Immediate prosthesis insertion key for treating ischemic priapism

London-Immediate insertion of a penile prosthesis as a treatment for acute refractory ischemic priapism resolves the acute episode of ischemic penile pain and treats the inevitable erectile dysfunction, according to a recent study.

Immediate insertion was surgically easier with fewer complications than delayed insertion of the penile prosthesis. In addition, it was associated with a lower rate of infection while preserving penile length in a series of men with refractory ischemic priapism treated at a single institution, reported first author Evangelos Zacharakis, MD, senior clinical fellow at St. Peter’s Andrology Centre, University College Hospital, London.

“Our take-home message is that if you make the decision to insert an implant in the priapism patient, it is better to do it sooner rather than later, as it will preserve the penile length; you’ll have less risk of infection or erosion; and the satisfaction rate is going to be better,” said Dr. Zacharakis, who worked on the study with David J. Ralph, BSc, MS, and colleagues.

Ischemic priapism is a surgical emergency. Persistent ischemia within the corpus cavernosum leads to irreversible cavernosal smooth muscle necrosis and the development of cavernosal fibrosis and severe erectile dysfunction. Waiting to insert the prosthesis can add difficulty to the procedure because corporal fibrosis may require an additional corporotomy and a scarred corporeal body can only accommodate shorter prostheses, Dr. Zacharakis said. A loss of penile length has been shown to decrease satisfaction rates following penile prosthetic surgery.

To help clarify the optimal timing of insertion of a penile prosthesis in men with ischemic priapism unresponsive to conservative management, the long-term results of immediate and delayed insertion of penile prosthesis were examined in a series of 95 men with refractory ischemic priapism who were treated at St. Peter’s Andrology Centre and the Institute of Urology at University College Hospital.

The etiology of the priapism was related to the use of antipsychotic agents in 27 patients, hemoglobinopathy in 39 patients, and was idiopathic in 29 patients.
Conservative management by aspiration and instillation of alpha-agonists had failed to resolve the priapism, and 28 patients had unsuccessful T-shunt surgery performed.

Sixty-eight men had immediate insertion; 64 had a malleable prosthesis inserted and four had an inflatable prosthesis. Twenty-seven had delayed insertion (12 malleable and 15 inflatable). The median time of priapism before prosthesis insertion was 171 hours in the group that underwent immediate insertion and 5 months in those with delayed insertion.

High satisfaction rate in immediate group
In the immediate insertion group, dilatation of the corpora was “easy in all cases,” said Dr. Zacharakis, who presented the findings at the 2012 AUA annual meeting in Atlanta. Minor distal fibrosis was encountered in six patients. After a median of 17 months, six revisions were needed, five because of infection and one due to curvature. Overall satisfaction was 96% without penile shortening (65 out of 68 patients had successful resumption of intercourse at follow-up).

In the group with delayed insertion, dense fibrosis made corporal dilatation difficult, Dr. Zacharakis said, necessitating a second distal corporal incision in 80%. After a mean follow-up of 21 months, seven patients required revision surgery, five because of infection, one due to erosion, and one due to mechanical failure. Twenty-five of the 27 patients patients are able to engage in sexual intercourse, but significant penile shortening resulted in a dissatisfaction rate of 40%.UT