Potential curative treatment of erectile dysfunction is available to a select population of patients. Arterial revascularization or venous surgery offers patients the possibility of restoration of normal erectile function without the necessity of medications, injections, or devices. Penile arterial bypass surgery was first described in the early 1970s (106, 107) and has undergone many modifications since its early description. Penile arterial insufficiency is most frequently the result of general arteriosclerosis as seen in other medical conditions with similar risk factors of hypercholesterolemia, hypertension, cigarette smoking, and diabetes mellitus.

Penile arterial insufficiency is diagnosed by performing an intracavernous injection test followed by self stimulation (audiovisual or manual) (108). Duplex ultrasonography of the penis performed during injection and stimulation test can help delineate echogenicity of corporal tissues, peak flow velocity of cavernosal arteries, thickness of tunica albuginea and cavernosal arteries, diameter and wave form of arteries. Once the diagnosis of pure arterial insufficiency has been confirmed, selective penile/pudendal arteriogram is necessary to identify penile vascular anatomy, demonstrate communication between cavernosal and dorsal arteries, confirm location of obstructive/traumatized arterial lesion, and plan surgical reconstruction.

Several techniques of revascularization have been described (109-112). Current approaches use the technique whereby the epigastric artery is anastamosed to the dorsal penile artery (revascularization) or the deep dorsal vein (arterialization). Long term results of these patients have been disappointing with an efficacy of 30-50% in well selected patients, but, with increasing accuracy of diagnostic modalities, improved operative techniques, and a narrowed selection criteria, long term results have significantly improved to greater than 60% (109, 113, 114). Young men with arterial insufficiency secondary to pelvic trauma are the ideal patients for this procedure (115). Recently, laparoscopy has been used to minimize the morbidity of the procedure (116). Overall long-term success in appropriately selected patients range from 34-80% spontaneous erections (109, 117). The most frequent side effect with penile arterialization has been hyperemia of the glans. This can occur in up to 13% of patients who have undergone epigastric artery-deep dorsal vein anastomosis. Other complications include infection, hematoma, and thrombosis of anastamosis.