title: The efficacy of the T-shunt procedure and intracavernous tunneling (snake maneuver) for refractory ischemic priapism.
abstract: OBJECTIVE
  The current management of ischemic priapism that is refractory to conventional medical therapy is a form of shunt procedure that diverts blood away from the corpus cavernosum. We assessed the outcome of the T-shunt and intracavernous tunneling for the management of ischemic priapism.
  
  
  METHODS
  During a 36-month period 45 patients presented with prolonged ischemic priapism. Patients were divided into subgroups according to the duration of priapism. All patients had an unsuccessful primary treatment, and underwent a T-shunt and intracavernous tunneling with cavernous muscle biopsies. All patients completed an IIEF-5 (International Index of Erectile Function-5) questionnaire preoperatively and 6 months postoperatively.
  
  
  RESULTS
  Resolution of the priapism using a T-shunt and snake maneuver occurred in all patients with a priapism duration of less than 24 hours and in only 30% of those with priapism lasting more than 48 hours. After a 6-month median followup the IIEF-5 score was significantly reduced from a mean of 24 (range 23 to 25) preoperatively to 7.7 (range 5 to 24), which was related to the duration of the priapism (p <0.0005). All patients with priapism for more than 48 hours had necrotic cavernous smooth muscle on biopsy and had severe erectile dysfunction requiring the insertion of a penile prosthesis. Those patients with moderate and mild erectile dysfunction were treated with phosphodiesterase type 5 inhibitors.
  
  
  CONCLUSIONS
  The success of the T-shunt with snake tunneling is dependent on the duration of priapism. When it is less than 24 hours the results are favorable, although erectile dysfunction is still present in 50% of patients. In those with a priapism duration greater than 48 hours the technique usually fails to resolve the priapism and all patients end up with erectile dysfunction due to smooth muscle necrosis.
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom; 2nd Department of Urology, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Zacharakis
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom.
authors.forename: Amr Abdel
authors.initials: AA
authors.lastname: Raheem
authors.affiliation: Histopathology Department, University College Hospital London, London, United Kingdom.
authors.forename: Alex
authors.initials: A
authors.lastname: Freeman
authors.affiliation: 2nd Department of Urology, National and Kapodistrian University of Athens, Athens, Greece.
authors.forename: Andreas
authors.initials: A
authors.lastname: Skolarikos
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom.
authors.forename: Giulio
authors.initials: G
authors.lastname: Garaffa
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom.
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Christopher
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom.
authors.forename: Asif
authors.initials: A
authors.lastname: Muneer
authors.affiliation: Institute of Urology, University College Hospital London, London, United Kingdom. Electronic address: dralph@andrology.co.uk.
authors.forename: David J
authors.initials: DJ
authors.lastname: Ralph
mesh_terms: D000328:Adult; D000368:Aged; D006801:Humans; D007511:Ischemia / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010413:Penis / Q000098:blood supply* / Q000601:surgery; D011317:Priapism / Q000150:complications / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome
keywords: ED; IIEF-5; International Index of Erectile Function; erectile dysfunction; fibrosis; ischemia; priapism