11
ESSM
Today
Key from Kols: Priapism
insertion into the shaft at the 2 or 10 o clock
position avoiding the neurovascular bundles
which can be performed under local or general
anaesthetic followed by repeated instillations of
α
-adrenergic agonists such as phenylephrine
(usually 200μg repeated to a maximum of
1500μg) in an attempt to increase the smooth
muscle tone and promote detumescence. Alter-
native
α
-adrenergic agonists include metara-
minol and adrenaline. High dose phenylephrine
has also been successfully utilised in small case
series (16) although in refractory cases it is un-
likely to be successful due to irreversible smooth
muscle dysfunction (17). Aspiration of ischaemic
blood alone may resolve the ischemic priapism
in up to one third of cases and therefore should
always be attempted, before injecting the phe-
nylephrine as the smooth muscle contraction is
impaired in an ischaemic microenvironment (18).
Treatment with phenylephrine should be per-
formed with continuous monitoring of the blood
pressure, especially in patients with hypertension
or cardiovascular disease, as phenylephrine has
a ionotropic and chronotropic effects and may
potentially precipitate a vascular event.
Although corporal blood aspiration and instillation
of
α
-adrenergic agonists should be performed in
all patients, irrespective of the time of presenta-
tion, priapism episodes lasting more than 24–36
hours are unlikely to respond to this intervention
per se due to the presence of irreversible dam-
age to the cavernosal smooth muscle. However,
aspiration of the corpora cavernosa and instilla-
tion of phenylephrine can lead to detumescence
in up to 100% of cases, if performed within
12 hours from the onset of priapism (19).
2) Shunt surgery
Patients who do not respond to aspiration and in-
stillation of
α
-adrenergic agonists undergo penile
shunt surgery as second line intervention. The
basis of the shunt surgery consists of a fistula
formation between the corpus cavernosum and
the glans penis, corpus spongiosum or the sa-
phenous vein. The aim of any of these surgical
techniques is to decompress the corpora caver-
nosum of the veno occlusion and re-establishes
the arterial inflow with a resultant complete flac-
cidity after the shunting procedure (20).
The Winter and Ebbehoj shunts are the most
widely used minimally invasive distal percutane-
ous shunts. The Winter shunt, characterized by
the placement of a large-bore needle into the
distal glans and corpus cavernosum is the less
invasive technique but is associated with higher
failure rate. The Ebbehoj technique consists of a
simple stab incision with a No 10 scalpel into the
corpora cavernosa through the distal aspect of
the glans penis. In case of failure of percutane-
ous shunt surgery, an Al-Ghorab shunt, which
is an open corporoglanular shunt involving the
excision of a segment of tunica albuginea at the
tip of the corpora (21).
Some authors have described a new shunt tech-
nique, which involves the creation of a wide con-
nection between the distal corpora and glans
penis. This technique, also known as the T-shunt,
involves the insertion of a No 10 blade through
the glans penis into the ipsilateral corpus caver-
nosum and then rotated of 90 degrees laterally,
away from the urethra, and pulled out, to create
a large fistula (Fig 2) (22).
The procedure can be repeated on the contralat-
eral side if detumescence is not achieved (TT
shunt procedure). In case of TT shunt failure, a
tunnelling manoeuvre should be attempted with
the aim to allow the blood to be drained from the
proximal aspect of the corpora cavernosa. This
procedure, also known as the corporal snake
manouvre, inserts of a 20 – 22 French urethral
sound through the previous T- or Al-Ghorab
shunt (Fig 3) (23, 24).
Initial reports considered the combination of a
distal shunt with the tunnelling manoeuvre a safe
technique, which allowed the resolution of the
priapism episode in almost all cases and excel-
lent recovery of erectile function (22).
However, a recent series of 45 patients has
shown that the success of T shunt and tunnel-
ling manoeuvre is dependent on the duration of
priapism. In particular, if carried out within 24
hours from the onset of priapism, this manoeuvre
allows the resolution of the priapism episode in
almost all cases, but long term refractory erectile
dysfunction is still present in 50% of patients
(Table 1). The outcome is even more dissatisfac-
tory if the duration of priapism is greater than 48
hours as the manoeuvre always fails to resolve
the priapism episode and all of the patients de-
velop refractory erectile dysfunction (25).
3) Penile prosthesis implantation
Penile prosthesis implantation, which is the
gold standard treatment in patients who have
developed severe erectile dysfunction as a
result of prolonged priapism, has in the last
decade offered an alternative option to shunt
surgery for the management of refractory
ischaemic priapism. Acute implantation of a
penile prosthesis in patients with refractory is-
chaemic priapism is now proposed by a number
of institutions (26 – 28).
In particular, patients with ischaemic priapism
>48 – 72 hrs, unresponsive to the initial man-
agement with blood aspiration and intracorporal
instillation of
α
-adrenergic agonists, are likely
to develop irreversible damage of the cavern-
osal smooth muscle, which will lead to fibrosis,
penile shortening and refractory erectile dys-
function. Therefore, immediate penile prosthesis
implantation in these patients can resolve the
painful erection, guarantee the adequate long
term rigidity for sexual penetration and prevent
the otherwise inevitable penile shortening (29).
In fact, immediate penile prosthesis implantation
in patients with prolonged iscaemic priapism
and cavernosal smooth muscle necrosis reduces
the painful priapic episode, guarantees the ad-
equate long term rigidity necessary for sexual
intercourse and prevents the otherwise inevitable
penile shortening secondary to the development
of corporal fibrosis.
Potential overtreatment of patients with no
evidence of necrosis in the cavernosal smooth
muscle is one of the risks associatied with this ap-
proach and therefore the correct timing of surgery
