Surgical Management of Ischemic Priapism

Abstract

Introduction Surgery is a mainstay in the management of ischemic priapism. The surgical armamentarium for this condition has recently been expanded with the introduction of several innovative procedures. Aim To review surgical procedures offered in the treatment of ischemic priapism and present a rational framework for their use. Methods Medline searches through July 2010 were conducted using the terms priapism, surgery, shunt, and prosthesis. Main Outcome Measure Expert opinion was based on review of the medical literature related to this subject matter. Results A host of surgical procedures exist to address the genital complications of both acute presentations of ischemic priapism and its non-acute pathologic sequelae, which include penile deformities and erectile dysfunction. For the former, the intervention is used principally in an emergent context with the intention to relieve the acute pathologic effects of the condition and preserve erectile function. For the latter, the intervention is aimed generally toward restoring anatomic normalcy and the functional ability to perform sexual intercourse. A rational framework for surgical management, based on the circumstances of the clinical presentation, is described. Conclusions The surgical management for ischemic priapism has evolved with the application of a host of surgical procedures. These procedures address acute and non-acute genital complications of the condition and are intended to retain or restore sexual ability effectively and safely. They can be applied using a rational clinical management framework.

Ischaemic priapism: A clinical review

“…[6,35] Some research has suggested that even though priapism may be resolved by more conservative treatments, after 24 hours of duration histological changes, like interstitial oedema, have begun to occur and there has been a loss of erectile function. [36] After 48 hours, smooth muscle necrosis begins and it has been suggested by Zacharakis et al [37] that the best course of action after this time is to insert a penile prosthesis to maintain erectile function.…”

“…Early insertion has been found to be procedurally easier than delayed insertion as delayed insertion allows further fibrosis to take place. [2,35] Further advantages include reduced major scarring, lower risks of complications (e.g. infection or urethral injury) and less penile shortening.…”

Urethrocutaneous fistula post-Al-Ghorab shunt

“…All the surgical approaches employed in the early management of priapism aim to preserve the erectile function, evaluating the risk of early and late complications. 6 Surgical complications are unusual, and fistula occurrences after a cavernospongiosal shunt procedure are even more uncommon. El-Bahnasawy and colleagues 7 included 50 patients with a diagnosis of ischemic priapism in a study and only 1 patient evolved to urethro-cutaneous fistula.…”

Resistant pediatric priapism: A real challenge for the urologist

“…The shunt surgeries provide an opening in the tunica albuginea of the cavernosal body and corpus spongiosum or a vein for blood drainage. 8 These shunt surgeries may be grouped as percutaneous and open distal shunts, open proximal shunts and vein anastomoses. 9 Distal Winter shunt is one of the least successful shunt operations, but it is relatively easy to perform with no sequel after the surgery.…”

“…11 Sacher's and Quackle's shunts are open proximal shunts, which should be considered after distal shunts and which can be performed with higher rates of complications. 8 Selective arterial embolization is usually preserved for arterial priapism. Success rates (89%) are reported in small studies.…”