Penile arterial revascularisation: inferior epigastric artery to the deep dorsal artery, end to side

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the nine steps, or use Back and Next. Watch the artery lift off the rectus, its branches clipped, the pedicle pass medial to the cord, the slit open between two clamps and the stitches go round. The triggers show no flow, a twisted pedicle, a nerve in the sling and a flushed glans.

Operative steps

1. Select the patient The operation is the selection. A young man with erectile dysfunction after pelvic or perineal trauma, no vascular risk factors, an isolated occlusion of the internal pudendal or common penile artery on pharmaco-arteriography, a patent inferior epigastric artery on the same study, and no veno-occlusive dysfunction on cavernosometry. Alternatives are discussed and recorded: oral therapy, intracavernosal injection, a penile prosthesis and, where the lesion suits it, endovascular treatment. This is not routine erectile dysfunction care.
   where it bites: a venous leak on cavernosometry is a contraindication; the operation revascularises an inflow lesion and nothing else.
2. Open the abdomen Supine, catheter in, the abdomen and genitalia prepped together. A lower midline incision from below the umbilicus to the pubis, the subcutaneous tissue divided, the rectus aponeurosis opened at the linea alba and the recti separated. The peritoneum stays closed. The left rectus is lifted superolaterally with padded retractors and the inferior epigastric neurovascular bundle lies on its posterior face.
   where it bites: the bundle is on the back of the muscle; a retractor placed under the muscle without looking tears it.
3. Harvest the donor Under loupes the inferior epigastric artery is dissected from its origin at the external iliac artery to the level of the umbilicus. Every side branch is clipped or tied and divided, never avulsed. Systemic heparin is given by the unit protocol, a microvascular clamp goes on the artery and it is divided at the umbilical level: a live pedicle on its own iliac origin, with its vein kept where it helps.
   where it bites: the origin from the external iliac is the one thing that cannot be re-made; branches are clipped, not torn, because a torn branch bleeds into the pedicle wall.
4. Expose the recipient A separate dorsal incision at the base of the penis is carried through dartos and Buck's fascia with the fundiform and suspensory ligaments preserved; a self-retaining retractor sets the field. The dorsal neurovascular bundle is identified and the left deep dorsal artery is isolated and circumferentially mobilised for a working length, the deep dorsal vein and the dorsal nerves held aside and untouched.
   where it bites: the dorsal nerves lie lateral to the arteries; a sling that takes the nerve costs sensation, and decreased sensation is a listed complication of this operation.
5. Route the pedicle A long curved clamp passes from the penile incision up the subcutaneous plane to the floor of the ipsilateral inguinal canal, medial to the spermatic cord, and the harvested artery is drawn down through the canal floor and the tunnel into the penile incision. The pedicle is laid flat and checked along its whole length: no twist, no kink, no tension, and the cord not caught.
   where it bites: a twist in the tunnel is invisible once the skin is closed and thromboses after release; the marker stripe is checked at the ring and at the root before the microscope comes in.
6. Prepare the joint The operating microscope is draped and brought in. Two microvascular clamps go on the deep dorsal artery clear of the nerve and a short arteriotomy is made on its anterior wall between them. Topical papaverine is applied to both vessels and good flow from the donor is confirmed before it is trimmed to lie on the arteriotomy without tension.
   where it bites: spasm at this stage looks like a bad donor; vasodilator and patience before any decision to abandon.
7. End-to-side anastomosis The inferior epigastric artery is joined end to side to the deep dorsal artery with fine monofilament, as interrupted sutures or two running halves. Heel and toe first, then the far wall in sequence, the vessel turned, and the near wall; every bite full thickness and the back wall never caught. The donor meets the recipient at an acute angle.
   where it bites: a back-wall stitch closes the lumen; a bite that misses the intima lifts a flap that thromboses.
8. Release and check All three clamps come off in order and the suture line is watched: a pulse that passes the joint and runs down the dorsal artery, no bleeding beyond what pressure settles. Patency is confirmed with a Doppler on the distal artery. No flow is a technical fault at the joint or in the route until proven otherwise.
   where it bites: bleeding at the suture line is answered with pressure and time, then a single extra stitch; never with a clamp left on.
9. Close Both incisions irrigated and haemostasis confirmed before the retractors come out. Dartos and the penile skin closed, then the rectus muscles, the aponeurosis, Scarpa's fascia and the skin of the abdominal wound, with the pedicle never compressed by any layer. Adhesive strips and a gauze dressing on both wounds; counts correct.
   where it bites: a tight closure at the ring or at the root is a second tunnel: the pedicle is checked again after every layer.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topics Erectile dysfunction and Andrology. Not a workplace-based assessment and not evidence of competence.