Maurice M. Garcia, Alan W. Shindel and Tom F. Lue Department of Urology, University of California, San Francisco

Transcription

1 ET AL. GARCIA ET AL. BJUI BJU INTERNATIONAL Surgery Illustrted Surgicl Atls T-shunt with or without tunnelling for prolonged ischemic pripism Murice M. Grci, Aln W. Shindel nd Tom F. Lue Deprtment of Urology, University of Cliforni, Sn Frncisco ILLUSTRATIONS y STEPHAN SPITZER, PATHOPHYSIOLOGY OF PROLONGED ISCHAEMIC PRIAPISM Bsed on our clinicl oservtions nd findings from colour duplex ultrsonogrphy efore nd fter shunting procedures, we present n illustrted schemtic of the pthophysiology of ischemic pripism nd the role of conventionl proximl nd distl shunts. c d 90 INDICATIONS The T-shunt is indicted in cses of ischemic pripism tht re refrctory to intrcvernous injection of diluted α- drenergic medictions. In ischemic pripism of >3 dys durtion, tissue deth nd oedem cn ostruct lood flow from the proximl to distl corpus cvernosum; in these cses T-shunt lone might e insufficient to restore penile circultion nd considertion must e given to plcing ilterl T-shunt with tunnelling of ech corpus cvernosum, using rigid stright F urethrl sound or diltor. PLANNING AND PREPARATION It is helpful to sk the ptient to descrie the qulity nd loction of pin efore strting the procedure. The urologist should hve thorough discussion with the ptient out the indictions, risks nd enefits of the procedure. It is essentil to give cler explntion to the ptient tht informs him tht pripism of prolonged durtion, lone, is risk fctor for erectile dysfunction, nd the T-shunt procedure might not modify tht risk. This discussion should e witnessed y 1754 JOURNAL COMPILATION 2008 BJU INTERNATIONAL 102, doi: /j x x

2 SURGERY ILLUSTRATED third prty nd clerly documented in the medicl record, s pripism cn e litigious issue. Prophylctic ntiiotics for few dys is recommended. A mild sedtive is useful djunct. RELATIVE CONTRAINDICATIONS Bleeding dithesis; Phimosis. A dorsl slit will e required to expose the glns. A nrrow penis with corporl dimeter tht will not ccommodte #10 lde. NECESSARY EQUIPMENT AND INSTRUMENTS Sterile surgicl drpe. Locl nesthetics, e.g. 0.25% upivcine without drenline. Syringe with 25 G needle. #10-lde sclpel. 4 0 chromic suture. Topicl ntiiotic ointment F stright urethrl sounds or diltors. PATIENT POSITIONING The ptient is plced supine; the glns penis nd penile shft re prepred with ntiseptic solutions. Preprtion of the entire penis llows the surgeon to hndle the penile shft during surgery without cusing contmintion. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1755

3 GARCIA ET AL. Figure 1 Figure 1. In pripism of 1 2 dys durtion, moderte oedem of the erectile tissue within the corpor cvernos is expected. The key to successful restortion of corporl circultion is lrge shunt tht cn drin the tremendous flow from post-ischemic hyperemi. This lowers the intrcvernous pressure nd thus llows smooth muscle contrction nd detumescence. Figure 1. In pripism of >3 dys durtion there is severe oedem/tissue deth within the corpor cvernos (drk re). A cvernosum-glns shunt does not dequtely drin the proximl corpor. Figure 1c. Similrly, proximl cvernosumvenous or cvernosum-spongiosum shunt does not dequtely drin the distl corpor. Figure 1d. A ilterl T-shunt with tunnelling of the corpor cvernos estlishes chnnel for the lood to pss through the entire corpus cvernosum nd exit to the glns to estlish circultion. Our three-step tretment recommendtion sed on the pthophysiology of prolonged ischemic pripism comprises: (i) if <1 dy, evcution of old lood + diluted α-drenergic; (ii) if 1-3 dys, T shunt; (iii) if >3 dys, T-shunt + tunnelling. c d 1756 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

4 SURGERY ILLUSTRATED SURGICAL STEPS Figure 2 The glns, which typiclly remins soft in ischemic pripism due to lterntive venous dringe, is plpted to identify the tips of the corporl odies. The plnned incision sites re mrked on the prepred glns penis using surgicl mrking pen (Fig. 2). It is preferle to inject oth sides with nesthetic t the strt of the procedure. Bupivcine 0.25%, 1 2 ml, is injected loclly within the dermis of the glns overlying ech of the two mrked tips of the corpor cvernos (Fig. 2). JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1757

5 GARCIA ET AL. Figures 3 nd 4 The #10-lde sclpel is positioned verticlly nd prllel to the urethrl metus over the mrked glns incision site. The lde cn e fcing up or down, dependng on surgeon preference. The #10-lde sclpel is dvnced into the glns to penetrte the tip of the ipsilterl corpus cvernosum until the hu is t the skin level. The sclpel lde is rotted 90 lterlly (i.e. lwys wy from the urethr). The sclpel is then withdrwn JOURNAL COMPILATION 2008 BJU INTERNATIONAL

6 SURGERY ILLUSTRATED JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1759

7 GARCIA ET AL. Figure 5 The se of the penile shft is grsped firmly, nd drk, deoxygented lood is milked out through the incision site. The superficil tissue edges of the glns incision site re closed with continuous 4 0 chromic sutures. Cre is tken to void plcing the sutures too deeply, s inclusion of deep glns tissue cn impir lood circultion through the newly creted shunt. The ptient is oserved for 15 min fter skin closure to ensure tht pripism does not recur JOURNAL COMPILATION 2008 BJU INTERNATIONAL

8 SURGERY ILLUSTRATED Figure 6 The rigidity of the penis is ssessed y using the thum nd index fingers to squeeze the corpor cvernos together t the level of the penile mid-shft. The procedure is considered successful if the ptient reports relief of the dull ischemic pin within the penile shft, nd if the penis is sufficiently soft tht cm indenttion cn e mde into the lterl spect of ech corporl ody. Topicl ntiiotic ointment is pplied to dress the wound, nd the ptient is dischrged fter period of oservtion. If the penis remins rigid, or if rigidity recurs within 15 min of cretion of unilterl T-shunt, the procedure is repeted on the contrlterl side. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1761

9 GARCIA ET AL. Figure 7 In ischemic pripism of >3 dys durtion nd/or when the penis is quite firm fter repeted milking, we would plce ilterl T- shunts followed y intrcvernous tunnelling using stright urethrl sound or diltor. To crete tunnelling of the corpor cvernos, stright F stright urethrl sound or diltor is inserted through ech glns incision nd dvnced to the penile crur. To determine how fr the sound will need to e dvnced such tht the tip of the sound reches the crur of the corpor cvernos, the sound is lid over the penile shft nd 3 5 cm is dded to the distnce from the glns to the peno-puic junction. After creting T-shunt, the sound is inserted into the corpus cvernosum gently nd orientted slightly lterlly ( 10 ) to ensure tht the tip of the sound is never dvnced towrd, or through, the urethr. Bilterl incision sites re closed with 4 0 chromic continuous sutures nd the wound is clened, dried nd dressed with only topicl ntiiotic ointment. Constrictive or circumferentil dressings re voided, s pressure from these cn limit dringe through the shunt(s). If the rigidity of the penis returns fter the procedure, colour duplex ultrsonogrphy is used to ssess lood flow within the cvernous rteries. The presence of lood flow is indictive of n open shunt, while sence of lood suggests recurrent pripism. However, it is importnt to consider tht in the gret mjority of cses of ischemic pripism lsting 5 dys, the cvernosl rteries might lredy e thromosed nd one might not e le to detect lood flow in the cvernous rtery fter T-shunt nd tunnelling JOURNAL COMPILATION 2008 BJU INTERNATIONAL

10 SURGERY ILLUSTRATED Figure 8 Figure 8 shows colour duplex ultrsonogrm when ischemic pripism recurs; there is no detectle rteril flow within the corpor. Figure 8 shows colour duplex ultrsonogrm fter successful T-shunt procedure; note the presence of high rteril flow within the cvernous rtery. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 1763

11 GARCIA ET AL. POSTOPERATIVE WOUND CARE The ptient should e counselled to stin from sexul ctivity involving the penis until the sorle sutures hve completely disppered (usully 2 3 weeks), nd the incision site is well heled. Antiiotic ointment should e pplied to the incision site(s) two or three times per dy. Appliction of circumferentil nd/or constrictive dressings to the penis should e voided. POSTOPERATIVE EVALUATION When in dout, colour duplex ultrsonogrphy cn e used to differentite recurrent ischemic pripism (no flow in the cvernous rteries) from post-ischemic hyperemi (high flow in the cvernous rteries). Assessment of oxygen nd cron dioxide tension in lood smple otined from the corpor cn lso e helpful. It might tke 4 6 h for cvernous lood gs vlues to ecome cidotic nd ischemic. The ville option if the T-shunt fils, is tunnelling with lrger sound or diltor through lrge Al Ghor type incision. SURGEON TO SURGEON With pripism of extended durtion (>36 h), only prtil detumescence cn e expected fter successful shunting. This is due to tissue deth, oedem nd postischemic hyperemi. It is common to dout the success of the shunt procedure in the light of such scenrio fterwrd. Clues tht the shunt hs een successful include: The ptient reports relief of pin within the penile shft (lthough pin t the glns incision sites is to e expected). The penile shft cn e squeezed nd deformed using the thum nd index fingers. If there is ny dout out the success of T- shunt with or without corporl tunnelling, penile colour duplex ultrsonogrphy cn e used to confirm the restortion of rteril lood flow to the corpor. In pripism of extended durtion, reestlishment of cvernosl lood circultion requires lrge shunt s well s n intrcvernous tunnel, to llow lood flow from proximl to distl portion of the corpus cvernosum efore its exit vi the cvernosum-glns shunt. Correspondence: Tom F. Lue, 400 Prnssus St, Suite A-610, Sn Frncisco, CA , USA. e-mil: tlue@urology.ucsf.edu 1764 JOURNAL COMPILATION 2008 BJU INTERNATIONAL