Shunt Placement in Priapism
A distal cavernoglanular (corporoglanular) shunt connecting the corpus cavernosum to the glans penis should be the first surgical choice, as it is the easiest to perform with the fewest complications. 1
Distal Shunt Anatomy and Techniques
The first-line surgical shunt creates a connection between the corpus cavernosum and the glans penis (cavernoglanular shunt), performed through the glans. 1 Three specific techniques exist:
Winter procedure: Uses a large biopsy needle inserted percutaneously through the glans into the corpus cavernosum tip (66% resolution rate) 1
Ebbehøj procedure: Uses a scalpel inserted percutaneously through the glans (73% resolution rate) 1
Al-Ghorab procedure: Excises a piece of the tunica albuginea at the tip of the corpus cavernosum through the glans (74% resolution rate, most effective of the three distal techniques) 1
The Al-Ghorab technique is the most effective distal shunt and can succeed even when the other two distal procedures fail. 1
Proximal Shunt Anatomy (Second-Line)
If distal shunting fails or severe distal penile edema/tissue damage exists, proximal shunts may be necessary: 1
Quackels procedure: Creates a shunt between the corpus cavernosum and corpus spongiosum (77% resolution rate, but 50% erectile dysfunction rate) 1
Grayhack procedure: Creates a shunt between the corpus cavernosum and saphenous vein (76% resolution rate, but 50% erectile dysfunction rate) 1
Critical Decision Points
Distal shunts carry significantly lower erectile dysfunction rates (≤25%) compared to proximal shunts (~50%), making them strongly preferred as first-line surgical management. 1
Surgical shunting should only be considered after intracavernous sympathomimetic injection has failed, particularly when priapism exceeds 48-72 hours duration. 1
Important Caveats
Proximal shunts are technically challenging and time-consuming 1
Serious complications include urethral fistulas and purulent cavernositis (Quackels) and pulmonary embolism (Grayhack) 1
Most shunts close spontaneously over time, but long-term patency may paradoxically lead to erectile dysfunction 1
Modified techniques like the T-shunt with intracavernous tunneling show promise for refractory cases, creating wider, more reliably patent shunts through the glans with surprisingly good erectile function recovery 2