The results of a pilot study show that a surgical technique called penoscrotal decompression (PSD) could be a viable way to treat cases of refractory ischemic priapism (RIP) that are not resolved with a distal shunt procedure.
When a man has RIP, time is of the essence. Within 6 hours of onset, corporal tissue changes can become permanent. About half of patients can recover erectile function if treated within 24 hours, but that likelihood quickly decreases after that time.
American Urological Association guidelines recommend a distal shunt procedure for men whose RIP does not respond to conservative treatments, such as aspiration and irrigation. However, outcomes are poor, especially in cases lasting 48 hours or more. Malleable penile prosthesis (MPP) implantation is another option, but the approach can damage the glans and raises risk for infection and erosion.
The researchers described their PSD technique as a “novel, glans-sparing approach of corporal decompression through a penoscrotal approach.” Their study compares the outcomes of PSD to the outcomes of MPP implantation at their institution.
Between 2008 and 2017, fourteen patients had surgery for RIP following a failed distal shunt procedure. Seven patients developed RIP due to medication, 2 had sickle cell disease, and 5 cases had unknown causes. The median duration of priapism before treatment was 61 hours.
Eight patients underwent MPP surgery, and six underwent PSD.
Overall, the patients ranged in age from 12 to 62, but the men in the PSD group tended to be younger, with a mean age of 23 compared to the mean age of 46 in the MPP group.
The authors noted that patient preparation for the PSD technique “is similar to that of patients undergoing penile prosthesis implantation.” In addition, surgeons consider the patient’s priapism history, conduct a physical examination, and perform a penile blood gas to confirm ischemic priapism.
The authors explained the procedure in this way (Note: Figures 3 and 4 may be viewed here):
Initial incision and dissection are identical to those used for penoscrotal inflatable penile prosthesis implantation. A 12-Fr urethral catheter is placed. The Lone Star retractor system (CooperSurgical, Trumbull, CT, USA) is laced with the hinges at the penoscrotal junction (we use ring model 3304G). The beaded strap is placed at the 1st groove of the smaller retractor ring with 4 beads inside the ring on either side of the bar and is positioned behind the base of the penile shaft. The sharp hook is placed inside the meatus and secured at the 12 o’clock position on the larger retractor ring, providing penoscrotal stabilization and penile stretch. A 3-cm transverse penoscrotal incision is performed and dissection is carried down to the level of the tunica albuginea of 1 corporal body. A pair of traction sutures of 2-0 PDS (Ethicon, Somerville, NJ, USA) is placed along the corpora. The corpora are sharply incised for approximately 2 cm, allowing for the escape of ischemic blood.
Corporal decompression is performed distally and proximally from the penoscrotal corporotomy using a pediatric Yankauer suction tip (Figure 2). Firm manual pressure expresses deoxygenated, sludged blood from the ipsilateral corpora and the contralateral corpora through cross-septal egress. If unilateral decompression results in immediate detumescence with return of bright red blood, then copious corporal irrigation using normal saline is performed and the corporotomy is closed. In severe cases in which unilateral dilation is inadequate (ie, contralateral corpora remain firm), bilateral corporal dilation is completed in an identical manner on the contralateral corpora (Figure 3). After copious saline irrigation, each corporotomy is closed. The wound is closed in multiple layers (deep layers using 2-0 poliglecaprone [Monocryl, Ethicon] and superficial skin using interrupted 3-0 poliglecaprone). Bacitracin ointment, scrotal fluffs, and scrotal support are applied.
After surgery, patients are monitored and discharged on postoperative day 0 or 1 after the removal of a Foley catheter and a voiding trial. Pain medication and a stool softener are provided at discharge. Patients are seen again in one to two weeks and advised to return to the hospital if priapism recurs.
Among the study participants, RIP and associated pain was resolved for all of the patients in the PSD group. They did not have recurring RIP episodes and did not need further treatment.
All of the men in the MPP group experienced pain relief. However, three patients needed revision surgery, some more than once. Extrusion was the most common reason.
“Although this series is limited by a small patient population and limited follow-up, the initial results are promising with successful resolution of RIP and potential for erectile recovery,” the authors wrote. They called for further research with larger groups of patients and longer follow-up time frames.
The study was published online in March in the Journal of Sexual Medicine.
American Urological Association
“Management of Priapism”
(Published 2003; Reviewed and Validity Confirmed 2010)
The Journal of Sexual Medicine
Fuchs, Joceline S., MD, et al.
“Penoscrotal Decompression—Promising New Treatment Paradigm for Refractory Ischemic Priapism”
(Full-text. Published online: March 14, 2018)