Editing Priapism (section)

==== Surgical management (Shunting) ====
* '''Principle of shunt procedure is to reestablish corporal inflow by relieving venous outflow obstruction'''; this requires creation of a fistula between the corpora cavernosa and the glans penis, corpora cavernosa and corpus spongiousum, or corpora cavernosa and dorsal or saphenous veins.

===== Indications (3)</span> =====
# '''<span style="color:#ff0000">Persistent acute ischemic priapism after intracavernosal phenylephrine and aspiration, with or without irrigation</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
#*'''Surgical shunting should not be performed until BOTH alpha adrenergics and aspiration and saline irrigation have been attempted</span>[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]'''
#'''<span style="color:#ff0000">Injections of sympathomimetics has resulted in a significant cardiovascular side effect</span>'''
#'''<span style="color:#ff0000">Malignant or poorly controlled hypertension</span>'''
#

* '''<span style="color:#ff0000">Consider for ischemic priapism events ≤72 hours</span>'''
** '''<span style="color:#ff0000">In priapism lasting > 72 hours, consideration should be given to foregoing a shunt</span>'''

===== <span style="color:#ff0000">Approach</span> =====
* '''<span style="color:#ff0000">Classification: distal vs. proximal</span>'''
*'''<span style="color:#ff0000">Distal (6)</span>'''
** '''<span style="color:#ff0000">Percutaneous (3)</span>''' (through distal glans towards corpus cavernosum) '''<span style="color:#0000ff">WET'''
**# '''<span style="color:#0000ff">W</span><span style="color:#ff0000">inter: large-bore needle or angiocatheter (least effective)</span>'''
**# '''<span style="color:#0000ff">E</span><span style="color:#ff0000">bbehoj: straight incision''' '''with No. 11 blade'''
**# '''<span style="color:#0000ff">T</span><span style="color:#ff0000"> shunt: No. 10 blade is rotated 90° after insertion'''
**#* '''After Ebbehoj or T shunt, the glans is sutured closed with absorbable suture.''' Discharge home if the penis remains flaccid for 15 minutes. If erection returns or persists, a second T shunt is recommended on the opposite side of the meatus.
** '''<span style="color:#ff0000">Open (3): </span><span style="color:#0000ff">ATC</span>'''
**# '''<span style="color:#0000ff">A</span><span style="color:#ff0000">l -Ghorab</span>: excision of a''' 5-mm '''circular cone segment of the distal tunica albuginea (see Figure in [https://pubmed.ncbi.nlm.nih.gov/27436080/ article])'''
**# '''<span style="color:#0000ff">T</span><span style="color:#ff0000">unnelling</span>''': modification of the Al-Ghorab; '''after excising the circular core of distal tunica albuginea, a 7/8 Hegar dilator is inserted down each corporal body through the tunica window'''
**#'''<span style="color:#0000ff">C</span><span style="color:#ff0000">ombined distal shunt and corporal tunneling</span> <span style="color:#ff0000">maneuver</span>'''
**#*Addition of tunneling may afford slightly higher rates of successful detumescence, but associated with greater degradation of post-procedure erectile function compared to distal shunting alone'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
* '''Proximal (3)''' 
**'''Options (open)'''
**# '''Proximal corpus cavernosum to spongiosum shunt (Quackles)'''; require a trans-scrotal or transperineal approach
**# '''Proximal corpus cavernosum to saphenous vein shunt (Grayhack)''' - a wedge of tunica albuginea is removed and the vein is anastomosed end to side of corpora cavernosa.
**#'''Proximal corpus cavernosum to deep dorsal vein shunt (Barry)'''
**'''Represents a historical procedure and has largely been replaced by distal shunts with tunneling procedures<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
***Technically more difficult to perform that distal, likely no surgeons who have extensive experience<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span>
**Should not be considered a mandatory procedure for men who have been confirmed to have failed distal shunting<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ '''★''']</span>
*'''<span style="color:#ff0000">A distal corporoglanular shunt, with or without tunneling, should be performed in patients with persistent acute ischemic priapism</span>'''
**The optimal type of distal corporoglanular shunt has not been defined'''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''
**'''<span style="color:#ff0000">Percutaneous distal shunting is less invasive than open distal shunting</span>''' and can be performed with local anesthetic in the emergency department.
** <span style="color:#ff0000">'''Open shunting procedures, especially those that require passage of dilators into the corpora cavernosa, will require general anesthesia and an operating room'''
*'''Inadequate evidence to quantify the benefit of performing a proximal shunt (of any kind) in a patient with persistent acute ischemic priapism after distal shunting.<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/35536142/ ★]</span>'''

===== Adverse Events of Shunting (6): =====
#'''<span style="color:#ff0000">Penile edema'''
#'''<span style="color:#ff0000">Hematoma'''
#'''<span style="color:#ff0000">Infection'''
#'''<span style="color:#ff0000">Urethral fistula'''
#'''<span style="color:#ff0000">Penile necrosis'''
#'''<span style="color:#ff0000">Pulmonary embolism'''

===== Methods to prevent shunt obstruction and subsequent failure (3): =====
# Avoid compressive penile dressings
# Consider anticoagulation
# Patient should periodically squeeze and release the distal penis to “milk” the shunt maintaining patency