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Clinical Value of Pelvic and Penile Magnetic Resonance Angiography in Preoperative Evaluation of Penile Revascularization

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Clinical Value of Pelvic and Penile Magnetic Resonance Angiography in Preoperative Evaluation of Penile Revascularization International Journal of Impotence Research (1999) 11, 83±86 ß 1999 Stockton Press All rights reserved 0955-9930/99 $12.00 http://www.stockton-press.co.uk/ijir Clinical value of pelvic and penile magnetic resonance angiography in preoperative evaluation of penile revascularization H John*1, GM Kacl2, K Lehmann1, JF Debatin2 and D Hauri1 1Department of Urology, University Hospital Zurich, Switzerland and 2Department of Radiology, University Hospital Zurich, Switzerland Penile angiography is invasive, costly and requires postinterventional surveillance. The aim of this pilot study was to determine whether three dimensional magnetic resonance (3D-MR)- angiography may replace conventional penile angiography in preoperative planning of penile revascularization. Twelve patients with a mean age of 39 (21 ± 59) y were evaluated. All patients underwent evaluation with intracavernous pharmacotesting, color Doppler sonography (CDS), digital subtraction angiography (DSA) and pelvic MR-angiography with gadolinium diethylene- triaminepentaacetic acid (Gd-Dota) 0.2 ± 0.3 mmol=kg body weight. MR-angiography demonstrated the anatomy of the internal iliac arteries in 9 out of 12 patients. Intrapenile vessels were visible in 7 out of 12 patients. In comparison DSA provided complete visualization of all pelvic and penile vessels. Relevant arterial obstruction was found in 10 out of 12 patients. CDS revealed a mean maximal arterial ¯ow of 27 (22 ± 40) cm=s and showed in accordance to angiography arterial insuf®ency in 10 out of 12 cases. Indication for revascularization could have been based on MR- angiography alone in only one patient. Therefore, selective penile angiography remains the `gold standard' for preoperative planning of revascularization procedures. Keywords: impotence; magnetic resonance; angiography Introduction planning of revascularization procedures has not yet been estabilished. The aim of this pilot study was to demonstrate, prospectively, the clinical value Revascularization procedures are the only method of 3D-MR-angiography of pelvic and penile vessels for return of normal functions in arteriogenic in comparison to CDS and penile angiography in the erectile dysfunction. Diagnosis of erectile dysfunc- preoperative evaluation prior to penile revascular- tion and its etiology should, ideally be ef®cient and ization in patients with proven arteriogenic erectile economical. In patients with arteriogenic failure, dysfunction. visualization of penile arteries is helpful in pre- operative planning, especially to demonstrate the presence of communicating branches between the dorsal and deep penile arteries. The use of CDS and Patients and methods pudendal arteriography have been standardized and 1,2 are widely described. MR-angiography is a rela- Twelve consecutive patients with mean age of 39 tively new technique that uses the transient short- (21 ± 59) y and with erectile dysfunction for a mean ening of T1 weighted relaxation time of blood duration of 30 (12 ± 45) months were evaluated. All following intravenous injection of gadolinium patients underwent a standardized evaluation in- 3,4 chelates to image blood vessels. Magnetic cluding intracavernous injection test with 10 mg resonance (MR) investigations have gained accep- Prostaglandin E1 (Caverject1, Pharmacia & Upjohn, tance in the last few years in the evaluation of DuÈ bendorf, Switzerland), nocturnal penile tumes- posttraumatic impotence, penile prosthesis and cence monitoring (Rigiscan1, Dacomed, Minneapo- 5±7 ®brous plaques in Peyronie's disease. The lis, MN), penile 7 MHz CDS (Acuson 128 XP, contribution of MR-imaging to the preoperative Acuson Corp., Mountain View, CA), 3D-MR-angio- graphy (1.5 Tesla Signa, GE Medical Systems, Milwaukee, Wisc.) and pharmoco-penile angiogra- phy (DSA). The cut-off values in CDS-examinations *Correspondence: Dr H John, Department of Pathology, SUNY Health Sciences Center, 750 East Adams St., Syracuse, New were for arterial disease <35 cm=s peak ¯ow velocity York 13210, USA. in the cavernosal arteries and elevated end-systolic Received 23 September 1998; accepted 20 October 1998 velocity >5cm=s for veno-occlusive disease. 84 mod ¯ow in pen and patie preo comb qua and especi tion- ang pude visi arter iliac the an End- etiol arter CDS, cluded an foll functi with CDS admini sagit pro Sous Patie Discussion (22 All Results wei giogra Patie 32 mete (20 noc cav unde MR (HJ, suspic used CDS 6 7 owing staglandin ernosal ± iography. -angiograp arterial tely ble ght turnal additional patie ile DH) and anatom erate perative ogy motio ies ies. 32 taly artifacts diastoli rs -Bois, nts. nts nts were out 35) ndal rwent arteries rev ination a unde in for however on phy ally ious stration were c max especi angiogr to in (Dotare m, ealed cm nts CDS and preoperat suspect in of CDS with 50 of Of signal pr n. DSA rwent venou in was not and intracaverno = rigi seven to insuf ior y imal the 12 a s addition France) demonst c pha erect s TR The these, with two planning is the in were Penile veloci hy ¯e ally afte of , (Table hav a sho dity su occlusi E1. patie aphy, m accepte to are ea perfor using of an rmacotest the 7.0, xible reception ed nine ®ciency s mean resol with 1 spected ile radiol the only pa c r rly CDS e ive wed in revascul out avernosogr , 0.2 ideal leakage 3D- . found interob two bolus ty, to rarectal nts add al TE rated pro ve La and the dys arterial 1). All med prox ution MRA. ve out ± Torso 3D-MR-ang CDS patien d have MRA-im ssels might measure ogists boratoire `road maxim of cav sal 2.1, 0.3 the as ximal itional patie pro screeni function Pe for ing failure in . MR arteriogen a injecti of imal imag in tumescen server 12 ernosom well. arization with mmol Four and nile sti patholog ximal during ang Flip an space In anatom cou ve 10 t pha and 12 surger nts (G have aphy 11 iography mulation al mapping as (#8) d pa no-occl penile this ing d ages K, ng oc pe and ld out an on). pa Flow- sed intr 40, CDS arter . out tients out in showed variat by Guerbet, iograph late clusive wel porti Gd- nile JD) . due replac method prior giograp with Drawbacks be tients. etry. y. pa y was ic ce cav Two avenou ical CDS, four 0.75 of pro were dist array of of ial Imaging l to Dota c tient, arterial demonst demonst usive of Comp arteries angiogr on ompared e ' ion, to penile and ernosom 12 as on rectile mo cedures low 12 12 response with ed al 3D- ¯ow y NEX, perfor of the out bowel were a uro suggest failure hy Pude = revas to ac co patien Aulna nitoring. kg s reduced ambig pa pa MR DSA acq inter sho mild 3D- ared MR-an- diseas arterial quired logists il penile H de® culariza bolus- (DS pha tients distal tients aphy. of of John rated rated para- 10 body from FOV uisi- ndal onl A med ade- MR- wed dys- was etry 3D- gas nal in- for ed ne A) is- 12 27 ts. m et in u- se in or tion to to y g e al Table 1 Clinical and imaging data of patients (n 12) with erectile dysfunction undergoing preoperative evaluation prior to revascularization procedure: Age, penile end-diastolic CDS-¯ow, cavernosography and assessment of Magnetic-Resonance (MR) angiography vs selective penile angiography (DSA) of internal iliac, pudendal and penile arteries. positive assessible, visible; negative not assessible, unenhanced CDS (systollc) CDS (diastolic) Internal Illac arteries Pudendal arteries Dorsal/deep penlle arteries peak ¯ow in end-diastolic Indication for dorsal velocitiy in dorsal Cavernosography revascularization Patient Age penile artery penile artery venous leackage MR DSA MR DSA MR DSA from MR alone 1 21 y 36 cm/s 3 cm/s not performed positive positive positive positive positive positive not possible 2 51 y 22 cm/s 2 cm/s not performed negative positive positive positive positive positive not possible 3 38 y 22 cm/s 6 cm/s none negative positive positive positive positive positive not possible 4 40 y 24 cm/s 4 cm/s not performed negative positive negative positive negative positive not possible 5 26 y 32 cm/s 2 cm/s not performed positive positive positive positive positive positive not possible 6 59 y 22 cm/s 4 cm/s not performed positive positive positive positive positive positive not possible 7 48 y 27 cm/s 3 m/s not performed positive positive negative positive negative positive not possible 8 23 y 28 cm/s 6 cm/s none positive positive positive positive positive positive possible 9 49 y 23 cm/s 8 cm/s mild positive positive negative positive negative positive not possible 10 49 y 29 cm/s 10 cm/s severe positive positive negative positive negative positive not possible 11 29 y 40 cm/s 2 cm/s not performed positive positive negative positive negative positive not possible 12 40 y 24 cm/s 3 cm/s not performed positive positive positive positive positive positive not possible Mean 39 (21 ± 59) y 27 (22 ± 40) cm/s 4 (2 ± 10) cm/s Total 10 out of 12 4 out of 12 suspected 2 out of 4 con®rmed 9 out of 12 12 out of 12 7 out of 12 12 out of 12 7 out of 12 12 out of 12 1 out of 12 suspected arteriogenic lesions venous leackages venous leackages positive positive positive positive positive positive possible MR angiography prior to penile revascularization H John et al 85 ity due to the variability in penile arterial anatomy muscle to intracavernous prostaglandin injection. and a variable relaxation of the cavernosal smooth Furthermore CDS is a functional, and not anatomic diagnostic tool.
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