International Journal of Impotence Research (1997) 9, 205±209

ß 1997 Stockton Press All rights reserved 0955-9930/97 $12.00

Long-term results following dorsal penile vein ligation in 126

patients with veno-occlusive dysfunction
D Schultheiss, MC Truss, AJ Becker, CG Stief and U Jonas

Department of Urology, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

One hundred and forty-seven patients who had dorsal penile vein ligation (DPVL) between 1987
and 1996 were re-investigated either during clinical consultation or by standardised telephone
interview respectively questionnaire.
One hundred and twenty-six patients were available for long-term follow-up. Postoperative
outcome was classi®ed into complete spontaneous erection, postoperative response to
pharmacotherapy or no satisfactory improvement. The short-term success after 1±3 months
according to this classi®cation was 31 (24.6%), 25 (19.8%) and 70 (55.6%). These results were
found to have deteriorated on long-term observation; with only 14 (11.2%), 24 (19.0%) and 88
(69.8%) respectively. Positive prognostic factors were preoperative duration of erectile
dysfunction of  7 y, a normal CC-EMG and a maintenance ¯ow of  45 ml/min. With all three
parameters present, longterm success (spontaneous erection plus responder to intracavernous
injection) rose from 30 to 67% in this selected group (P  0.001).
Our study shows that long-term success for unselected patients undergoing DPVL is
disappointing; however, careful patient selection signi®cantly improves long-term results.

Keywords: erectile dysfunction; venous leakage; prognostic factors; surgery

Introduction follow-up period of at least 2 y and with larger

Surgery of the penile veins has been performed for
over 100 y and presents the oldest method of
operative treatment for erectile dysfunction:1 The
®rst publication originated in 1873 and was com-
piled by F. Parona, Italy, who carried out sclero-
therapy of the veins of the penis. In 1895 and 1902,
ligature of the veins was performed by H. Raymond,
J. Duncan and J. Wooten. Following these individual
case reports, F. Lydston, in 1908, performed a series
of 100 operations. Since 1935, O. Lowsley, with over
1000 operations, has performed the greatest number
of operations so far. In 1953, he was the ®rst to
present a follow-up of 273 patients with a success
rate of 58%.
With the introduction of new diagnostic methods
and the strong desire for alternatives to the penile
prosthesis, new concepts for penile venous surgery
were introduced by Ebbehoj and Wagner2, as well as
Wespes and Schulman.3 The appeal of this ap-
proach is the regain of spontaneous erections after
rather minimal surgery. Over the past years, several
studies with a long follow-up have reported increas-
ingly poor long-term results. Investigations per-
formed between 1993±1996 with an average
Correspondence: Dr D Schultheiss.
Received 14 March 1997; accepted 8 July 1997
groups (44±134 patients) revealed spontaneous
erections in 19.4±44.2% of cases.4±7
Studies over the past years have made obvious
that most factors for veno-occlusive dysfunction, the
pathological changes of the cavernous smooth
muscle, and subtunical occlusion mechanisms, are
not affected by surgery. This explains a new
development of `leakages' postoperatively, thus
resulting in poor long-term prognosis for surgery of
the veins of the penis.8±11
Furthermore, modi®cations in operative proce-
dures, for example ligation of crural veins or
spongiolysis, demonstrated no signi®cant improve-
ment of long-term success despite the higher
morbidity rate. These modi®cations are still under
controversial discussion.6,12
An improvement of this poor outcome can only
be achieved if the patients are better classi®ed
preoperatively in the future. The proposed prog-
nostic factors here have been assessed most con-
troversially and, up till now, have not lead to an
unanimous concensus. We therfore re-investigated
and re-assessed our patients who underwent DPVL
following an initial analysis in 1993 and 1994.12,13
Patients and methods
From November 1987 until February 1996, 147
patients with venous leakage underwent dorsal vein
 Long-term results following dorsal penile vein ligation
D Schultheiss et al
206
ligation of the penis. The patients were subjected to
a standardised diagnostic programme including a
detailed case history, sexual-psychological consul-
tation with a psychologist or psychiatrist excluding
psychogenic erectile dysfunction,14 physical exam-
ination, laboratory investigations, bidirectional dop-
pler investigations or colour duplex of the arteries of
the penis, corpus cavernosum electromyography
(CC-EMG)15 and an intracavernous pharmacotesting
with a maximum dose of 30 mg papaverin/1 mg
phentolamin resp. 20 mg PGE 1.16
Only in case inadequate erection was obtained,
the patient underwent pharmacocavernosometry
and pharmacocavernosography. This procedure
was undertaken only if the patient was willing to
undergo DPVL if indicated. The diagnosis of veno-
occlusive insuf®ciency and the following indication
for surgery was determined by a maintenance ¯ow
> 15 ml/min. All patients were informed in detail on
the minor success rate of DPVL and possible
alternative therapies. Surgery was performed under
general or regional anaesthesia. All super®cial veins
of the penis were exposed, double-ligated and
separated; after opening of Buck's fascia (taking care
not to damage the neurovascular bundle) the deep
dorsal vein of the penis between the suspensory
ligament of the penis and distal third of the penis
was dissected and resected.
Of the 147 operated patients, 126 could be
assessed for short-term outcome after 1±3 months
as well as for long-term outcome after 6±76 months.
The data were collected either during clinical visits
or with standardised telephone interviews or with
the help of a questionnaire. According to the success
patients were divided into three groups: complete
spontaneous erections, postoperative positive re-
sponse to intracavernous pharmacotherapy and
failure to intracavernous injections. A re-evaluation
with pharmacocavernosometry and -graphy was not
performed as a pathologic ®nding would not have
resulted in offering the patients DPVL for a second
time. A univariate statistical analysis of the sig-
ni®cance of the data obtained was deduced by Chi-
Square test and Log-Rank test (Kaplan±Meier
curves) and for the most part, a multivariate analysis
by means of Logistic resp. Cox-regression analysis.
Furthermore a decision-tree analysis of events was
performed to reassure the results.17
Results
Surgery was performed on 147 patients between
November 1987 and February 1996. Assessment in
126 cases was obtained for a short-term success rate
after 1±3 months and long-term success rate after 6±
76 months (mean 33  19.6). Age of patients was
between 20±71 y (mean 48  11.7). Duration of
disease in 104 patients with secondary erectile
dysfunction was 2±300 months (median 48); 22
cases demonstrated primary dysfunction.
Findings derived from the short-term success
after 1±3 months revealed 31 patients (24.6%) to
have a spontaneous erection suf®cient for sexual
intercourse; 25 (19.8%) responded to intracavernous
injection following operation and 70 (55.6%) de-
monstrated no response to DPVL. These results were
found to have deteriorated on long-term observation;
with only 14 (11.2%) showing spontaneous erec-
tions, 24 (19.0%) responding to intracavernous
injection and 88 (69.8%) showing no bene®t. Of
the ®rst two groups 22 patients showed deteriora-
tion of erectile capacity over a longer period of time,
after initial success in 56 patients. Figure 1 (Kaplan±
Meier curve) demonstrates that in 19 of 22 patients
(86%) deterioration took place within the ®rst year
after surgery (P  0.001; Binominal test).
Postoperative complications were observed in 19
patients (15.1%). There was one pronounced hae-
matoma formation and consecutive skin necrosis
which required surgical revision. Three cases of
penile deviation were found, eight temporary or
persistent cases of sensitivity impairment, one case
of minor haematoma, four cases of pain in the glans
or shaft region and two cases of (subjective) penile
shortening.
No statistically signi®cant correlation could be
made between success of DPVL and existing risk
factors resp. accompanying diseases (for example
diabetes mellitus, coronary heart disease, pelvic
trauma or penile induration) or previous surgery (for
example TUR-P, pelvic surgery). No signi®cant
in¯uence was revealed based on the patient's age
and the degree of erection during preoperative
pharmacotesting. A favourable prognostic factor
was a short period of erectile dysfunction prior to
operation or the presence of primary erectile
dysfunction (P  0.021 resp. P  0.043; Logistic
regression, multivariate). A low maintenance ¯ow
Figure 1 Duration of operation success (spontaneous erectile
competency or pharmaco response) following penile venous
surgery.

(20±300 ml/min, median 67.5) also showed to be of
signi®cant relation to the outcome of operation
(P  0.027; Logistic regression, multivariate).
A third signi®cant prognostic factor was the CC-
EMG. This investigation was done preoperatively in
118 patients and produced a normal ®nding in
56.8% of cases and an abnormal ®nding in 43.2% of
cases. In the group with spontaneous erections
competency over a long-term duration, this rate
shifted from 84.6±15.4% (P  0.012; Log-Rank test,
univariate).
The signi®cant importance of the three factors,
the duration of erectile dysfunction (resp. presence
of primary erectile dysfunction), maintenance ¯ow
and CC-EMG was con®rmed in an additional
decision-tree analysis (Figure 2: P  0.001).14 Suc-
cess of operation was de®ned here as spontaneous
Figure 2 Decision-tree analysis of operation success (spontaneous erectile competency or response to intracavernous injection)
according to the three prognostic factors: Duration of erectile dysfunction, CC-EMG and maintenance ¯ow (P  0.001).
Long-term results following dorsal penile vein ligation
D Schultheiss et al
207
erection competency or response to intracavernous
injection. The success rate doubled from 30±67%
when all three mentioned prognostic factors were
proved positive. By way of calculation, a favourable
assessment was made for the duration of erectile
dysfunction  7 y, maintenance ¯ow  45 ml/min
and a normal CC-EMG.
Discussion
Until recently, the success rates of penile vein
ligation were reported to be 10±80%.9 Studies
producing particularly good results were often
affected by the low number of patients and a
follow-up duration of only 1±2 y. In the relevant
 Long-term results following dorsal penile vein ligation
D Schultheiss et al
208
studies performed since 1993, the success rate of
spontaneous erectile competency has dropped to
20±45% with an average follow-up period of well
over 2 y.2,5±7,12,18 This trend applies to our patient
criteria revealing, at last assessment in 1994,12 a
spontaneous erectile capacity of 35% in 77 patients
with an average follow-up period of 21 months. In
this study, only 11% of patients have demonstrated
a consistent spontaneous erectile capacity after an
average of 33 months. This emphasises clearly that
long-term success is relatively infrequent following
penile venous surgery, whereby, deterioration of
initial success of operation within our patient
criteria was observed in over 80% of cases within
the ®rst 12 months postoperatively.
It therefore appears obvious that the actual
pathologic feature causing venous leakage is not
treated by DPVL. It is widely held today that the
increased blood ¯ow through the cavernous venous
system is due to a functional defect within the
corpus cavernosum. The main focus of discussion
relates to cell degeneration of the cavernous smooth
muscle structures as well as an impairment of the
subtunical occlusion mechanisms.4,7,9,10,12,19 Follow-
ing successful surgery, the same patho-physiological
changes take place in the corpus cavernosum
including the rechannelling of an increased venous
blood ¯ow, thus producing a renewed case of
erectile dysfunction.
This hypothesis is strengthened by our results,
which prove that a maintenance ¯ow  45 ml/min
produced by pharmacocavernosometry may be
considered as a favourable prognostic factor. One
can deduce here that an intracavernous defect is not
so pronounced, the venous blood ¯ow is abnormally
raised to a certain degree and an improved success
rate can be expected. The importance of a main-
tenance ¯ow is controversially viewed, whereby, a
number of authors refuse to accept any prognostic
factors6,9,10,20,21 and others con®rm our results.7,18,22
The length of time since the beginning of erectile
dysfunction is also of importance.4,20 A possible
borderline appears to be around 7 y. This may infer
that a noxa leads to limited cavernous impairment
and recovery can be expected in this case. CC-EMG
measures the electrical activity of the cavernous
smooth muscles. Should there be abnormal ®ndings,
a lesion of autonomic nerves may be indicated
leading to a reduced or abnormal potential rate. On
the other hand, it could also be the cause of a
primary smooth muscle cell degeneration. Since
only non-responders to pharmacotesting were in our
group of patients, an abnormal CC-EMG seems to
indicate smooth muscle cell degeneration or iso-
lated nerve impairment; however, with an intact
smooth muscle system, an erection suf®cient for
intercourse should be possible after intracavernous
injection. This argument is supported by our results
which prove that a normal CC-EMG is a signi®cant
prognostic factor for success of operation.12;13 Al-
most 85% of patients with spontaneous erections
following penile venous surgery revealed an un-
remarkable ®nding on CC-EMG.
Conclusions
We were able to show that with a combination of
duration of erectile dysfunction  7 y, a mainte-
nance ¯ow of  45 ml/min and a normal CC-EMG,
the rate of success of DPVL (spontaneous erection or
postoperative response to intracavernous substance)
rose from an average of 30 to 67%. These three
prognostic factors are of importance when selecting
patients. However, the overall rate of success still
remains disappointing over a long-term period.
Despite temptation in clinical routine to spare
pharmaco-negative patients from having to accept a
penile prothesis, the indication for venous surgery
with a view to these facts should be considered only
after thorough diagnosis.
Acknowledgements
Mrs B Wiese (Department of Biometrics, Medizi-
nische Hochschule Hannover) is kindly thanked for
her help in performing biostatistical work.
This study was supported in part by a grant from
the Deutsche Forschungsgemeinschaft DFG Sti
96/10±1.
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