Variations in the Arterial Blood Supply to the Penis and the Accessory Pudendal Artery: A Meta-Analysis and Review of Implications in Radical Prostatectomy

Purpose: The aim of this meta-analysis was to analyze the available literature and provide comprehensive data on the prevalence and variations of the accessory pudendal artery and the 3 types of penile blood supply, including type 1-internal pudendal artery only, type 2-internal pudendal artery and accessory pudendal artery, and type 3-accessory pudendal artery only. Materials and Methods: We performed an extensive search of the major databases and identified 23 studies in a total of 4,945 patients suitable for inclusion in this meta-analysis. Studies eligible for inclusion included cadaveric, imaging or intraoperative studies. Extracted data were pooled into a meta-analysis with a random effects model using MetaXL, version 5.0 (EpiGear International, Sunrise Beach, Queensland, Australia). The chi-square test and Higgins I 2 statistics were used to assess heterogeneity among included studies. Results: Our findings revealed that the most common type was type 1 with a pooled prevalence estimate of 61.9%, followed by types 2 and 3 with a pooled prevalence estimate of 32.8% and 5.4%, respectively. In our analysis of the accessory pudendal artery the vessel was present in 28.5% of patients. When present, unilateral accessory pudendal arteries were most common (pooled prevalence estimate 72.5%) or they were present on the right or the left side (pooled prevalence estimate 48.0% or 52.0%, respectively). They most commonly originated from the obturator artery and the inferior vesical artery (pooled prevalence estimate 48.9% and 29.6%, respectively). The most common type was apical accessory pudendal arteries (pooled prevalence estimate 60.9%). Conclusions: A penile blood supply originating at least in part from an accessory pudendal artery represents more than a third of cases. Based on the anatomical findings when an accessory pudendal artery is present, we advocate attempted preservation of the vessel during radical prostatectomy to best maintain the penile arterial blood supply, especially in patients with type 3 or inolder patients with type 2.