Surgical therapy is an important part of the urologists' arsenal in the treatment of medically refractory ED. With advances in basic science research, newer pharmacological therapies and potentially future genetic therapy will slowly decrease the indications of surgical therapy. Historically, surgical therapy to treat the flaccid penis did not begin until the turn of the twentieth century. Extraordinarily, similar procedures are still being practiced today. Wooten in 1902 described the ligation of the dorsal vein of the penis as a method for restoring erections (101). Penile prosthesis surgery was described in the early 1930s. (102) The superficially placed rigid prosthesis made from synthetic material soon followed.(103) It was not until the early seventies that satisfactory results were seen with the introduction of modern prosthetic devices which fit into the corpora cavernosa and provided both good functional as well as cosmetic results(102, 104, 105).

Penile arterial bypass surgery was first reported in the early seventies as a treatment for erectile dysfunction with many variations in technique existing in the literature. Finally, venous leak surgery was re-introduced in the early eighties to treat corporal veno-occlusive dysfunction. To this day, prosthesis surgery is considered the standard surgical treatment of erectile dysfunction except in a judiciously selected group of patients, which can be offered curative vascular surgical repair.

Young patients with congenital or traumatically acquired ED may be candidates for curative surgical therapy (arterial bypass or venous surgery). Patients with generalized penile disease should be offered prosthesis surgery. Indications for prosthesis surgery include: patients with a poor response to non-surgical therapies; inappropriate candidates for vascular surgery including generalized arterial disease, old age, heavy smokers, drug abusers, and chronic systemic disease. Patients that decline vascular surgery (arterial and venous) or decline to use non-surgical therapies can also be considered for prosthesis surgery after receiving appropriate counselling and detailed informed consent.

Patients considering vascular surgery require a detailed evaluation of their pelvic and perineal vasculature. Arteriogenic erectile dysfunction is the inability to produce adequate arterial inflow to the cavernosa to achieve an erect state, while venogenic erectile dysfunction is the inability to achieve or maintain erection due to inability to store blood within the corpora cavernosa. Arterial insufficiency can be the result of trauma to the perineum, congenital anomalies (rare), and long-standing systemic disease (hypercholesterolemia, atherosclerosis, diabeties mellitus). The various causes of veno-occlusive dysfunction have been broadly categorized into the following: ectopic veins, abnormalities of the tunica albuginea (e.g. Peyronie's disease), abnormalities of the cavernosal smooth muscle leading to inadequate relaxation (fibrosis secondary to priapism, aging), inadequate neurotransmitter release, and an abnormal communication between the corpus cavernosum and spongiosum or glans penis secondary to trauma or a surgical shunt procedure to treat priapism.