 21 mo (70/77 reviewed)31/77 (40%) full spontaneous erections at 6 moFour of 31 initial responders later required intracavernosal pharmacotherapy; normal SPACE predicted six-month success (28/41 vs 3/36).
Kim & McVary 1995[14]1529 mo (mean)60% potentShorter ED duration predicted success; 40% penile contracture
Cayan 2008[9]26≥ 12 moComplete erectile improvement in 11/26 (42%); partial in 8/26 (31%)Mean IIEF-5 6.7 → 16.3; complete or partial satisfaction in 23/26 (88%) with or without PDE5i
Rahman 2005[20]11 (highly selected congenital crural leak, median age 28)34 mo (mean, range 6–58)Marked improvement in 9/11 (82%)IIEF-5 8.9 → 17.5 (mean); items 2, 3, and 5 improved (p < 0.05)
Allaire 2021[3] (combined ligation + embolization)4514 mo73.3% primary and 82.2% secondary successProspective; combined open and endovascular. Primary success was clinical EHS ≥ 3 with penetrative intercourse possible, no vascular reoperation, and no prosthesis; secondary success was penetrative intercourse after allowing reoperation
Allaire 2025[4] (mixed venous procedures)171PC-PDS at 3 mo; clinical follow-up mean 23 mo138/171 (80.7%) met the study’s composite: three-month pharmacologically challenged EHS >3 with a gain ≥0.5, or postoperative erection stability if preoperative challenged EHS was 481.9% received ligation plus embolization, 12.9% ligation alone, and 5.3% embolization alone; 24/171 (14.0%) required vascular reoperation

Pattern. Freedman reported intercourse-capable erections in 34/46 (74%) within 6 months; Hwang reported excellent erections in 28/30 (93%) within 3 months.[12][13] At later follow-up, Freedman reported unaided intercourse in 11/46 (24%) after >12 months, Hwang spontaneous erections in 12/30 (40%) after a mean 27.5 months, and Wespes intercourse-capable potency in 31/67 (46%) at long-term follow-up.[12][13][11] The 2021 Allaire combined-procedure report found 73.3% primary success at a mean 14 months.[3] Its 45 patients were included in the 2025 cohort of 171, in which 138/171 (80.7%) met a composite of three-month pharmacologically challenged EHS >3 with a gain ≥0.5 or postoperative erection stability when preoperative challenged EHS was 4; mean clinical follow-up was 23 months, and 81.9% received both ligation and embolization.[4] These overlapping reports came from one group and neither included a randomized comparator; longer-term durability remains uncertain.[3][4]

Complications​

ComplicationRateNotes
Penile shorteningHwang: 3 cases (35 operated; 30 long-term followed); Freedman: 20/46 (43%)Counsel explicitly.[12][13]
Penile hypoesthesia / glans numbnessWespes: 4/67 (6%); Hwang: 4 cases (complication denominator unstated); Freedman: 9/46 (20%)[11][12][13]
Penile deviation / curvature3/30 (Hwang)[13]
Wound infection1/30 (Hwang)[13]
Early reoperation for penile or groin complication (Allaire 2025)11/171 (6.4%)The mixed-procedure cohort also reported two symptomatic pulmonary emboli.[4]
Recurrent ED after an initial response7/67 relapsed several months after surgery in Wespes’ series.[11]Overall late favorable outcomes in older series ranged from 24% to 46%, but those rates include primary nonresponse and measure different endpoints.[12][11] Incomplete treatment of leak sites, especially crural veins, was proposed as a cause; cavernosography after failed stripping has shown a persistent cavernosal vein.[13][8]
Penile contracture40% (Kim & McVary 1995)[14]
Hematoma with skin necrosis1 case in Stief’s 77-patient seriesRequired multiple plastic revisions and left significant glans paresthesia.[10]
Persistent preputial edema14 cases in Stief’s seriesReported as a postoperative side effect.[10]

Emerging — venous-leak embolization​

Endovascular embolization of venous-leak sites has emerged as a less invasive alternative or adjunct:

  • Hoppe 2026 multicenter registry (n = 175): 82/138 (59.4%) achieved an IIEF-15 improvement of at least 4 points at a mean 9.2 months.[15] Venous leak recurred or persisted in 10.2% at a mean 16 months.[15] Non-target pulmonary embolism occurred in 3/175 (1.7%).[15] A partly overlapping SwissPower analysis found a ≥4-point IIEF-6 improvement in 62/140 (44.3%) at nine months and patient-reported improvement in 102/142 (72%) at six weeks after venous embolization.[22]
  • Allaire 2021 and 2025. The 2021 combined-procedure cohort (n = 45) reported 37/45 (82.2%) secondary success after allowing reoperation, with 32% of successful men achieving penetration without medication.[3] The overlapping 2025 cohort (n = 171) found that 138/171 (80.7%) met a composite of three-month pharmacologically challenged EHS >3 with a gain ≥0.5 or postoperative erection stability when preoperative challenged EHS was 4; 81.9% received both modalities.[3][4]
  • PiVET-ED trial. The published protocol describes a prospective, randomized, single-blinded, sham-controlled study of pelvic vein embolization for venogenic ED (planned n = 80), designed to provide randomized evidence.[16]

Guideline position​

BodyPosition
AUA 2018[1]Not recommended . Unlikely to result in long-term success; delays prosthesis treatment
EAU 2025 and March 2026 limited update[17][18]Venous ligation surgery for veno-occlusive dysfunction is "no longer recommended because of poor long-term results" (guideline text, without a strength rating; section 5.6.11.b of the March 2026 update, which also questions the concept of venogenic ED and reports 60–70% long-term success for revascularization in young men with post-traumatic arterial stenosis)

When to refer / when not to operate​

  • Select cautiously. Assess venous dysfunction, arterial inflow, and competing ED causes; counsel about high recurrence and the AUA and EAU non-recommendations.[1][4][18] Young age, primary leak, nonsmoking status, and absence of major vascular comorbidity characterize some older favorable cohorts.[5][9][10]
  • Guideline caution. The AUA advises against penile venous surgery for ED and describes penile prosthesis as a more reliable surgical option.[1] Evaluate arterial disease and other untreated organic causes before considering a venous procedure; failed medical therapy alone is not a contraindication in the published venous-surgery cohorts.[4][5]
  • Embolization. Embolization or combined ligation plus embolization has been reported from experienced centers.[3][4][15] In Allaire's 2025 series, patients at high thromboembolic risk did not undergo embolization; Hoppe's registry reported non-target pulmonary embolism in 3/175 treated men (1.7%).[4][15]

Postoperative management​

  • Activity restriction. Avoid intercourse, masturbation, cycling, and strenuous exercise for 4–6 weeks.
  • Postoperative imaging. Cayan used duplex ultrasound or cavernosography as needed; the Allaire 2025 cohort repeated pharmacologically challenged duplex at three months.[9][4]
  • PDE5 inhibitor response. In Cayan's 26-man series, 12 men achieved satisfactory erections with PDE5 inhibitors after surgery despite preoperative nonresponse.[9]
  • PRO assessment. IIEF / IIEF-5 at baseline, 3 mo, 6 mo, 12 mo, with annual follow-up given known late attrition.
  • Counseling. Counsel preoperatively that penile shortening was reported in 3 patients in Hwang's 35-man series (30 had long-term follow-up) and in 20/46 (43%) men in Freedman's series[13][12], and discuss the high long-term recurrence rate; document the AUA 2018 non-recommendation.[1]

See Also​

References​

1. Burnett AL, Nehra A, Breau RH, et al. Erectile dysfunction: AUA guideline. J Urol. 2018;200(3):633–641. doi:10.1016/j.juro.2018.05.004

2. Hsieh CH, Hsu GL, Chang SJ, et al. Surgical niche for the treatment of erectile dysfunction. Int J Urol. 2020;27(2):117–133. doi:10.1111/iju.14157

3. Allaire E, Sussman H, Zugail AS, et al. Erectile dysfunction resistant to medical treatment caused by cavernovenous leakage: an innovative surgical approach combining pre-operative work-up, embolisation, and open surgery. Eur J Vasc Endovasc Surg. 2021;61(3):510–517. doi:10.1016/j.ejvs.2020.08.048

4. Allaire E, Hauet P, Floresco J, et al. Ligation and embolization in one procedure for caverno-venous leakage in 171 patients with drug-resistant erectile dysfunction. Ann Vasc Surg. 2025;121:664–672. doi:10.1016/j.avsg.2025.08.025

5. Sasso F, Gulino G, Weir J, Viggiano AM, Alcini E. Patient selection criteria in the surgical treatment of veno-occlusive dysfunction. J Urol. 1999;161(4):1145–1147. doi:10.1016/s0022-5347(01)61614-8. PMID 10081857

6. Wespes E, Schulman CC. Venous leakage: surgical treatment of a curable cause of impotence. J Urol. 1985;133(5):796–798. doi:10.1016/s0022-5347(17)49231-7

7. Aversa A, Sarteschi LM. The role of penile color-duplex ultrasound for the evaluation of erectile dysfunction. J Sex Med. 2007;4(5):1437–1447. doi:10.1111/j.1743-6109.2007.00546.x

8. Hsu GL, Hsieh CH, Wen HS, et al. Penile venous anatomy: an additional description and its clinical implication. J Androl. 2003;24(6):921–927. doi:10.1002/j.1939-4640.2003.tb03145.x

9. Cayan S. Primary penile venous leakage surgery with crural ligation in men with erectile dysfunction. J Urol. 2008;180(3):1056–1059. doi:10.1016/j.juro.2008.05.024

10. Stief CG, Djamilian M, Truss MC, et al. Prognostic factors for the postoperative outcome of penile venous surgery for venogenic erectile dysfunction. J Urol. 1994;151(4):880–883. doi:10.1016/s0022-5347(17)35112-1

11. Wespes E, Delcour C, Preserowitz L, et al. Impotence due to corporeal veno-occlusive dysfunction: long-term follow-up of venous surgery. Eur Urol. 1992;21(2):115–119. doi:10.1159/000474815

12. Freedman AL, Costa Neto F, Mehringer CM, Rajfer J. Long-term results of penile vein ligation for impotence from venous leakage. J Urol. 1993;149(5 Pt 2):1301–1303. doi:10.1016/s0022-5347(17)36374-7

13. Hwang TI, Yang CR. Penile vein ligation for venogenic impotence. Eur Urol. 1994;26(1):46–51. doi:10.1159/000475341

14. Kim ED, McVary KT. Long-term results with penile vein ligation for venogenic impotence. J Urol. 1995;153(3 Pt 1):655–658. doi:10.1097/00005392-199503000-00029. PMID: 7861508

15. Hoppe H, Heymann G, Müller D, et al. Midterm outcomes of venous leak embolization in patients with venogenic erectile dysfunction unresponsive to phosphodiesterase-5 inhibitors. Cardiovasc Intervent Radiol. 2026;49(3):556–566. doi:10.1007/s00270-025-04246-w

16. Moriarty HK, Kavnoudias H, Blecher G, et al. PIVET-ED: a prospective, randomised, single-blinded, sham controlled study of pelvic vein embolisation for treatment of erectile dysfunction. Cardiovasc Intervent Radiol. 2022;45(2):155–161. doi:10.1007/s00270-021-03021-x

17. Salonia A, Capogrosso P, Boeri L, et al. European Association of Urology Guidelines on Male Sexual and Reproductive Health: 2025 Update on Male Hypogonadism, Erectile Dysfunction, Premature Ejaculation, and Peyronie's Disease. Eur Urol. 2025;88(1):76–102. doi:10.1016/j.eururo.2025.04.010

18. EAU. Guidelines on Sexual and Reproductive Health, Limited Update March 2026, sections 5.5.4, 5.6.11.a and 5.6.11.b.

19. Villalta JD, Lue TF. Vascular Surgery for Erectile Dysfunction. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:641–654. doi:10.1007/978-1-4614-7708-2_45

20. Rahman NU, Dean RC, Carrion R, Bochinski D, Lue TF. Crural ligation for primary erectile dysfunction: a case series. J Urol. 2005;173(6):2064–2066. doi:10.1097/01.ju.0000158447.12163.f5

21. Flores JM, West M, Mulhall JP. "Efficient use of penile Doppler ultrasound for investigating men with erectile dysfunction." J Sex Med. 2024;21(8):734-739. doi:10.1093/jsxmed/qdae070

22. Diehm N, Do PDD, Röllig M, et al. "Endovascular therapy for erectile dysfunction: insights from more than 1000 treatments." CVIR Endovasc. 2026;9(1):23. doi:10.1186/s42155-026-00666-y

23. Phan T, Lukies M, Zia A, et al. "PIVET-ED: a prospective, randomised, single-blinded, sham-controlled study of pelvic vein embolisation for the treatment of venogenic erectile dysfunction - interim results." Alfred Research Alliance Abstract Book. 2024:69-70. PDF