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Reversal of BPH by Super-selective Intraprostatic Androgen Deprivation Therapy
Figure 1: Anatomy (Left Side) of the Testicular and Figure 2: Anatomy of Testicular and Prostatic Venous
Prostatic Venous Drainage Systems Under Drainage Systems After Destruction of One-way
Normal Conditions Valves in Internal Spermatic Veins
Renal vein K
RV
K
ISV
(to right
0mmHg
testis)
(-5/+5)
Right ISV Left ISV
IVC

ISV (left)
Inferior
ISV
40cm 35cm
vena cava
V
35cm 40cm
CI
CI
CI
Int. I
Int. I Int. I
6mmHg
+27mmHg
VV
+32mmHg
VP DV
CV
CV VV
6mmHg
VV
6mmHg
CV
PP
PP
PP
P
DV
DV
SV
SV
P
SV
PVP
VP
PVP
T
T
TA T
TA
Left testis
Right Left
The testes and the prostate share a common drainage venous flow: vesicular vein (VV),
internal iliac vein (IIV), common iliac vein (CIV) and inferior vena cava (IVC). Since no one-way
Loss of one-way valves in the internal spermatic vein (ISV) causes increased hydrostatic
valves exist between the testicular and prostatic drainage systems, and the hydrostatic
pressures in the testicular drainage system nearly six times above the pressures in the
pressure is equal, venous blood from both arrives at a common vessel – VV – at
prostate venous drainage system and loss of mechanism directing venous blood upwards in
approximately 6mmHg, and blood arriving from both sides flows jointly towards IIV, CIV and
ISVs. Deferential veins (DVs) become an alternative route for testicular venous drainage,
IVC. CI = common iliac; CV = cremasteric vein; DV = deferential vein; Int.I = internal iliac;
carrying high concentrations of free testosterone (FT) under elevated hydrostatic pressure
ISV = internal spermatic; IVC = inferior vena cava; K = kidney; P = prostate; PP = pampiniform
(about six times normal). According to the principle of communicating vessels (Bernoulli),
plexus; PVP = prostatic venous plexus (Santorini); RV = renal vein; SV = scrotal vein; T = testis;
since pressure at the testicular side is higher than at the prostate side, testicular venous
V = one-way valve; VP = vesicular plexus.
blood will flow into the prostate venous drainage (from high to low pressure) via the
vesicular plexus (VP) and prostatic venous plexus (PVP) to the prostate gland. Consequently,
Fluid Mechanics Analysis of the FT arrives at the prostate not only physiologically via the prostate artery but mainly via the
Testicular Venous Drainage System
prostate venous drainage system (the ‘back door’), carrying undiluted and yet unbound to
sex-hormone-binding globulin (SHBG) and high concentrations of FT, which bypasses the
Without competent OWVs the ISVs cease to function as drainage systemic circulation and is not detected in the peripheral blood.
systems and become passive vessels. Each ISV then contains a vertical
blood column that produces elevated hydrostatic pressure in the varicocele treatment was originally developed by Comhaire and
testicular venous drainage system, found to be approximately six to Kunnen
16
for the treatment of varicocele in male infertility and has been
eight times normal. Note that the pressure in this system depends only modified and further perfected specifically as the Gat–Goren
on the height of the vertical blood column and not on the diameter of technique
17
for treatment of impaired venous drainage apparatus in the
the blood vessel (see Equation 1).
9,10
This pathologically elevated male reproductive system, including all vertical venous bypasses and
hydrostatic pressure causes persistent hypoxia in the testicular collaterals, bilaterally.
11,17
The mechanisms leading to BPH are explained
microcirculation, leading to deterioration in spermatogenesis
11
followed below in some detail.
by a reduction in testosterone production.
12,13
Each ISV is associated
with a network of small bypasses and retroperitoneal collaterals Flow in the Testicular and Prostate Venous
produced in the course of the disease, and each of these, when Drainage Systems in Normal Conditions and
vertically orientated, results in similar pathological hydrostatic pressure After Destruction of One-way Valves
in the pampiniform plexus (PP).
14,15
Hence, effective treatment of Normally, as seen in Figure 1, the prostatic venous drainage flows in
varicocele must include the occlusion of the ISVs on both sides and of part through the prostatic venous plexus (PVP), the vesicular vein
all the associated vertical venous bypasses and the retroperitoneal (VV), the internal iliac vein (II), the common iliac vein (CI) and,
collaterals by microsurgery or by super-selective retrograde ultimately, to the inferior vena cava (IVC). The testes are drained
venographic techniques.
11
The technique for percutaneous transvenous mainly via the ISVs, with some participation by three other vessels:
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