What is the management of priapism using shunting (surgical tunneling)?

From the Guidelines

In patients with acute ischemic priapism who have failed pharmacologic intracavernosal reversal and aspiration, with or without irrigation, a distal corporoglanular shunt with tunneling should be considered as a surgical management option. This approach is based on the latest guidelines from the American Urological Association (AUA) and the Society for the Study of Male Reproduction (SMSNA), as outlined in the 2021 study 1. The decision to proceed with surgical intervention, including tunneling, depends on the duration of the priapism and the failure of non-surgical interventions. Key points to consider when evaluating the use of tunneling in priapism management include:

• The optimal type of distal corporoglanular shunt for the treatment of acute ischemic priapism has not been defined, and no studies have directly compared the various surgical approaches 1.
• The use of tunneling is associated with greater degradation of post-procedure erectile function compared to distal shunting alone, as reported in several studies 1.
• Pooled data suggest that the addition of tunneling may afford slightly higher rates of successful detumescence, although the success rates of studies without tunneling are driven lower by the poor results seen with Winter’s shunts 1.
• Clinicians should consider corporal tunneling in patients with acute ischemic priapism who failed a distal corporoglanular shunt, as recommended by the AUA and SMSNA guidelines 1. The procedure involves creating a shunt between the corpus cavernosum and the glans penis to relieve trapped blood, and patients should be monitored for complications including bleeding, infection, and erectile dysfunction. Overall, the use of tunneling in priapism management should be carefully considered, taking into account the potential benefits and risks, as well as the individual patient's circumstances and the duration of the priapism.

From the Research

Priapism Management with Tunneling

• Priapism is a persistent penile erection lasting longer than 4 hours, requiring emergency management to prevent irreversible erectile dysfunction 2.
• There are three subtypes of priapism: ischemic, non-ischemic, and stuttering priapism, each with different management approaches 2, 3.
• For ischemic priapism, initial management includes corporal blood aspiration and instillation of phenylephrine, followed by surgical shunts if necessary 2.
• Tunneling is a technique used in surgical shunts, such as the T-shunt, to create a wide area, reliably patent shunt and restore blood flow to the corpora cavernosa 4.

T-Shunt with Tunneling

• The T-shunt technique involves creating a shunt between the corpora cavernosa and the corpus spongiosum, with tunneling to facilitate blood flow 4.
• This technique has been shown to result in immediate resolution of ischemic penile pain and rigidity, with excellent recovery of erectile function in most patients 4.
• The T-shunt with tunneling may be performed under local anesthetic and is considered a simple and reliable procedure 4.

Indications for Tunneling

• Tunneling is indicated for patients with ischemic priapism of 24-48 hours duration, or those who have failed distal shunt procedures 2.
• It is also indicated for patients with ischemic priapism of 48-72 hours duration, as a last resort before penile prosthesis implantation 2.
• The decision to perform tunneling should be based on the individual patient's condition and the failure of other management approaches 2, 4.