Endovascular treatment of recurrent erectile dysfunction due to venous occlusive disease

of the internal pudendal veins without the possibility of embolizing the external pudendal vein, the periprostatic venous plexus, and the DDV. In fact, many papers were published referring to the embolization techniques of the deep dorsal vein and the related efferents (internal and external pudendal veins and the periprostatic venous plexus).8,9 At our institution, we developed a minimally invasive technique with an anterograde approach of the DDV under US-guided puncture.10 Subsequently, we performed the selective catheterization and embolization under fluoroscopic guidance of the periprostatic plexus and both the internal and external pudendal veins, using N-butyl-2-cyanoacrylate (NBCA). We are convinced that this approach Dear Editor, We have read with great interest the excellent review by Kim et al.1 which reports the tools available in interventional radiology (IR) to face the frustrating problem of impotence. The social and psychological implication of this pathology drove the effort of scientific medicine searching for a solution for centuries.2 As known, the etiology of vasculogenic Erectile Dysfunction (ED) is complex and multifactorial providing either arterial or venous dysfunction, and the precise interplay of all physiologic mechanisms involved is not completely understood. Vasculogenic ED offers the opportunity to exploit modern IR techniques restoring compromised arterial inflow in case of artery insufficiency or reducing venous outflow in case of veno-occlusive dysfunction (VOD). The paper exhaustively reports the state-of-the art on this topic discussing endovascular embolization techniques and the inherent limitations. The ZEN (Zotarolimus-Eluting Peripheral Stent System for the Treatment of Erectile Dysfunction in Males with Suboptimal Response to PDE5 Inhibitors) trial well represents a modern option to treat the inadequate arterial inflow to corpora cavernosa.3 However, normal pelvic vascular anatomy and the correlation between the pelvic arterial disease and the ED are still not clear, and further studies are necessary to better define the role of pudendal stenting.1 The physiology of VOD was demonstrated in the 1970s;4 patients suffering of ED due to VOD, usually have damage to the corporeal smooth musculature or the tunica albuginea, or both, which results in impairments of vascular dilation. Hence, penis veins were the subject of medical and nonmedical therapies for centuries as the “penile ring” system could prove.5 Concerning the VOD and the penis deep dorsal vein (DDV), the option of surgical ligation, although developed some decades ago, was improved in the last years with encouraging outcomes.6 Kim et al.1 clearly underline the role of the embolization techniques and their limitations dealing with VOD. The authors report the work of Aschenbach et al.7 which obtained an 88.8% clinical success rate after endovascular internal pudendal vein embolization therapy with histoacryl-lipiodol using a trans-femoral approach. The retrograde approach of the technique requires a bilateral selective catheterization LETTER TO THE EDITOR