OPERATION TECHNIQUE about priaspsm in human
- 2. PRE- OPERATIVE PREPARATION 2 • 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 3 • 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 4 • 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 5 • 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 6 • 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. 9 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 18
- 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 19
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Editor's Notes
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