Treatment of Recurrent Ischemic Priapism by Saphenocavernous Shunt
Nicholas S Cortolillo, Rennier Martinez, Michael Lopez, Rebecca Lee, Reagan Ross
University Of Miami Miller School of Medicine, Atlantis, FL
Ischemic priapism is a urologic emergency which when left untreated could lead to irreversible penile tissue necrosis and permanent erectile dysfunction. Decompression of the corpora cavernosa is therapeutic and can be achieved with a variety of methods, beginning with aspiration followed by intracavernous injection with sympathomimetic drugs. This method achieves detumescence in as many as 80% of patients. Failure of aspiration methods requires surgical intervention, which involves the creation of an arteriovenous shunt that allows blood to drain from the corpora cavernosa into venous circulation. Shunts may be created between the corpora cavernosa and either the glans penis (named "Al-Ghorab" shunts), or corpus spongiosum ( "Sacher" shunts), or a graft vein. We present a rare case of recurrent ischemic priapism that failed aspiration and shunting procedures but achieved successful detumescence with a Sapheno-Cavernous Shunt, of which less than 5 are reported in the surgical literature.
A 49-year-old male with no significant medical or surgical history except for recurrent
idiopathic priapism of two years duration presents with an episode of ischemic priapism refractory to aspiration methods and several shunting procedures. Vascular Surgery assistance was requested in creating a Sapheno-Cavernous shunt to decompress the penis. Under general anesthesia an incision was made inferior to the inguinal ligament and medial to the femoral pulse on the patientís right groin. The saphenous vein was mobilized distal to the saphenofemoral junction. A separate incision was made at the base of the penis to expose the right corporal body. The saphenous vein was ligated distally and tunneled subcutaneously to the right corporal body. The patient was systemically anticoagulated. Buckís fascia and an 1.5 cm ellipse of tunica albuginea was excised and the saphenous vein was spatulated and anastamosed to the corpus covernosum with interrupted 5-0 PDS suture. Constant suction was required during creation of the anastamosis since control of inflow to the corpus cavernosa was not possible. Immediately after shunt creation, the patient achieved moderate detumuscence and had a Doppler signal over the vein graft that augmented with compression of the penile shaft. Postoperatively the patient remained fully anticoagulated while a blood pressure cuff applied to the penile shaft was inflated for 10 seconds every 30 minutes to maintain flow of blood out of the corporal bodies and into the vein graft.
By postoperative day 1, complete flaccidity of the penis was achieved with relief of all pain. The patient was discharged home postoperative day 3. At one month postoperatively, a surveillance ultrasound duplex was performed as shown in Figure 2, demonstrating continued patency of the shunt. The patient will require further workup to assess for underlying arteriovenous malformation.
Figure 1- Surgical field after creation of the anastomosis at the base of
the penile shaft.
Figure 2- Ultrasound duplex imaging 1 month postoperatively, showing patency of shunt in the setting of continued penile flaccidity.
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