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Indications

  1. Top of page
  2. Indications
  3. Methods
  4. Comparison with other methods
  5. References

Winter shunts and other modified corporoglandular shunts are commonly used for the treatment of priapism [1,2]. Although it is a common practice to use a corporoglandular shunt as the initial surgical procedure for all patients with priapism who do not respond to intracorporeal pharmacotherapy, we find it helpful to assess penile blood flow using colour Doppler ultrasonography to select the appropriate shunting procedure for each patient. Patients with distal corporeal thrombosis are unlikely to respond to corporoglandular shunting. With information provided by colour Doppler ultrasonography we describe a new surgical shunting procedure for a patient with difficult to treat priapism.

Methods

  1. Top of page
  2. Indications
  3. Methods
  4. Comparison with other methods
  5. References

A 49-year-old white man initially presented to a local urologist with an idiopathic priapism of 3 days’ duration. Both intracavernosal pharmacotherapy and a corporoglandular shunt failed to resolve his priapism, and he was subsequently referred to us. Colour Doppler ultrasonography revealed the presence of cavernosal arterial flow at the proximal and mid-penile shaft, where diastolic flow reversal was also detected. However, no blood flow could be detected at the distal penile shaft (Fig. 1). A proximal shunt was constructed; with the patient placed in a ‘frog-leg’ position, an oblique incision was made lateral to the penile base. A 2.5 cm segment of saphenous vein was harvested from the lower leg. One end of the saphenous vein graft was anastomosed end-to-end to the dorsal vein using a 6–0 prolene continuous suture. The dorsal vein was spatulated to match the size of the saphenous vein. The other end of the saphenous vein graft was spatulated and anastomosed to an elliptical opening created on the lateral aspect of the corpora ≈1.5 times the size of the saphenous vein. The corporeal–saphenous vein anastomosis was performed with a continuous suture using 4–0 prolene (Fig. 2). After surgery, the priapism resolved completely.

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Figure 1. a, Colour Doppler ultrasonogram shows that cavernosal artery blood flow ceases at the mid-penile shaft. b, A cross-section shows no detectable flow in the cavernosal bodies at the distal penile shaft (solid arrow). There is blood flow at the urethra (open arrow).

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Figure 2. The penile venocorporeal shunt using a saphenous vein graft.

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Colour Doppler ultrasonography was performed 1 and 4 months after surgery (Fig. 3); the saphenous vein-graft penile venocorporeal shunt remained open. The patient noted spontaneous but brief erections and was capable of satisfactory sexual intercourse using a vacuum erection device.

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Figure 3. Colour Doppler ultrasonogram after surgery shows an open penile venocorporeal shunt (arrow).

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Comparison with other methods

  1. Top of page
  2. Indications
  3. Methods
  4. Comparison with other methods
  5. References

Despite the long interval from the onset of priapism, the selection of an appropriate shunting procedure appears to have preserved this patient’s erectile capacity. Grayhack et al. described a corpus saphenous shunt for the treatment of priapism [3]. Instead of dissecting the saphenous vein at the thigh, we used a segment of saphenous vein at the ankle as a free graft, to create a shunt from the proximal corpora to the dorsal vein of penis. The harvest of the saphenous vein at the ankle is simple and requires only a small incision (2 cm in this case) and the creation of a penile venocorporeal shunt requires only a small (2.5 cm) incision at the base of penis. Compared with the shunt of Grayhack et al., the advantages of the penile venocorporeal shunt are: a short and more direct course of drainage, easy dissection of the saphenous vein at the ankle and smaller incisions. Compared with the corpus spongiosum shunt, the penile venocorporeal shunt has the advantages of not requiring dissection of the urethra and avoiding the potential problem of corporo-urethral fistula and other urethral complications. Furthermore, the penile venocorporeal shunt is easy to access for ligation when necessary.

References

  1. Top of page
  2. Indications
  3. Methods
  4. Comparison with other methods
  5. References
  • 1
    Winter CC. Cure for idiopathic priapism. New procedure for creating fistula between glans penis and corpora cavernosa. Urol 1976; 8: 389
  • 2
    Ercole CJ, Pontes JE, Pierce JM. Changing surgical concepts in the treatment of priapism. J Urol 1981; 125: 2101
  • 3
    Grayhack JT, McCullough W, O’Connor Vj Jr, Trippel O. Venous bypass to control priapism. Invest Urol 1964; 1: 50913