V11-05: PROMISING NEW TREATMENT PARADIGM FOR REFRACTORY ISCHEMIC PRIAPISM AFTER FAILED DISTAL SHUNT: PENOSCROTAL DECOMPRESSION
For prolonged ischemic priapism, outcomes after distal shunt are poor, with only 30&[permil] success among priapistic episodes lasting >48 hours. Recently, in cases of refractory ischemic priapism (RIP) persisting after distal shunt, we have implemented a novel penoscrotal decompression (PSD) in lieu of early malleable penile prosthesis (MPP) and/or proximal shunt. We present our initial experience with corporal decompression via penoscrotal approach.
We retrospectively reviewed 14 patients with RIP undergoing surgical management after distal penile shunt (2008-2017). Patients without confirmed ischemic priapism on penile blood gas and those treated with MPP or PSD without prior distal shunt were excluded. Median duration of priapism prior to presentation was 61 hours (range 7-240) with etiologies of drug-induced (50&[permil]), idiopathic (35.7) and sickle cell disease (14.3&[permil]). Patients were refractory to multiple prior treatments (median 3 (range 1-75)) and all patients had failed at least one distal shunt (range 1-4).
Median age of patients undergoing treatment for RIP after failed distal shunt was 38.5 years. MPP was inserted in 8 patients (57.1&[permil]), while the most recent 6 patients (42.9&[permil]) underwent PSD. All PSD patients (6/6) were successfully treated with corporal dilation without need for additional intervention and noted immediate relief of pain postoperatively. At most recent follow-up, one patient has reported normal spontaneous erections at 1 month. Unilateral corporal decompression was successful in 66.7&[permil] (4/6), while in two more severe cases, bilateral decompression was necessary to achieve detumescence without need for further intervention. In contrast, 37.5&[permil] (3/8) of patients undergoing MPP after failed distal shunt required a total of 8 revision surgeries during median follow-up of 41.5 months. The most common indications for revision surgery after MPP included distal urethral erosion (4/8, 50&[permil]), impending lateral erosion (2/8, 25&[permil]) and glanular erosion (1/8, 12.5&[permil]).
Our initial experience demonstrates favorable outcomes with PD compared to early prosthesis in RIP patients who have failed a distal shunt. RIP should be thought of and managed as a penile compartment syndrome, with treatment focused on complete decompression and restored perfusion rather than shunt creation. Corporal decompression resolves RIP through a glans-sparing approach and avoids the high complication rate of prosthetic insertion after failed distal shunt.