Overcoming Refractory Ischaemic Priapism: The Emergence of Penoscrotal Decompression

Overcoming Refractory Ischaemic Priapism: The Emergence of Penoscrotal Decompression | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Overcoming Refractory Ischaemic Priapism: The Emergence of Penoscrotal Decompression Mohamed Mubarak, Qasim Isa, John Hayes, Ian Pearce, Vaibhav Modgil This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5421547/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Mar, 2025 Read the published version in International Journal of Impotence Research → Version 1 posted 9 You are reading this latest preprint version Abstract Penoscrotal decompression (PSD) has emerged as a promising surgical intervention for refractory ischemic priapism, involving proximal corporotomies and the drainage of ischemic blood. Initial outcomes have shown high success rates in achieving detumescence, low recurrence rates, and relatively good preservation of erectile function. This meta-analysis aims to comprehensively evaluate PSD's effectiveness across three key metrics: detumescence, prevention of recurrence, and erectile function preservation. A systematic review and meta-analysis, following PRISMA guidelines, identified 11 publications that met the inclusion criteria. They encompassed five case reports, four abstracts, and two observational cohort studies, with data on 97 patients who presented with refractory ischemic priapism. Notably, around half (44.3%) of the patients had conventional distal shunts prior to PSD. Overall following PSD, detumescence was achieved in 92% (CI 95%, 0.84 to 0.95). Post-PSD recurrence of priapism occurred in 12% (95% CI, 0.06 to 0.21). Erectile function was preserved in 51% of the patients who had follow-up (95% CI, 0.39 to 0.61). These findings inform us that PSD proves to be a viable and effective surgical option for refractory ischaemic priapism with a key feature being better sexual function preservation outcomes. Given the paucity of data, further larger scale prospective studies of robust designs are still necessary to better establish PSD’s role within the treatment algorithm for refractory ischaemic priapism. Health sciences/Medical research Health sciences/Health care/Therapeutics Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Ischaemic priapism is a urological emergency defined by a prolonged, erection persisting for greater than four hours in the absence of sexual stimulation. Ischaemic priapism is a compartment syndrome of the penis, characterised by stagnation within the corpora cavernosa and resultant hypoxia, hypercapnia and tissue necrosis. [1] The causes of ischaemic priapism are diverse and include iatrogenic factors, psychoactive medications, treatments for erectile dysfunction (such as prostaglandins), and underlying medical conditions such as blood disorders (e.g. sickle cell disease), myeloproliferative diseases, and malignancies. (Table 1) [2-5] The Initial treatment for ischaemic priapism involves addressing any potential aetiological factors, such as sickle cell crisis, in parallel with conservative measures such as hydration, analgesia and physical activity in an attempt to stimulate blood flow redirection. If these measures fail, corporal cannulation and aspiration of up to 150 mL of blood, with or without saline irrigation, is recommended. [3-5] Phenylephrine injections into the corpora have also been recommended, albeit with controlled doses and concurrent cardiac monitoring. The recommended dose of phenylephrine, as outlined by various consensus statements, is 200-250mcg given every 5-10 minutes for a maximum dose of 1 gram in 1 hour. [3-5] When priapism persists despite these measures, it is classified as refractory ischemic priapism, and surgical shunting is considered the next option. This includes distal shunting techniques such as the Winter, Ebbehoj, and T shunts. While proximal shunting, and other techniques were also explored in the past, they have fallen out of favour due to their higher risk of complications. [2] (Table 2) Recently, decompression through proximal corporotomies, also known as penoscrotal decompression (PSD), has been described as a novel surgical option for refractory ischaemic priapism. First described by Fuchs et al. in 2018, this technique involves a penoscrotal incision to expose, and incise the corpora, allowing the drainage of ischemic blood and facilitating detumescence. [6] Fuchs et al., along with subsequent publications have reported promising outcomes for PSD, highlighting a high success rate, low recurrence, and good preservation of erectile function. Nevertheless, to date, the available literature on PSD remains limited and has yet to be comprehensively evaluated to determine its role within the treatment algorithm for priapism. This systematic review and meta-analysis aim to comprehensively assess the available literature on the outcomes of PSD in adult patients with refractory ischemic priapism. 2. Methods 2.1 Overview & Research Question This systematic review and meta-analysis, registered with PROSPERO (CRD42024553248), was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. [7] The research question was formulated using the PICO framework: Population: Adult male patients presenting with refractory ischaemic priapism. Intervention: Penoscrotal Decompression Control: Nil. Outcomes Primary: Preservation of Erectile Function Secondary: Detumescence, Recurrence In view of the limited data available, all studies addressing penoscrotal decompression in adults with priapism were included. 2.2 Search Strategy & Study Selection Nine major databases were searched (PubMed, Google Scholar, Scopus, Web of Science, Semantic Scholar, The Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), and VIP Chinese Journal Service Platform). There were no restrictions on language, country, or publication date. All relevant texts up to June 2024 were included in the initial screening process. Given the research question, all published literature was eligible for screening, except systematic reviews, meta-analyses, editorials, guidelines, expert opinions, and comments. Eligible texts were uploaded into Covidence Software [8] and screened by two reviewers (MM, QI). Discrepancies were resolved through discussion or, if necessary, by involving a third reviewer. Figure 1 presents the PRISMA flow diagram outlining the study selection and screening process. 2.3 Data Extraction Baseline characteristics and variables of interest extracted included: study name, year of publication, country, language, study design, total sample size, cause of priapism, duration of erection, distal shunt performance, PSD laterality, detumescence rate, recurrence rate, and erectile function status at follow-up. 2.4 Risk of Bias (RoB) Assessment The Newcastle Ottawa Scale (NOS) was used to assess the risk of bias. [9] Two reviewers (MM, QI) carried out the NOS assessment, and discrepancies were either settled through discussion or a third reviewer, if required. The assessment outcomes were then plotted onto a traffic light plot with the final outcome. 2.5 Data Synthesis & Analysis Microsoft Excel was used for data collection, organization, and initial analysis. Descriptive statistics, including measures of central tendency and frequencies, were first calculated. A meta-analysis of proportions was conducted using the 'meta' package in R Studio [10]. To account for potential heterogeneity between studies, a random-effects model was employed, with results presented through forest plots. Heterogeneity was assessed using Higgins' I² and Cochrane’s Q test. Publication bias was evaluated through funnel plot visualization and Egger’s test. A P-value of < 0.05 was considered statistically significant. 3. Results 3.1 Study Characteristics (Table 3) 110 studies were initially screened and 11 met our criteria for review and subsequent meta-analysis. [6, 11-20) The eligible studies include 5 case reports, 4 abstracts of observational studies, and 2 published observational studies. All but two studies were based in the United States. The studies covered data from 97 patients who underwent PSD to decompress refractory priapic episodes. Table 3 presents the average and median ages at presentation, along with the time since the onset of priapism. (Table 3) Among the studies that reported causes of priapism, drug-induced was the leading cause (65%), followed by sickle cell disease (16.3%) and idiopathic causes (16.3%). Less than half of the patients (44.3%) had undergone a distal shunt procedure prior to PSD, and 55.1% of men underwent bilateral penoscrotal decompression. Baumgarten et al., [13] reported that after two unsuccessful unilateral PSD, all subsequent patients in their series had bilateral PSD. Notably, some later studies published in the literature do not clarify whether unilateral or bilateral decompression was pre-determined or adjusted intra-operatively due to insufficient detumescence with a unilateral approach. 3.2 Detumescence (Figure 2) All 11 studies reported immediate detumescence, including data from a total of 97 patients. Only one study documented failed detumescence in two patients (2%) following unilateral PSD, which was subsequently converted to bilateral PSD. The overall detumescence rate was 92% (95% CI: 0.82-0.96). There was low heterogeneity on Higgins’ I 2 and Cochrane’s Q Test (I 2 = 0.0%, Q = 5.3, p > 0.05). An Eggers test for publication bias demonstrated no significant evidence of funnel plot asymmetry (p > 0.05). Furthermore, a leave-one-out analysis demonstrated that no single study significantly influenced the overall outcome, supporting the conclusion that the calculated rate of immediate detumescence of 92% was robust and bias free. 3.3 Recurrence (Figure 3) All but one of the included studies commented on the recurrence of priapism post-PD, bringing the total number of patients down to 84. The overall recurrence rate was 12% (95% CI: 0.06-0.21). Four patients required a conversion to a bilateral PSD, one recurrence episode resolved with intra-cavernosal phenylephrine, and another one required the insertion of a malleable penile prosthesis on day two. Heterogeneity tests (I 2 = 0.0%, Q = 3.15, p > 0.05) and Eggers test (p = 0.18) were unremarkable. A leave-one-out analysis demonstrated that no single study influenced the overall recurrence rate significantly. 3.4 Post-Operative Erectile Function (Figure 4) Approximately 78% of the patients (n = 76) underwent postoperative erectile function assessment. Half of these patients (50%) reported satisfactory erectile function sufficient for sexual intercourse. However, no objective measures of erectile function, such as the IIEF-5 or SHIM scores, were used to quantify this outcome. Post-operative erectile function preservation at follow up was 51% (95% CI: 0.39-0.61). Heterogeneity was low amongst the included studies (I2 = 0.0%, Q = 5.87, p > 0.05). Eggers test indicated no evidence of funnel plot asymmetry (p = 0.79). Leave-one-analysis did not demonstrate any significant changes to the erection preservation rates at follow up. 3.5 Risk of Bias Assessment The NOS risk of bias assessment demonstrated an intermediate risk of bias across all the included studies. All studies scored well in most selection domains and the outcome domains. However, because all studies were observational and lacked a predefined control or placebo group, they were rated as having a high risk of bias in selection domain 2 (Selection of Non-Exposed Cohort) and in comparability. As a result, all the studies scored a six out of nine, placing them at intermediate risk of bias. 4. Discussion Refractory ischaemic priapism represents a challenging urological emergency. As priapism represents a compartment syndrome of the penis, rapid decompression is crucial to prevent irreversible damage and tissue necrosis. [1–2] Guidelines recommend surgical management when conservative measures, such as aspiration and phenylephrine injection, fail to achieve detumescence. [3–5] Although no single surgical technique has proven superior, available options range from distal to proximal shunts. [2] This study focuses on Penoscrotal Decompression (PSD), a novel technique described in the last decade. Early evidence demonstrates promising outcomes with PSD, including good detumescence rates, low recurrence, and considerable preservation of erectile function. According to the current standards of practice, the first line of surgical treatment following failed conservative management is the creation of a distal shunt. Distal shunts create a small fistulous tract between the corpus cavernosum and glans allowing trapped ischaemic blood to escape and, subsequently, promote detumescence. [1–2] Known techniques include the Winter, Ebbehoj, and T-shunt procedures, all of which revolve around the same surgical principles. Although commonly used, they are associated with risks of failure and erectile dysfunction. [2] Proximal shunts, such as the Grayhack and Quackel shunts, have also been used but are less common due to complexity and higher morbidity rates. [2] Approximately 44% of patients included in this review had a failed distal shunt prior proceeding to PSD. Shunting is associated with poor long-term sexual adverse effects with studies reporting post-procedural erectile dysfunction rates ranging between 50–96% [22–24]. According to European Association of Urology (EAU) guidelines, shunt surgery is unlikely to be effective in maintaining erectile function after 36 hours of priapism. The consensus is that patients who present with prolonged priapism may benefit from early penile prosthesis implantation, as shunt procedures typically fail to preserve erectile function beyond a certain duration of ischaemic priapism. [5, 21] Given these limitations, Penoscrotal Decompression (PSD) has emerged as a potential alternative, offering improved functional outcomes in both early and late phases of treatment. The rarity of priapism complicates research efforts, as most available evidence comes from small, retrospective case series or individual case reports. To date, only two full manuscripts—Fuchs et al. [6] and Baumgarten et al. [13] —have been published on PSD, both reporting excellent detumescence rates (100% and 92%) low recurrence (0% and 8%), and partial preservation of erectile function (16% and 60%). Compared to distal shunt techniques, the early and late outcomes of PSD appear favourable. Similarly, PSD also demonstrates an advantage over early malleable penile implant insertion. Within similar patient populations, PSD had better long-term outcomes for RIP as 37.5% of patients who had early malleable penile implants required a total of 8 revision surgeries during a 41-month median follow up duration. [6] Interestingly, within PSD itself, unilateral and bilateral decompression were reported to deliver varying levels of success. Although difficult to discern from most included studies, between Fuchs et al. [6] and Baumgarten et al. [13] 14 unilateral and 17 bilateral decompressions were done. The former study suggests no difference in detumescence success between either approach, whereas the latter suggests that bilateral decompression is associated with better detumescence as they encountered two failures following unilateral decompressions which were then converted to a bilateral approach with subsequent success. The main limitation associated with the dataset available is the variability in approach and technique. For example, it is unclear whether decompression alone or additional manoeuvres (i.e. tunnelling, suctioning) were performed. Furthermore, decision-making criteria for unilateral versus bilateral PSD remain ambiguous. Baumgarten et al. [13] reported converting to bilateral PSD after two failed attempts with the unilateral approach, but other studies do not provide a clear rationale for offering patients unilateral or bilateral decompression. Additionally, limited follow-up periods and the lack of an objective tool to quantify erectile function restrict the ability to fully assess the long-term outcomes of PSD. Overall, while understanding the difficulty associated with conducting a controlled study, a standardised technical and follow up approach in prospective series could perhaps produce more reliable data. Pooling data from different studies following similar standard approaches can further elucidate the role of PSD and its comparative efficacy to other more established surgical approaches, as one question that poses itself is PSD’s feasibility as a primary surgical approach to priapism, and whether the reported successful outcomes are dampened by the fact that its use is delayed as it is a second-line approach. Conclusion Although a relatively novel technique, early evidence suggests that PSD is a promising approach for managing refractory ischemic priapism. One key advantage of PSD is the ability to access the corpora proximally without disrupting the distal tunica albuginea or the glans. Given the favourable outcomes reported thus far, PSD may eventually surpass distal shunts as a first-line treatment option for refractory priapism. However, given the novelty and scarcity of data, these presumptions are premature. There are yet several important questions to be answered about PSD, including its optimal position within the treatment algorithm (first-line versus second-line), the preferred laterality of approach (unilateral versus bilateral), and intra-operative prognostic markers to guide decisions between decompression alone and penile prosthesis insertion. Declarations Funding: Nil Ethical Approval: Not Applicable Conflict of Interest: Nil Author Contribution Statement: MM: Study Conception & Design, Data Collection & Analysis, Manuscript Writing & Editing QI: Study Conception & Design, Data Collection, Manuscript Writing JH: Data Collection, Manuscript Writing & Editing VB: Supervision, Manuscript Writing & Editing, Approval of Final Version IP: Supervision, Manuscript Writing & Editing, Approval of Final Version References Silberman M, Stormont G, Leslie SW, Hu EW. Priapism [Internet]. Nih.gov. StatPearls Publishing; 2023. 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Tables Table 1: Causes of Ischaemic Priapism [2-5] Aetiological Group Causes Idiopathic Haematological/Vascular Sickle Cell Disease Thalassemia G6PD Hypercoagulable States Vasculitis Oncological Infiltrative: Bladder, Prostate, Urethra, Testis, Rectum Metastatic: Lung, Renal Other: Leukaemia, Multiple Myeloma Infectious Bites Toxins Rabies Neurogenic Neurosyphilis Spinal Cord Injuries Cauda Equine Syndrome Autonomic Neuropathies Metabolic Diabetes Amyloidosis Drug-Induced Vasoactive Agents Alpha-Adrenergic Receptor Agonists Anxiolytics Anti-Depressants Anti-Hypertensives Hormones Recreational Anaesthesia (Spinal) Table 2: Different shunts used in the management of refractory ischaemic priapism [2] Type of Shunt Technique Name Description Percutaneous Distal Shunts Winter Corporoglanular fistulae created using a large biopsy needle Ebbehoj Corporoglanular fistulae created using a #11 blade T-Shunt Similar to an Ebbehoj shunt with an additional modification: Lateral rotation of a #10 blade 90 o away from the urethral meatus to widen the corporoglanular fistulae Open Distal Shunts Al-Ghorab Glanular incision followed by the excision of a cone segment of the distal tunica albuginea. Burnett’s (Snake) Manoeuvre Similar to Al-Ghorab with an additional modification: Corporal dilation with Hegar dilators and evacuation of ischaemic blood. Proximal Shunts Quackel Incised/excised ellipse-shaped defects from spongosial and coroporal anastomosed together. Grayhack Saphenous vein ligation and anastomosis to corpora cavernosa. Barry Dorsal penile vein (superficial or deep) ligation with anastomosis to corpora cavernosa. Table 3: Study Characteristics & Baseline Data Study Name & Year Location Study Design No. of Patients Aetiology Duration of Priapism PSD Laterality Fuchs 2018 USA Observational 6 Drug Induced - 3 SCD - 2 Idiopathic - 1 Median: 60h (Range: 7-168) Unilateral - 4 Bilateral - 2 Yi 2019 USA Observational 13 Drug Induced - 8 SCD - 4 Idiopathic - 1 Mean 61.2h Not reported Khater 2020 USA Case Report 1 Drug Induced (Tamsulosin) 72h Not reported Baumgarten 2020 USA Observational 25 Drug Induced - 19 SCD - 2 Idiopathic - 3 Other - 1 constriction device Mean: 71h Unilateral - 10 Bilateral - 15 Yi 2020 USA Observational 22 Not reported 66.2h (6-168) Unilateral - 12 Bilateral - 10 Mallory 2021 USA Case Report 1 Drug Induced 30h Bilateral Ottiano 2022 USA Case Report 1 Not reported 72h Not reported Gin 2023 UK Observational 13 Drug-Induced/Iatrogenic - 6 Idiopathic - 5 SCD - 2 Median: 48h (IQR 38-56) Unilateral - 4 Bilateral - 9 Elkholy 2023 Egypt Observational 13 Not reported 48h-240h Not reported Qian 2023 USA Case Report 1 Drug Induced 120 Bilateral Akula 2024 USA Case Report 1 Drug Induced 24 Unilateral Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 12 Mar, 2025 Read the published version in International Journal of Impotence Research → Version 1 posted Editorial decision: revise 31 Dec, 2024 Review # 2 received at journal 09 Dec, 2024 Reviewer # 2 agreed at journal 27 Nov, 2024 Review # 1 received at journal 19 Nov, 2024 Reviewer # 1 agreed at journal 19 Nov, 2024 Reviewers invited by journal 12 Nov, 2024 Submission checks completed at journal 12 Nov, 2024 Editor assigned by journal 09 Nov, 2024 First submitted to journal 09 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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North East Deanery","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Mubarak","suffix":""},{"id":377289360,"identity":"bd7e6f26-dc60-4b33-b065-5df05a81d051","order_by":1,"name":"Qasim Isa","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Qasim","middleName":"","lastName":"Isa","suffix":""},{"id":377289361,"identity":"80e16fb7-477c-4961-90ff-5019b3bbdfcb","order_by":2,"name":"John Hayes","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Hayes","suffix":""},{"id":377289362,"identity":"39e75b6b-ced8-40cb-96ad-cd9daf739187","order_by":3,"name":"Ian Pearce","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ian","middleName":"","lastName":"Pearce","suffix":""},{"id":377289363,"identity":"3ccad98d-734e-444a-9fef-0430245e41a8","order_by":4,"name":"Vaibhav Modgil","email":"","orcid":"","institution":"Manchester Royal","correspondingAuthor":false,"prefix":"","firstName":"Vaibhav","middleName":"","lastName":"Modgil","suffix":""}],"badges":[],"createdAt":"2024-11-09 11:20:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5421547/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5421547/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41443-025-01044-3","type":"published","date":"2025-03-12T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71676009,"identity":"6fc2c681-fa7d-46b0-9914-007f7d365935","added_by":"auto","created_at":"2024-12-17 15:42:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83099,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flowchart\u003c/p\u003e","description":"","filename":"PSDFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5421547/v1/3821e09df318a1ac347aac3a.png"},{"id":71674263,"identity":"8c852955-b9b6-4ab2-bffa-ebb3dc171ecc","added_by":"auto","created_at":"2024-12-17 15:34:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":120360,"visible":true,"origin":"","legend":"\u003cp\u003eDetumescence Rates\u003c/p\u003e","description":"","filename":"PSDFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5421547/v1/8b485927bcddcd93bd0b44ff.png"},{"id":71676410,"identity":"09ebc374-9f87-48a0-b81f-a4e3b93aa1d2","added_by":"auto","created_at":"2024-12-17 15:50:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":195097,"visible":true,"origin":"","legend":"\u003cp\u003eRecurrence Rates Following PSD\u003c/p\u003e","description":"","filename":"PSDFigure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5421547/v1/2ac8cb62bf41315e4d6656ba.png"},{"id":71674265,"identity":"86897eb3-d96a-412d-b06d-d04c2dc56d18","added_by":"auto","created_at":"2024-12-17 15:34:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":208717,"visible":true,"origin":"","legend":"\u003cp\u003eErectile Function Preservation At Follow Up\u003c/p\u003e","description":"","filename":"PSDFigure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5421547/v1/3986a6b325317a515b32d33e.png"},{"id":78430154,"identity":"3dfe421d-a99a-445f-9cee-57467af81dca","added_by":"auto","created_at":"2025-03-13 07:12:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1099989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5421547/v1/ce79d5a4-0e20-4692-9c9f-63948e4988db.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Overcoming Refractory Ischaemic Priapism: The Emergence of Penoscrotal Decompression","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIschaemic priapism is a urological emergency defined by a prolonged, erection persisting for greater than four hours in the absence of sexual stimulation. Ischaemic priapism is a compartment syndrome of the penis, characterised by stagnation within the corpora cavernosa and resultant hypoxia, hypercapnia and tissue necrosis. [1] The causes of ischaemic priapism are diverse and include iatrogenic factors, psychoactive medications, treatments for erectile dysfunction (such as prostaglandins), and underlying medical conditions such as blood disorders (e.g. sickle cell disease), myeloproliferative diseases, and malignancies. (Table 1) [2-5]\u003c/p\u003e\n\u003cp\u003eThe Initial treatment for ischaemic priapism involves addressing any potential aetiological factors, such as sickle cell crisis, in parallel with conservative measures such as hydration, analgesia and physical activity in an attempt to stimulate blood flow redirection. If these measures fail, corporal cannulation and aspiration of up to 150 mL of blood, with or without saline irrigation, is recommended. [3-5] Phenylephrine injections into the corpora have also been recommended, albeit with controlled doses and concurrent cardiac monitoring. The recommended dose of phenylephrine, as outlined by various consensus statements, is 200-250mcg given every 5-10 minutes for a maximum dose of 1 gram in 1 hour. [3-5] When priapism persists despite these measures, it is classified as refractory ischemic priapism, and surgical shunting is considered the next option. This includes distal shunting techniques such as the Winter, Ebbehoj, and T shunts. While proximal shunting, and other techniques were also explored in the past, they have fallen out of favour due to their higher risk of complications. [2] (Table 2)\u003c/p\u003e\n\u003cp\u003eRecently, decompression through proximal corporotomies, also known as penoscrotal decompression (PSD), has been described as a novel surgical option for refractory ischaemic priapism. First described by Fuchs et al. in 2018, this technique involves a penoscrotal incision to expose, and incise the corpora, allowing the drainage of ischemic blood and facilitating detumescence. [6] Fuchs et al., along with subsequent publications have reported promising outcomes for PSD, highlighting a high success rate, low recurrence, and good preservation of erectile function. Nevertheless, to date, the available literature on PSD remains limited and has yet to be comprehensively evaluated to determine its role within the treatment algorithm for priapism. This systematic review and meta-analysis aim to comprehensively assess the available literature on the outcomes of PSD in adult patients with refractory ischemic priapism.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1 Overview \u0026amp; Research Question\u003c/p\u003e\n\u003cp\u003eThis systematic review and meta-analysis, registered with PROSPERO (CRD42024553248), was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. [7] The research question was formulated using the PICO framework:\u003c/p\u003e\n\u003col style=\"list-style-type: upper-alpha;\"\u003e\n \u003cli\u003ePopulation: Adult male patients presenting with refractory ischaemic priapism.\u003c/li\u003e\n \u003cli\u003eIntervention: Penoscrotal Decompression\u003c/li\u003e\n \u003cli\u003eControl: Nil.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOutcomes\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003ePrimary: Preservation of Erectile Function\u003c/li\u003e\n \u003cli\u003eSecondary: Detumescence, Recurrence\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eIn view of the limited data available, all studies addressing penoscrotal decompression in adults with priapism were included.\u003c/p\u003e\n\u003cp\u003e2.2 Search Strategy \u0026amp; Study Selection\u003c/p\u003e\n\u003cp\u003eNine major databases were searched (PubMed, Google Scholar, Scopus, Web of Science, Semantic Scholar, The Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), and VIP Chinese Journal Service Platform). There were no restrictions on language, country, or publication date. All relevant texts up to June 2024 were included in the initial screening process. Given the research question, all published literature was eligible for screening, except systematic reviews, meta-analyses, editorials, guidelines, expert opinions, and comments. Eligible texts were uploaded into Covidence Software [8] and screened by two reviewers (MM, QI). Discrepancies were resolved through discussion or, if necessary, by involving a third reviewer. Figure 1 presents the PRISMA flow diagram outlining the study selection and screening process.\u003c/p\u003e\n\u003cp\u003e2.3 Data Extraction\u003c/p\u003e\n\u003cp\u003eBaseline characteristics and variables of interest extracted included: study name, year of publication, country, language, study design, total sample size, cause of priapism, duration of erection, distal shunt performance, PSD laterality, detumescence rate, recurrence rate, and erectile function status at follow-up.\u003c/p\u003e\n\u003cp\u003e2.4 Risk of Bias (RoB) Assessment\u003c/p\u003e\n\u003cp\u003eThe Newcastle Ottawa Scale (NOS) was used to assess the risk of bias. [9] Two reviewers (MM, QI) carried out the NOS assessment, and discrepancies were either settled through discussion or a third reviewer, if required. The assessment outcomes were then plotted onto a traffic light plot with the final outcome.\u003c/p\u003e\n\u003cp\u003e2.5 Data Synthesis \u0026amp; Analysis\u003c/p\u003e\n\u003cp\u003eMicrosoft Excel was used for data collection, organization, and initial analysis. Descriptive statistics, including measures of central tendency and frequencies, were first calculated. A meta-analysis of proportions was conducted using the \u0026apos;meta\u0026apos; package in R Studio [10]. To account for potential heterogeneity between studies, a random-effects model was employed, with results presented through forest plots. Heterogeneity was assessed using Higgins\u0026apos; I\u0026sup2; and Cochrane\u0026rsquo;s Q test. Publication bias was evaluated through funnel plot visualization and Egger\u0026rsquo;s test. A P-value of \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1 Study Characteristics (Table 3)\u003c/p\u003e\n\u003cp\u003e110 studies were initially screened and 11 met our criteria for review and subsequent meta-analysis. [6, 11-20) The eligible studies include 5 case reports, 4 abstracts of observational studies, and 2 published observational studies. All but two studies were based in the United States. The studies covered data from 97 patients who underwent PSD to decompress refractory priapic episodes. Table 3 presents the average and median ages at presentation, along with the time since the onset of priapism. (Table 3)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the studies that reported causes of priapism, drug-induced was the leading cause (65%), followed by sickle cell disease (16.3%) and idiopathic causes (16.3%). Less than half of the patients (44.3%) had undergone a distal shunt procedure prior to PSD, and 55.1% of men underwent bilateral penoscrotal decompression. Baumgarten et al., [13] reported that after two unsuccessful unilateral PSD, all subsequent patients in their series had bilateral PSD. Notably, some later studies published in the literature do not clarify whether unilateral or bilateral decompression was pre-determined or adjusted intra-operatively due to insufficient detumescence with a unilateral approach.\u003c/p\u003e\n\u003cp\u003e3.2 Detumescence (Figure 2)\u003c/p\u003e\n\u003cp\u003eAll 11 studies reported immediate detumescence, including data from a total of 97 patients. Only one study documented failed detumescence in two patients (2%) following unilateral PSD, which was subsequently converted to bilateral PSD. The overall detumescence rate was 92% (95% CI: 0.82-0.96). There was low heterogeneity on Higgins\u0026rsquo; I\u003csup\u003e2\u003c/sup\u003e and Cochrane\u0026rsquo;s Q Test (I\u003csup\u003e2\u003c/sup\u003e = 0.0%, Q = 5.3, p \u0026gt; 0.05). An Eggers test for publication bias demonstrated no significant evidence of funnel plot asymmetry (p \u0026gt; 0.05). Furthermore, a leave-one-out analysis demonstrated that no single study significantly influenced the overall outcome, supporting the conclusion that the calculated rate of immediate detumescence of 92% was robust and bias free.\u003c/p\u003e\n\u003cp\u003e3.3 Recurrence (Figure 3)\u003c/p\u003e\n\u003cp\u003eAll but one of the included studies commented on the recurrence of priapism post-PD, bringing the total number of patients down to 84. The overall recurrence rate was 12% (95% CI: 0.06-0.21). Four patients required a conversion to a bilateral PSD, one recurrence episode resolved with intra-cavernosal phenylephrine, and another one required the insertion of a malleable penile prosthesis on day two. Heterogeneity tests (I\u003csup\u003e2\u003c/sup\u003e = 0.0%, Q = 3.15, p \u0026gt; 0.05) and Eggers test (p = 0.18) were unremarkable. A leave-one-out analysis demonstrated that no single study influenced the overall recurrence rate significantly.\u003c/p\u003e\n\u003cp\u003e3.4 Post-Operative Erectile Function (Figure 4)\u003c/p\u003e\n\u003cp\u003eApproximately 78% of the patients (n = 76) underwent postoperative erectile function assessment. Half of these patients (50%) reported satisfactory erectile function sufficient for sexual intercourse. However, no objective measures of erectile function, such as the IIEF-5 or SHIM scores, were used to quantify this outcome. Post-operative erectile function preservation at follow up was 51% (95% CI: 0.39-0.61). Heterogeneity was low amongst the included studies (I2 = 0.0%, Q = 5.87, p \u0026gt; 0.05). Eggers test indicated no evidence of funnel plot asymmetry (p = 0.79). Leave-one-analysis did not demonstrate any significant changes to the erection preservation rates at follow up.\u003c/p\u003e\n\u003cp\u003e3.5 Risk of Bias Assessment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe NOS risk of bias assessment demonstrated an intermediate risk of bias across all the included studies. All studies scored well in most selection domains and the outcome domains. However, because all studies were observational and lacked a predefined control or placebo group, they were rated as having a high risk of bias in selection domain 2 (Selection of Non-Exposed Cohort) and in comparability. As a result, all the studies scored a six out of nine, placing them at intermediate risk of bias.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eRefractory ischaemic priapism represents a challenging urological emergency. As priapism represents a compartment syndrome of the penis, rapid decompression is crucial to prevent irreversible damage and tissue necrosis. [1\u0026ndash;2] Guidelines recommend surgical management when conservative measures, such as aspiration and phenylephrine injection, fail to achieve detumescence. [3\u0026ndash;5] Although no single surgical technique has proven superior, available options range from distal to proximal shunts. [2] This study focuses on Penoscrotal Decompression (PSD), a novel technique described in the last decade. Early evidence demonstrates promising outcomes with PSD, including good detumescence rates, low recurrence, and considerable preservation of erectile function.\u003c/p\u003e \u003cp\u003eAccording to the current standards of practice, the first line of surgical treatment following failed conservative management is the creation of a distal shunt. Distal shunts create a small fistulous tract between the corpus cavernosum and glans allowing trapped ischaemic blood to escape and, subsequently, promote detumescence. [1\u0026ndash;2] Known techniques include the Winter, Ebbehoj, and T-shunt procedures, all of which revolve around the same surgical principles. Although commonly used, they are associated with risks of failure and erectile dysfunction. [2] Proximal shunts, such as the Grayhack and Quackel shunts, have also been used but are less common due to complexity and higher morbidity rates. [2] Approximately 44% of patients included in this review had a failed distal shunt prior proceeding to PSD. Shunting is associated with poor long-term sexual adverse effects with studies reporting post-procedural erectile dysfunction rates ranging between 50\u0026ndash;96% [22\u0026ndash;24]. According to European Association of Urology (EAU) guidelines, shunt surgery is unlikely to be effective in maintaining erectile function after 36 hours of priapism. The consensus is that patients who present with prolonged priapism may benefit from early penile prosthesis implantation, as shunt procedures typically fail to preserve erectile function beyond a certain duration of ischaemic priapism. [5, 21]\u003c/p\u003e \u003cp\u003eGiven these limitations, Penoscrotal Decompression (PSD) has emerged as a potential alternative, offering improved functional outcomes in both early and late phases of treatment. The rarity of priapism complicates research efforts, as most available evidence comes from small, retrospective case series or individual case reports. To date, only two full manuscripts\u0026mdash;Fuchs et al. [6] and Baumgarten et al. [13] \u0026mdash;have been published on PSD, both reporting excellent detumescence rates (100% and 92%) low recurrence (0% and 8%), and partial preservation of erectile function (16% and 60%). Compared to distal shunt techniques, the early and late outcomes of PSD appear favourable. Similarly, PSD also demonstrates an advantage over early malleable penile implant insertion. Within similar patient populations, PSD had better long-term outcomes for RIP as 37.5% of patients who had early malleable penile implants required a total of 8 revision surgeries during a 41-month median follow up duration. [6] Interestingly, within PSD itself, unilateral and bilateral decompression were reported to deliver varying levels of success. Although difficult to discern from most included studies, between Fuchs et al. [6] and Baumgarten et al. [13] 14 unilateral and 17 bilateral decompressions were done. The former study suggests no difference in detumescence success between either approach, whereas the latter suggests that bilateral decompression is associated with better detumescence as they encountered two failures following unilateral decompressions which were then converted to a bilateral approach with subsequent success.\u003c/p\u003e \u003cp\u003eThe main limitation associated with the dataset available is the variability in approach and technique. For example, it is unclear whether decompression alone or additional manoeuvres (i.e. tunnelling, suctioning) were performed. Furthermore, decision-making criteria for unilateral versus bilateral PSD remain ambiguous. Baumgarten et al. [13] reported converting to bilateral PSD after two failed attempts with the unilateral approach, but other studies do not provide a clear rationale for offering patients unilateral or bilateral decompression. Additionally, limited follow-up periods and the lack of an objective tool to quantify erectile function restrict the ability to fully assess the long-term outcomes of PSD.\u003c/p\u003e \u003cp\u003eOverall, while understanding the difficulty associated with conducting a controlled study, a standardised technical and follow up approach in prospective series could perhaps produce more reliable data. Pooling data from different studies following similar standard approaches can further elucidate the role of PSD and its comparative efficacy to other more established surgical approaches, as one question that poses itself is PSD\u0026rsquo;s feasibility as a primary surgical approach to priapism, and whether the reported successful outcomes are dampened by the fact that its use is delayed as it is a second-line approach.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough a relatively novel technique, early evidence suggests that PSD is a promising approach for managing refractory ischemic priapism. One key advantage of PSD is the ability to access the corpora proximally without disrupting the distal tunica albuginea or the glans. Given the favourable outcomes reported thus far, PSD may eventually surpass distal shunts as a first-line treatment option for refractory priapism. However, given the novelty and scarcity of data, these presumptions are premature. There are yet several important questions to be answered about PSD, including its optimal position within the treatment algorithm (first-line versus second-line), the preferred laterality of approach (unilateral versus bilateral), and intra-operative prognostic markers to guide decisions between decompression alone and penile prosthesis insertion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM: Study Conception \u0026amp; Design, Data Collection \u0026amp; Analysis, Manuscript Writing \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eQI: \u0026nbsp;Study Conception \u0026amp; Design, Data Collection, Manuscript Writing\u003c/p\u003e\n\u003cp\u003eJH: Data Collection, Manuscript Writing \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eVB: Supervision, Manuscript Writing \u0026amp; Editing, Approval of Final Version\u003c/p\u003e\n\u003cp\u003eIP: Supervision, Manuscript Writing \u0026amp; Editing, Approval of Final Version\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSilberman M, Stormont G, Leslie SW, Hu EW. Priapism [Internet]. Nih.gov. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459178\u003c/li\u003e\n\u003cli\u003eLevey HR, Segal RL, Bivalacqua TJ. Management of priapism: an update for clinicians. Therapeutic Advances in Urology [Internet]. 2014 Jul 18;6(6):230\u0026ndash;44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236300/\u003c/li\u003e\n\u003cli\u003eMuneer A, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, et al. BAUS consensus document for the management of male genital emergencies: priapism. BJU International. 2018 Apr 10;121(6):835\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBivalacqua TJ, Allen BK, Brock GB, Broderick GA, Chou R, Kohler TS, et al. The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline. Journal of Urology. 2022 Jul;208(1):43\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eMilenkovic U, Cocci A, Veeratterapillay R, Dimitropoulos K, Boeri L, Capogrosso P, et al. Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel. International Journal of Impotence Research [Internet]. 2022 Sep 23; Available from: https://pubmed.ncbi.nlm.nih.gov/36151318/\u003c/li\u003e\n\u003cli\u003eFuchs JS, Shakir N, McKibben MJ, Mathur S, Teeple S, Scott JM, et al. Penoscrotal Decompression\u0026mdash;Promising New Treatment Paradigm for Refractory Ischemic Priapism. ▯The ▯journal of sexual medicine. 2018 Mar 14;15(5):797\u0026ndash;802.\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an Updated Guideline for Reporting Systematic Reviews. British Medical Journal [Internet]. 2021 Mar 29;372(71). Available from: https://www.bmj.com/content/372/bmj.n71\u003c/li\u003e\n\u003cli\u003eCovidence - Better systematic review management [Internet]. Covidence. 2023. Available from: https://www.covidence.org\u003c/li\u003e\n\u003cli\u003eWells G, Shea B, O\u0026rsquo;Connell D, Peterson J, Welch V, Losos M, et al. Ottawa Hospital Research Institute [Internet]. Ohri.ca. 2019. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp\u003c/li\u003e\n\u003cli\u003eWang N. Conducting Meta-analyses of Proportions in R. Journal of Behavioral Data Science [Internet]. 2023 Nov 7;3(2):64\u0026ndash;126. Available from: https://jbds.isdsa.org/jbds/article/view/60\u003c/li\u003e\n\u003cli\u003eYi Y, Davenport M, Cordon B, Gahan J, Bergeson R, Morey A. PD44-07\u0026emsp;PENOSCROTAL DECOMPRESSION AS A GLANS SPARING ALTERNATIVE TO SHUNT PROCEDURES FOR SURGICAL RELIEF OF REFRACTORY ISCHEMIC PRIAPISM. Journal of Urology. 2019 Apr;201(Supplement 4).\u003c/li\u003e\n\u003cli\u003eKhater U, Ramasamy R, Shah HN. Tamsulosin-Induced Priapism: Report of Two Cases and Review of Literature. Journal of Endourology Case Reports. 2020 Sep 1;6(3):174\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBaumgarten AS, VanDyke ME, Yi YA, Keith CG, Fuchs JS, Ortiz NM, et al. Favourable multi‐institutional experience with penoscrotal decompression for prolonged ischaemic priapism. BJU International. 2020 Jul 31;126(4):441\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eYi Y, Baumgarten A, Keith C, Ortiz N, Davenport M, Cordon B, et al. 357 Penoscrotal Decompression as a Glans Sparing Alternative to Shunt Procedures for Surgical Relief of Refractory Ischemic Priapism. The Journal of Sexual Medicine. 2020 Jan 1;17(Supplement_1):S96\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMallory CW, Lopategui DM, Cordon BH. Melanotan Tanning Injection: A Rare Cause of Priapism. Sexual Medicine. 2021 Feb;9(1):100298.\u003c/li\u003e\n\u003cli\u003eOttaiano N, Sanekommu G, Koller C, Hellstrom W, Morey A, Raheem O. V12-12\u0026emsp;PENOSCROTAL DECOMPRESSION OF REFRACTORY ISCHEMIC PRIAPISM: SURGICAL TECHNIQUE. Journal of Urology. 2022 May;207(Supplement 5).\u003c/li\u003e\n\u003cli\u003eLee WG, Wardak S, Ralph D. (244) Penoscrotal Decompression: A New Paradigm for Managing Prolonged Ischemic Priapism. The Journal of Sexual Medicine. 2023 May 1;20(Supplement_1).\u003c/li\u003e\n\u003cli\u003eM Elkholy, Zahran A, F Yafi. (160) Prospective Evaluation of Proximal Decompression for the Management of Refractory Ischemic Priapism. The Journal of Sexual Medicine [Internet]. 2024 Mar 1 [cited 2024 Nov 9];21(Supplement_2). Available from: https://doi.org/10.1093/jsxmed/qdae002.146\u003c/li\u003e\n\u003cli\u003eQian L, Reddy A, Izquierdo-Pretel G, Swain S. Successful Management of Prolonged Acute Ischemic Priapism With Penoscrotal Decompression: A Case Report and Review of the Literature. Cureus [Internet]. 2023 Mar 27 [cited 2023 Nov 3]; Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10132700/#:~:text=Intracavernosal%20injection%20of%20Trimix%20(a\u003c/li\u003e\n\u003cli\u003eAkula KP, Hofer MD. Rapid adoption of penoscrotal decompression for ischemic priapism in private practice. Urology Case Reports. 2024 Mar;53:102681.\u003c/li\u003e\n\u003cli\u003eReed-Maldonado AB, Kim JS, Lue TF. Avoiding complications: surgery for ischemic priapism. Translational Andrology and Urology. 2017 Aug;6(4):657\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eEvangelos Zacharakis, Amr Abdel Raheem, Freeman A, Skolarikos A, Garaffa G, Christopher AN, et al. The Efficacy of the T-Shunt Procedure and Intracavernous Tunneling (Snake Maneuver) for Refractory Ischemic Priapism. 2014 Jan 1;191(1):164\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eOrta\u0026ccedil; M, \u0026Ccedil;evik G, Akdere H, Erme\u0026ccedil; B, Kadıoğlu A. Anatomic and Functional Outcome Following Distal Shunt and Tunneling for Treatment İschemic Priapism: A Single-Center Experience. The Journal of Sexual Medicine. 2019 Aug;16(8):1290\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eUnal S, Serkan Karakus, Comb WD, Burnett AL. Clinical outcomes of the Burnett \u0026ldquo;snake\u0026rdquo; maneuver shunt modification for ischemic priapism. The Journal of Sexual Medicine. 2024 Jul 6;21(8):723\u0026ndash;8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Causes of Ischaemic Priapism \u003csup\u003e[2-5]\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAetiological Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCauses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdiopathic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaematological/Vascular\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSickle Cell Disease\u003c/p\u003e\n \u003cp\u003eThalassemia\u003c/p\u003e\n \u003cp\u003eG6PD\u003c/p\u003e\n \u003cp\u003eHypercoagulable States\u003c/p\u003e\n \u003cp\u003eVasculitis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOncological\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInfiltrative: Bladder, Prostate, Urethra, Testis, Rectum\u003c/p\u003e\n \u003cp\u003eMetastatic: Lung, Renal\u003c/p\u003e\n \u003cp\u003eOther: Leukaemia, Multiple Myeloma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfectious\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBites\u003c/p\u003e\n \u003cp\u003eToxins\u003c/p\u003e\n \u003cp\u003eRabies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeurogenic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNeurosyphilis\u003c/p\u003e\n \u003cp\u003eSpinal Cord Injuries\u003c/p\u003e\n \u003cp\u003eCauda Equine Syndrome\u003c/p\u003e\n \u003cp\u003eAutonomic Neuropathies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMetabolic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eAmyloidosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrug-Induced\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 413px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVasoactive Agents\u003c/p\u003e\n \u003cp\u003eAlpha-Adrenergic Receptor Agonists\u003c/p\u003e\n \u003cp\u003eAnxiolytics\u003c/p\u003e\n \u003cp\u003eAnti-Depressants\u003c/p\u003e\n \u003cp\u003eAnti-Hypertensives\u003c/p\u003e\n \u003cp\u003eHormones\u003c/p\u003e\n \u003cp\u003eRecreational\u003c/p\u003e\n \u003cp\u003eAnaesthesia (Spinal)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2: Different shunts used in the management of refractory ischaemic priapism \u003csup\u003e[2]\u003c/sup\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4606%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Shunt\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTechnique Name\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7723%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 54.8926%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003ePercutaneous Distal Shunts\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 17.4606%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eWinter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.278%;\"\u003e\n \u003cp\u003eCorporoglanular fistulae created using a large biopsy needle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eEbbehoj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.278%;\"\u003e\n \u003cp\u003eCorporoglanular fistulae created using a #11 blade\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eT-Shunt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.278%;\"\u003e\n \u003cp\u003eSimilar to an Ebbehoj shunt with an additional modification: Lateral rotation of a #10 blade 90\u003csup\u003eo\u003c/sup\u003e away from the urethral meatus to widen the corporoglanular fistulae\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4606%;\"\u003e\n \u003cp\u003e\u003cem\u003eOpen Distal Shunts\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.5809%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 17.4606%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eAl-Ghorab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.0996%;\"\u003e\n \u003cp\u003eGlanular incision followed by the excision of a cone segment of the distal tunica albuginea.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eBurnett\u0026rsquo;s (Snake) Manoeuvre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.0996%;\"\u003e\n \u003cp\u003eSimilar to Al-Ghorab with an additional modification: Corporal dilation with Hegar dilators and evacuation of ischaemic blood.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 75.2199%;\"\u003e\n \u003cp\u003e\u003cem\u003eProximal Shunts\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 17.4606%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eQuackel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.0996%;\"\u003e\n \u003cp\u003eIncised/excised ellipse-shaped defects from spongosial and coroporal anastomosed together.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eGrayhack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.0996%;\"\u003e\n \u003cp\u003eSaphenous vein ligation and anastomosis to corpora cavernosa.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6598%;\"\u003e\n \u003cp\u003eBarry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.0996%;\"\u003e\n \u003cp\u003eDorsal penile vein (superficial or deep) ligation with anastomosis to corpora cavernosa.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3: Study Characteristics \u0026amp; Baseline Data\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"964\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Name \u0026amp; Year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAetiology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Priapism\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSD Laterality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eFuchs 2018\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced - 3\u003cbr\u003e\u0026nbsp;SCD - 2\u003cbr\u003e\u0026nbsp;Idiopathic - 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eMedian:\u003c/p\u003e\n \u003cp\u003e60h (Range: 7-168)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eUnilateral - 4\u003cbr\u003e\u0026nbsp;Bilateral - 2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eYi 2019\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced - 8\u003cbr\u003e\u0026nbsp;SCD - 4\u003cbr\u003e\u0026nbsp;Idiopathic - 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eMean 61.2h\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eKhater 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCase Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced (Tamsulosin)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e72h\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eBaumgarten 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced - 19\u003cbr\u003e\u0026nbsp;SCD - 2\u003cbr\u003e\u0026nbsp;Idiopathic - 3\u003cbr\u003e\u0026nbsp;Other - 1 constriction device\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eMean: 71h\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eUnilateral - 10\u003cbr\u003e\u0026nbsp;Bilateral - 15\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eYi 2020\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e66.2h (6-168)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eUnilateral - 12\u003cbr\u003e\u0026nbsp;Bilateral - 10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eMallory 2021\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCase Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e30h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eOttiano 2022\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCase Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e72h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eGin 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug-Induced/Iatrogenic - 6\u003cbr\u003e\u0026nbsp;Idiopathic - 5\u003cbr\u003e\u0026nbsp;SCD - 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003eMedian:\u003c/p\u003e\n \u003cp\u003e48h \u0026nbsp;(IQR 38-56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eUnilateral - 4\u003cbr\u003e\u0026nbsp;Bilateral - 9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eElkholy 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e48h-240h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eQian 2023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCase Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.0041%;\"\u003e\n \u003cp\u003e\u003cem\u003eAkula 2024\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.0249%;\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003eCase Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDrug Induced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-impotence-research","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijir","sideBox":"Learn more about [International Journal of Impotence Research](http://www.nature.com/ijir/)","snPcode":"41443","submissionUrl":"https://mts-ijir.nature.com/cgi-bin/main.plex","title":"International Journal of Impotence Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5421547/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5421547/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePenoscrotal decompression (PSD) has emerged as a promising surgical intervention for refractory ischemic priapism, involving proximal corporotomies and the drainage of ischemic blood. Initial outcomes have shown high success rates in achieving detumescence, low recurrence rates, and relatively good preservation of erectile function. This meta-analysis aims to comprehensively evaluate PSD's effectiveness across three key metrics: detumescence, prevention of recurrence, and erectile function preservation. A systematic review and meta-analysis, following PRISMA guidelines, identified 11 publications that met the inclusion criteria. They encompassed five case reports, four abstracts, and two observational cohort studies, with data on 97 patients who presented with refractory ischemic priapism. Notably, around half (44.3%) of the patients had conventional distal shunts prior to PSD. Overall following PSD, detumescence was achieved in 92% (CI 95%, 0.84 to 0.95). Post-PSD recurrence of priapism occurred in 12% (95% CI, 0.06 to 0.21). Erectile function was preserved in 51% of the patients who had follow-up (95% CI, 0.39 to 0.61). These findings inform us that PSD proves to be a viable and effective surgical option for refractory ischaemic priapism with a key feature being better sexual function preservation outcomes. Given the paucity of data, further larger scale prospective studies of robust designs are still necessary to better establish PSD\u0026rsquo;s role within the treatment algorithm for refractory ischaemic priapism.\u003c/p\u003e","manuscriptTitle":"Overcoming Refractory Ischaemic Priapism: The Emergence of Penoscrotal Decompression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 15:34:45","doi":"10.21203/rs.3.rs-5421547/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-12-31T09:56:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-12-09T09:43:46+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-11-27T12:42:38+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-11-19T16:03:16+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-11-19T15:28:46+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2024-11-12T16:31:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-12T11:22:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-09T11:18:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Impotence Research","date":"2024-11-09T11:18:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-impotence-research","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijir","sideBox":"Learn more about [International Journal of Impotence Research](http://www.nature.com/ijir/)","snPcode":"41443","submissionUrl":"https://mts-ijir.nature.com/cgi-bin/main.plex","title":"International Journal of Impotence Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"76e93124-bd4a-4a04-bb54-adfbb569d395","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":40167362,"name":"Health sciences/Medical research"},{"id":40167363,"name":"Health sciences/Health care/Therapeutics"}],"tags":[],"updatedAt":"2025-03-13T07:12:00+00:00","versionOfRecord":{"articleIdentity":"rs-5421547","link":"https://doi.org/10.1038/s41443-025-01044-3","journal":{"identity":"international-journal-of-impotence-research","isVorOnly":false,"title":"International Journal of Impotence Research"},"publishedOn":"2025-03-12 04:00:00","publishedOnDateReadable":"March 12th, 2025"},"versionCreatedAt":"2024-12-17 15:34:45","video":"","vorDoi":"10.1038/s41443-025-01044-3","vorDoiUrl":"https://doi.org/10.1038/s41443-025-01044-3","workflowStages":[]},"version":"v1","identity":"rs-5421547","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5421547","identity":"rs-5421547","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}