Angiographic Observations Derived From CT Cavernosography
James Trussler, MD, MS1, Diana Aponte-Colon, BA2, Mohanned Alnammi, MD1, Sebastian Flacke, MD1, Andrew McCullough, MD1.
1Lahey Hospital and Medical Center, Burlington, MA, 2Tufts University School of Medicine, Boston, MA.
BACKGROUND: Understanding penile arterial anatomy and its preservation is of interest to reconstructive and oncologic surgeons. Traditionally, the predominant cavernosal arterial supply is thought to be the cavernous artery (CA), originating from the internal pudendal artery (IPA). Penile duplex dopplers have demonstrated the existence of accessory cavernous arteries originating from the dorsal artery of the penis. Assessment of the arterial anatomy has been limited to imprecise doppler ultrasound and invasive fluoroscopic angiography. Herein we describe the ability of CTC to delineate heretofore undescribed arterial anatomy of the penis. We describe our observations on the importance of the contribution of the dorsal penile artery (DA) to the blood supply of the corpora cavernosa in men evaluated by CTC.
METHODS: CTC images were reviewed from a sequential cohort of men. Briefly, a maximal erection is induced by intracavernosal injection (ICI) and inflation with 50% iodinated contrast media. A CT scan of the pelvis is then obtained. Imaging was reviewed to delineate the arterial anatomy with respect to the CA and DA perforators distal to the pubic symphysis..
RESULTS: 14 men had imaging available for review collected between October 2019 and March 2020. The average age was 59.4 years and BMI 28.7; 7.1% of patients had cardiac disease or diabetes, while 14.2% had sleep apnea. Erectile dysfunction was the primary indication in 71.4%, 42.9% had comorbid penile curvature. 42% of men had an identifiable CA with a mean diameter of 1.95mm. 78.6% of men had at least one identifiable perforating branch of the dorsal artery into the cavernosum, the average count being 2.83 (range 0-6). The mean penetrating angle was 51.8°. The mean distance from the pubic symphysis to the first, second, and third perforating arteries was 2.22cm (range 0.3-7.3), 3.27cm (range 1.0-5.3), and 3.95cm (range 1.2-5.7), respectively, with a mean diameter of 1.76mm.
CONCLUSIONS: This is the first time that CTC has been used to describe variability in penile arterial anatomy. Our results suggest that most men with ED have multiple accessory arteries penetrating the cavernosa distal to the pubic symphysis. These arteries, in aggregate, may provide major blood flow to the cavernosa. The results of this study have implications for the reconstructive and oncologic surgeon where DA's originating from the accessory pudendal arteries may be sacrificed. Additionally, these results may call into question the predictive value of penile dopplers where the exact artery that is being measured is uncertain. Penile arterial anatomy is more diverse than previously reported. Based on our CTC study, the corpora cavernosa receive significant blood supply from the dorsal arteries Limitations of this study include small sample size, observational nature, and lack of normal controls.
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