Supervisors info:
Ιωάννης Κακίσης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ, Επιβλέπων
Γεώργιος Γερουλάκος, Ομότιμος Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αχιλλέας Χατζηϊωάννου, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Erectile dysfunction (ED) is defined as the inability to obtain or maintain an erection firm enough for satisfactory sexual performance. It affects nearly 52% of men aged 40–70 years with prevalence increasing with age (1,2). The pathophysiology of ED is complex and multifactorial, with neural, vascular, hormonal, and psychologic processes needed for successful erection. The traditional armamentarium for ED treatment begins with lowering cardiovascular risk factors by improving diet, exercising regularly, and stopping tobacco use. Patients who fail conservative measures are placed on oral PDE-5 inhibitor pharmacotherapy to induce relaxation of cavernosal and arterial smooth muscle by preventing degradation of cyclic guanosine monophosphate (3,4). Individuals with primarily vasculogenic ED may require escalating therapy if oral therapies are ineffective, often involving more intrusive or invasive treatments, such as intracavernosal injections, vacuum pump therapy, surgical ligations, and penile implants (5). In recent years, endovascular treatments for refractory vasculogenic ED have increased in popularity, including angioplasty or stenting for arterial insufficiency (AI) and embolization procedures for veno-occlusive dysfunction (VOD). The etiology of vasculogenic ED is also multifactorial. Most patients with long‑standing atherosclerotic disease will likely not be good candidates for IPA stenting due to the diffuse nature of atherosclerotic disease. Appropriate patient selection will be paramount for success and depend on clinicians’ abilities to interpret imaging data and correlate degrees of atherosclerotic burden with severity of ED. More accurate and noninvasive methods for the diagnosis of focal stenotic lesions that are likely amenable to endovascular revascularization techniques will provide added benefit in patient selection. Moreover, techniques such as computed tomographic angiography (CTA) to evaluate pelvic arterial lesions are currently being studied by Wang et al.25 for planned percutaneous angioplasty of distal penile vasculogenic lesions in the PERFECT‑1 study.26 Results indicate a positive correlation between obstructive lesions identified at the time of intervention and those previously discovered on CTA. Such noninvasive imaging has the potential to identify a larger subset of men with ED secondary to isolated obstructive lesions. In summary, endovascular intervention with angioplasty and DES placement offers hope for men with ED from focal arterial lesions resulting from blunt trauma. However, long‑term data will be required to evaluate its efficacy fully.
Although hemodynamically feasible, the pathophysiology of ED is commonly multifactorial, even in such isolated lesions. Whereas coronary and peripheral vasculature are often amenable to luminal diameter increases that result in long‑term patency, the penile anatomy is co‑dependent on surrounding anatomy for successful tumescence. Furthermore, when endothelial dysfunction, microvascular changes or structural defects that result in CVOD accompany arterial inflow stenosis, isolated therapy with endovascular stent placement becomes less effective. The hope for a less invasive method to treat ED in select populations may be possible in the future. but its time is not right now
