Treatment of Neurogenic Erectile Dysfunction with Genitofemoral Nerve Transfer
Eric G Wimmers, MD, Department of Plastic and Reconstructive Surgery, The Institute for Advanced Reconstruction, Shrewsbury, NJ and Andrew Elkwood, MD, The Institute for Advanced Reconstruction, Shrewsbury, NJ
Male sexual arousal is a complex process that involves psychogenic, hormonogenic, reflexogenic, vasculogenic, and neurogenic processes. We performed a novel technique of genitofemoral nerve transfer to restore cavernous nerve function in patients with neurogenic causes of erectile dysfunction (ED). Typical causes of neurogenic ED include prostatectomy, prostate radiation, pelvic surgery, pelvic trauma and diabetes. The genitofemoral nerve was chosen as the ideal candidate for nerve transfer due to its proximity, as well as mixed-autonomic nerve function which includes the synergistic function of the cremasteric reflex.
Materials & Methods
Multiple cadaver surgeries confirmed the anatomic feasibility of transferring the genital branch of the genitofemoral nerve to the cavernous nerve, though an extra-pelvic approach. The first two patients who qualified for the procedure had respective etiologies of pelvic trauma and complications from prostate biopsy. Pre-operative and frequent post-operative International Index of Erectile Function (IIEF-5) scores were obtained, as well as detailed reports of nocturnal, morning, spontaneous, and chemically-induced erections were recorded. Objective evaluation included pre-op and 1-year-post-op penile duplex with Caverject injection. Intra-operative EMG confirmed presence of multiple genital branches of the genitofemoral nerve on each side of the scrotum. Cavernous nerves were identified at the base of the penis under the pelvic brim. Bilateral genitofemoral nerves were tunneled deep in subcutaneous tissue between the external inguinal ring and base of penis. End-to-side neurorrhaphy was performed with operating microscope.
The two patients demonstrated respective increases of 116% and 180% at the 1-year follow-up IIEF-5. Subjectively, they were both able to achieve complete erections, enough for satisfactory intercourse. There were also progressive increased reports of nocturnal and morning erections starting at 3 months post-op, indicative of restored autonomic nerve function. Penile duplex demonstrated significant changes 1-year post nerve transfer. Both patients, pre-operatively, had normal arterial inflow, and venous insufficiency which improved with nerve transfer. Following Caverject injection, there was a 133% and 13% increase, respectively, in arterial velocity compared to pre-op duplex. In addition, the venous insufficiency was corrected with 44% and 46% reduction in venous leak, respectively.
Correction of neurogenic causes of ED is possible by utilizing genitofemoral nerve transfer to the cavernous nerve, as demonstrated by significant increase in IIEF-5 scores, subjective reports, and improved penile duplex studies. The cavernous nerves control the inflow & outflow to the corpus cavernosum; as demonstrated in this study, reversal of venous insufficiency may be possible with genitofemoral nerve transfer.
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