2. PRE- OPERATIVE PREPARATION
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• The initial step in preoperative preparation is discerning between ischemic and nonischemic
priapism. Persistent pain is typically associated with and is an important predictor of ischemic
priapism.
• A clinical history detailing the episode duration, degree of pain, priapism-predisposing conditions
(e.g., SCD), history and course of previous episodes, history of genital injury or trauma, and use
of pharmacotherapy may provide useful diagnostic insights.
• Physical examination should entail inspection and palpation of the phallus to evaluate the extent
of tumescence as well as for signs of trauma. Ischemic priapism is characterized by the presence
of cavernosal body rigidity and tenderness without glan- ular involvement.
3. PRE- OPERATIVE PREPARATION
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• Blood gas analysis is a helpful diagnostic tool.
o Nonischemic priapism (pH >7.40, pO2 >50 mm Hg, pCO2 <50 mm Hg).
o Ischemic priapisam (pH <7.25), hypoxia (pO2 <30 mm Hg), and hypercarbia (pCO2
>60 mm Hg).
• Patients should also be evaluated for the presence of hematologic or coagulation
disorders because they may be unaware of underlying conditions. The use of urine
toxicology and drug screens can also help in assessing for the use of
pharmacotherapeutic and recreational drugs.
• Penile color duplex ultrasonography can be used independently of corporal blood gas
analysis to aid in the diagnosis of ischemic priapism.
4. ISCHEMIC PRIAPISM
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• First-line management of major ischemic priapism immediate decompression through the use
of corporal aspiration and irrigation. Antibiotics should be administered. A local penile shaft block
or dorsal nerve block.
• Blood is then aspirated using a 16- or 18-gauge needle inserted directly into the corpus
cavernosum at the lateral aspects of the proximal penile shaft. This needle can also be used for
diagnostic and therapeutic evacuation of blood, irrigation with saline, and injection of an α-
adrenergic sympathomimetic agent.
• Evacuation and irrigation of stagnant blood allows for corporal decompression and promotes
recovery of arterial blood flow within the corpora. The use of α-adrenergic sympathomimetics in
concert with aspiration and irrigation has been reported to improve the rate of priapism resolution
from 30% up to 80%.
• Occasionally, high-flow priapism follows an episode of ischemic priapism that has been
successfully treated. This is typically self- limiting and requires only close observation.
5. NON-ISCHEMIC PRIAPISM
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• High-flow priapism Initial observation is reasonable because about half resolve
spontaneously. The use of ice and pressure in the early posttrauma period may induce
vasospasm and thrombosis of the ruptured artery, aiding resolution.
• If high-flow priapism persists, patients may be counseled in an elective setting on
available options.
• These include continued observation, selective embolization, and androgen ablation
6. PATIENT POSITIONING
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• Patient positioning can be divided into percutaneous distal shunts (Winter, Ebbehoj, T-
shunt), open distal shunts (Al-Ghorab, Burnett), open proximal shunts (Quackels,
Sacher), and vein anastomotic shunts (Gray- hack, Barry).
• Typically, a bedside procedure is attempted first. If this proves unsuccessful, open
operative intervention with a distal shunting procedure is performed next.
• Rarely, open proximal shunting or vein anastomosis is required. The placement of a
penile prosthesis in the setting of acute priapism is an emerging option for the
management of refractory episodes.
• The patient should be placed in supine position, with adequate local anesthetic in
addition to intravenous or oral pain relief as supplements.
7. PERCUTANEOUS
DISTAL SHUNTS
Winter (Corporoglanular) Shunt:
• Locate and numb rigid parts of the penis (corpora cavernosa)
• Use a large needle through the tip to address erection issues
• Insert needle carefully to avoid urethral injury
• Create openings in the tissue, potentially on both sides
• Close skin puncture if there's bleeding
• If the problem persists, consider repeating the procedure or
exploring alternative approaches
8. EBBEHOJ
(CORPOROGRANULAR) SHUNT
If a Winter shunt is unsuccessful, larger sized fistulas can
be created using a #11 blade. The blade is passed
percutaneously through the glans in a similar manner to
the Winter technique
The blade may be passed multiple times and bilaterally as
needed to achieve the desired effect. 3-0 chromic sutures
may be used for skin closure if needed.
9. Note the differences between the Ebbehoj and T
shunts. In the Ebbehoj technique the No. 11 blade leaves a
straight incision into the glans and corpus cavernosum. In the
creation of a T shunt the No. 10 blade is rotated (90 degrees
away from the urethra) after insertion and is then withdrawn. In
both the percutaneous techniques deoxygenated blood is milked
out of the open wounds; once bright red blood is seen, the skin is
closed, leaving the deeper incision of the open surgical fistula. In
either procedure the maneuver may be repeated on the opposite
corpus.
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Ebbehoj shunt
Winter shunt
10. OPEN DISTAL SHUNTS
Anesthesia:
General anesthesia with local anesthetic
Procedure Goal:
Create a larger window between ischemic corpus cavernosum
and corpus spongiosum
Preparation:
Standard prep and drape
Tourniquet around penis base to minimize bleeding and improve
visualization
Penrose drain secured with clamp for function
Foley catheter placement to identify and avoid urethral injury
11. Incision and Dissection:
1-cm transverse incision made approximately 1 cm from dorsal
coronal margin
Avoid transverse incision in distal penile shaft near corona to
prevent sensory nerve disruption and penile atrophy
Dissect and expose distal corpora cavernosa using palpation of
rigid corporal bodies as a guide
Excision:
Grasp distal corpora cavernosa with Kocher clamp or secure with
temporary 2-0 suture
Bilateral sharp excision of conical segment of tunica albuginea
from each corporal body (approx. 5 mm)
Express deoxygenated dark blood until color and character
change
When detumescence occurs, do not close the defect in corpora
cavernosa
Closure:
Skin closure with 3-0 chromic sutures
12. Burnett (Corporoglanular) Shunt
After a distal tunical defect has been created as in the Al-Ghorab
technique, a 7/8-mm Hegar dilator is inserted. The dilator should
be directed slightly laterally (away from the urethra) and as
proximally into each corporal body as possible
13. Frog-leg positioning is helpful in palpating the proper placement
of the dilators in the proximal corporal bodies. Stagnant blood is
removed with the aid of external pressure in a proximal to distal
direction
14. The appearance of bright, oxygenated blood indicates restoration
of arterial flow. Closure is then performed at the level of the skin
only, using 3-0 chromic sutures
15. OPEN PROXIMAL
SHUNTS
Quackels (Corporospongiosal) Shunt
Incisions and excisions for Quackels (corporospongiosal) shunt.
A longitudinal perineal incision of 5 cm is made in the midline.
Dissection is carried to the level of the bulbocavernosus muscle.
The underlying corpus spongiosum is then exposed, and a 1-cm
longitudinal portion of spongiosum is incised
16. VEIN ANASTOMATIC
SHUNT
Grayhack (Cavernosaphenous) Shunt
A longitudinal 3-cm incision is made in the dorsolateral aspect of
the proximal penile shaft. Dissection to the level of the tunica
albuginea is carried out. A vertical skin incision is made in the
medial portion of the ipsilateral thigh at the junction of the
saphenous vein and femoral vein. Intraoperative
ultrasonographymay be used to identify relevant anatomy.
17. VEIN ANASTOMATIC
SHUNT
Barry (Cavernodorsal Vein) Shunt
A 4-cm longitudinal incision is made dorsally at the base of the
penis. The incision is carried down through the skin to the level
of the tunica albuginea. Alternatively, a circumcision incision
followed by degloving is performed. The deep or superficial
dorsal vein of the penis is identified, with care to avoid injury to
the arteries and nerves. The vein is mobilized for a distance of 3
cm beyond the anticipated site of anastomosis and then ligated
and divided. The proximal limb of the vein is spatulated.
18. PENILE PROTHESIS SURGERY
For priapism episodes lasting longer than 72 hours, long-term
ED is almost certain. Placing a penile prosthesis in the acute setting is
effective at treating priapism. It may also obviate subsequent penile
shortening associated with prolonged priapism caused by scarring.
A penoscrotal or infrapubic approach is possible, depending on
surgeon experience and preference. Broad-spectrum preoperative
antibiotics are required. Intraoperative evacuation of all stagnant blood
followed by copious intracavernosal irrigation is recommended. Standard
intraoperative and postoperative care as described for penile prosthesis
surgery is otherwise appropriate
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19. POSTOPERATIVE CARE AND
COMPLICATIONS
• A postoperative Foley catheter is placed for patient comfort
and to promote proper hygiene at the incision site.
• The use of a scrotal support with soft fluff dressings should be
worn for 3 days postoperatively or until edema subsides.
• Wound care is performed with twice-daily application of
antibiotic ointment at the incision site until sutures are
absorbed.
• Oral antibiotics directed at skin flora may be given for 1 week
along with analgesics
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