833 - EMBOKARE
Watch Sex Matters, With Dr. Rachel Rubin to discuss "genitourinary syndrome of menopause" or GSM.
Suspect in middle age and older males where there is now poor response to phosphodiesterase-5 inhibitors and penile injection therapy. Risk factors include previous injury (e.g., associated with episodes of priapism), increasing age, diabetes, smoking, prostatectomy, pelvic radiation, and androgen deprivation therapy. The patient may be referred from an ED specialist already following a positive work-up for VOD.
Patient will first complete the International Index of Erectile Function (IIEF) questionnaire and undergo a physical exam.
If history, IIEF results, and PE are suggestive of VOD, the patient will then undergo a duplex ultrasound exam of the penile vasculature, under IV sedation if necessary. 15 minutes following an anterolateral intracavernosal injection of 10-20 micrograms of prostaglandin E1 (during the rigid phase), a Doppler flow analysis of the dorsal penile arteries is performed. If the peak systolic flow velocity is >25 cm/sec and there is a persistent end-diastolic velocity of >5 cm/sec with a resistive index of<0.75, then VOD is strongly suspected. If this is the case, then, under deeper sedation or general anesthesia, using local lidocaine anesthesia and ultrasound guidance, a micropuncture entry needle is directed into the deep dorsal penile vein. The0.018” guidewire of this kit is then directed cephalad into the internal pudendal, periprostatic or iliohypogastric vein in order to insert the 4Fsheath that is part of the kit. 2000 U of heparin and 2.5 mg of verapamil are injected through this sheath. Venography is performed through the sheath in order to define the venous drainage anatomy. 1-2 microcatheters are inserted over a 0.008”-0.010” guidewire into the target veins. Any collateral connections with the greater saphenous veins near the inguinal areas should be embolized with 1-2 fibered platinum coils (to avoid any non-target embolization of the femoral vein). Embolization of the of the right and left main draining veins is conducted through the microcatheters using a 1:2 mixture of NBCA + ethiodol. The microcatheter is rapidly removed and the opposite side is then catheterized and embolized through a second microcatheter. The 4F sheath is then removed and hemostasis is achieved with manual compression. The patient is awakened from anesthesia, and after a 2 hour observation period, the patient is sent home. We would expect mild-to-moderate post-embolization discomfort treated with ibuprofen or possibly Percocet for 3-4 days.
There is a 1-2% chance of complications such as NBCA pulmonary emboli (almost always asymptomatic) and nontarget femoral vein embolization.
Two-to-four weeks later, the patient has a follow-up visit where they complete a second IIEF questionnaire and undergo a PE.
