Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment İschemic Priapism: A Single-Center Experience

Abstract

Background Ischemic priapism (IP) is a urologic emergency that requires early intervention. The main aim of IP treatment is to relieve the cavernosal pressure and provide erectile function. Aim The aim of this study was to determine the correlation between preoperative risk factors (patient’s age, duration of priapism, preoperative erectile function) and postoperative erectile dysfunction (ED). Methods This retrospective study consisted of 25 patients diagnosed with refractory IP between 2009–2017. The diagnosis of IP was confirmed by medical history, physical examination, and cavernosal blood gas analysis. All of the patients underwent the T-shunt procedure ± tunneling after a failed initial intervention. Results The mean age at the time of the IP diagnosis was 46.84 years (range 23–77). The average follow-up time of the study population was 40.4 months (range 3–114), and the median time from the occurrence of IP to surgery was 58 hours (range 24–240). In all cases, rapid resolution of the erection was achieved with the T-shunt ± tunneling procedure. In 1 patient, priapism recurred after 12 hours. Postoperative ED was reported by 16 (84.21%) patients, with degrees of mild, mild to moderate, and severe in 6, 1, and 9 of these cases, respectively. During the follow-up, the mean International Index of Erectile Function–5 (IIEF-5) score was 12.68 (range 5–23). Only 3 (15.78%) patients achieved successful sexual intercourse without any treatment. 6 (31.5%) patients required the aid of phosphodiesterase type 5 inhibitors, and 1 (5.26%) patient required the aid of a vacuum erection device. The 9 (47.36%) patients with severe ED failed to respond to medical treatment and were considered candidates for a penile implant. According to Kendall’s tau-b correlation coefficient analysis, there was a positive correlation between the preoperative and postoperative IIEF-5 scores (P = .005), whereas the patient’s age and duration of priapism were negatively correlated with the postoperative IIEF-5 score (P = .016 and P = .046, respectively). Clinical Implications Treatment options of IP should be discussed with patients in terms of both preoperative erectile function and the duration of priapism. Strengths & Limitations The small sample size and retrospective nature of this study were the main limitations. Conclusions Despite high success and low complication rates of T-shunt surgery, the rate of undisturbed erectile function is only 14.6%. The patient’s age, the existence of preoperative ED, and the duration of priapism are associated with postoperative IIEF-5 scores.

Platelet volume parameters as a tool in the evaluation of acute ischemic priapism in patients with sickle cell anemia

“…In patients with priapism < 12 hours, interstitial edema and minor endothelial defects predominate in the smooth muscle. On the contrary, extensive necrosis of the smooth muscle cells was detected after priapism lasting > 48 hours (28,29). Moreover, the presence of intravascular clots inside the cavernous sinuses causes venous obstruction and recurrent priapism (30).…”

Diagnosis and Management of Priapism

“…These procedures can salvage unassisted erections in 15% of IP cases and erections responsive to oral medications in another 31% of men (depending on priapism duration and type of shunt). 9 Without distal corpus cavernosal surgical shunt creation, virtually all patients with persistent IP will have complete erectile dysfunction. Additionally, shunting can lead to complications such as infection, skin necrosis, urethral injury, fistula formation, and cavernositis.…”

“…Distal corpus cavernosal surgical shunt creation, with or without tunneling, is reserved for patients who do not improve with first-line treatments or for more than 48 hours after onset of priapism. These procedures can salvage unassisted erections in 15% of IP cases and erections responsive to oral medications in another 31% of men (depending on priapism duration and type of shunt) . Without distal corpus cavernosal surgical shunt creation, virtually all patients with persistent IP will have complete erectile dysfunction.…”

Acute Ischemic Priapism: An AUA/SMSNA Guideline

“…The overwhelming majority of studies include small patient cohorts and are retrospective in nature, except for one prospective study that included 19 patients. 4 Similarly, there are no studies comparing shunting alone versus shunting with tunneling. Four studies reporting on various distal shunts with corporal tunneling, including the Burnett snake maneuver, demonstrate generally high rates of immediate success at relieving priapism.…”

“…Erectile dysfunction (ED) is the most significant complication in patients with prolonged acute ischemic priapism, and the likelihood of developing ED is related to the length of an acute ischemic priapism event. 3–5 Bennett and Mulhall demonstrated that sickle cell patients with priapism of >36 hours had permanent ED with no men recovering erectile function, 6 and while the exact time point of irreversible smooth muscle loss is undetermined, it is recognized that smooth muscle edema and atrophy occur in as early as six hours. 3,4 As the duration of the priapism increases, patients may be refractory to first-line treatments, such as aspiration, with or without irrigation, and ICI with phenylephrine.…”