Some reports have questioned the possible benefits from this type of vascular surgery. The number of questions remain unanswered. Nevertheless, longterm success rates of 50 to 60 percent have been reported for penile revascularization and are considered by some to be less than optimal. Patients who end up with a combination of arterial and veno-occlusive disease should be offered alternative choices, such as vacuum constriction devices, penile implants and, in more milder cases, vasoactive intracorporal injections. My experience is that the DICC studies should be done in the labs of the surgeons best capable of doing the surgery and limited to those referral centers. Also, the second phase studies of Goldstein's dynamic infusion cavernosometry and cavernosography (DICC) should demonstrate functional arterial or venous disease. Color duplex doplar sonographic studies should be done before considering pudendal arteriography. They are very good at their specialty, and the rest of us are not, so patients who need this type of treatment should probably be referred to one of five or six urologists in the country who are doing this type of procedure on a relatively larger volume than anyone else.

In each region of the United States there are outstanding urologists who are dedicated to vascular microsurgical techniques. Practically no other patients will be. Such a patient may be a candidate for penile revascularization procedures. This will usually be a younger patient with a history of trauma, no history of diabetes, no history of smoking, and no history of any other underlying diseases such as systemic arteriosclerosis or veno-occlusive dysfunction.

Occasionally, a male patient's invasive x-rays (arteriogram) will reveal an isolated lesion on the pudendal artery in the pelvis. Again, I want to stress that only rarely is an erectile dysfunction patient a candidate for even the specialized vascular testing that is available. Several urological surgeons have contributed greatly to the development of surgical techniques for these vascular procedures, which are described in detail in medical literature that is widely read within urological specialties but does not need to be reviewed here." Vascular surgery is a rarely needed or used treatment for erectile dysfunction but can be divided into two major areas: arterial revascularization of the penis, essentially repairing damaged vessels bringing blood into the penis; and surgery for veno-occlusive disorder, essentially correcting problems with the mechanics which clamp down on blood outflow. The young single male will have a much more difficult time explaining to his partner why he has to use the "mechanical oral sex device," as it was described by one patient. The device may also be used successfully with men who have a malfunctioning penile implant in place.°; The vacuum constriction device is much more acceptable to older males in a steady relationship than to the young single man. In those men, combining intracavernous injection with the vacuum erection device may enhance the erection.