What investigations are recommended for a patient planned for penile artery grafting (PAG) plus plasty?

Preoperative Investigations for Penile Artery Grafting (PAG) + Plasty

For patients planned for penile artery grafting with plasty, you must obtain comprehensive vascular imaging with penile duplex Doppler ultrasound to document focal arterial occlusive disease, exclude generalized vascular disease, and confirm intact venous occlusive function, along with baseline cardiovascular risk assessment and hormonal evaluation. 1

Essential Vascular Studies

Penile Duplex Doppler Ultrasound

• Mandatory preoperative assessment to document the presence and location of focal arterial occlusive disease in the penile vasculature 1
• Must demonstrate focal arterial occlusion rather than diffuse vascular disease, as only patients with isolated arterial lesions are appropriate surgical candidates 1
• Evaluate peak systolic velocities in the cavernosal arteries, dorsal arteries, and external pudendal system to map perfusion territories 2
• Critical pitfall: Failing to use Doppler assessment to evaluate vascular complications is a common error 3

Cavernosometry Assessment

• Perform preoperative cavernosometry to assess venous occlusive function and exclude venous leak 4, 5, 6
• Document that the patient can generate adequate intracavernosal pressure for rigid erections 6
• Patients with documented venous leak have significantly worse outcomes and should be counseled against arterial reconstruction 5

Baseline Erectile Function Documentation

Objective Erectile Assessment

• Nocturnal penile tumescence testing (RigiScan) for 3 consecutive nights to document baseline erectile rigidity 6
• Must demonstrate at least one erection nightly with base and tip rigidity greater than 60% and duration of at least 10 minutes 6
• Absence of base-tip discrepancies is required to confirm adequate distal perfusion 6

Validated Questionnaires

• Complete International Index of Erectile Function (IIEF) questionnaire preoperatively to establish baseline erectile function domain scores 5
• This provides objective comparison for postoperative outcomes at 6-month follow-up 5

Cardiovascular and Metabolic Screening

Mandatory Laboratory Tests

• Morning serum total testosterone measurement to identify hypogonadism 7
• Fasting glucose or HbA1c to screen for diabetes, which may present first as erectile dysfunction 7
• Fasting lipid profile to evaluate cardiovascular risk factors 7
• Blood pressure measurement as part of cardiovascular assessment 1

Exclusion of Generalized Vascular Disease

• The surgical candidate must be otherwise healthy with no evidence of generalized vascular disease 1
• Screen for risk factors including smoking, diabetes, hypertension, and hyperlipidemia that suggest diffuse vasculopathy 1
• Patients with multiple cardiovascular risk factors are not appropriate candidates for arterial reconstruction 1

Physical Examination Requirements

Penile and Genital Assessment

• Detailed physical examination of the penis and external genitalia, recording morphology, size, and location of any lesions 1
• Check for abnormalities in testicular size, fibrosis in the penile shaft, and retractable foreskin 1
• Document penile length at baseline for postoperative comparison 6

Vascular Examination

• Assess peripheral pulses and signs of peripheral vascular disease 1
• Examine for evidence of atherosclerotic disease in other vascular beds 1

Patient Selection Criteria Documentation

Age and Disease Characteristics

• Ideal candidate is 55 years old or younger with recently acquired erectile dysfunction 1
• Document recent onset of symptoms (not chronic, long-standing dysfunction) to exclude cavernous myopathy from chronic ischemia 1
• Confirm failure of medical therapy with PDE5 inhibitors before considering surgical intervention 1

Critical Exclusion Criteria

• Patients with diffuse vascular disease are not candidates 1
• Those with chronic ischemia leading to cavernous myopathy should be excluded 1
• Presence of venous leak on cavernosometry predicts poor outcomes 5

Additional Imaging When Indicated

Advanced Vascular Imaging

• Consider MRI of the penis if there is uncertainty regarding vascular anatomy or the feasibility of arterial reconstruction 1
• Ultrasound serves as an alternative if MRI is not available 1

Common Pitfalls to Avoid

• Do not proceed without documenting focal arterial disease: Patients with diffuse atherosclerosis have poor outcomes 1
• Do not ignore venous leak: Baseline venous insufficiency predicts postoperative erectile dysfunction 5
• Do not operate on older patients with multiple risk factors: Age and cardiovascular comorbidities significantly worsen outcomes 5
• Do not skip nocturnal tumescence testing: This objective measure confirms baseline erectile capacity independent of psychological factors 6