(176) DECOMPRESSION, SUBCORONAL INTERNAL SHUNT AND TUNNELING (DESIST), A NOVEL TECHNIQUE FOR PRIAPISM: BALANCING EFFICACY AND MORBIDITY
Authors: Sun A , Babbar P 
Published: December 2024

Abstract

Introduction
Acute ischemic priapism is a urological emergency characterized by prolonged penile erection leading to tissue ischemia and potential erectile dysfunction. Classically, refractory ischemic priapism (RIP) was managed with distal shunt procedures performed through the glans penis, sometimes in combination with corporal tunneling. While such techniques are effective in creating an outflow pathway, they result in significant trauma to the glans penis and subsequent scarring and disfigurement. Penoscrotal decompression, a newer technique which is rapidly gaining popularity, is atraumatic to the glans but does not establish a shunt for continued blood outflow, and may be challenging for surgeons not accustomed to the penoscrotal exposure.

Objective
Here, we describe a novel technique-named Decompression, Subcoronal Internal Shunt and Tunneling (DeSIST) designed to combine the benefits of existing methods while minimizing associated morbidity.

Methods
The DeSIST procedure involves a small subcoronal incision on one side of the penis to expose the distal corpus cavernosum. Controlled decompression is achieved by creating a small 1 cm incision in the tunica albuginea and evacuating clotted blood. Tunneling is then performed by passing a pediatric sucker or small 9 mm brooks dilator down the channel of the corpora, establishing an outflow tract for pressurized blood. Subsequently, nasal speculum is placed inside the corpora distally and passed to the tip of the corpora. Between the tines of the nasal speculum, an 11 blade is then passed until it is felt to cut into the distal corporal tip. This 11 blade can then be spun in a similar fashion to the classic “T-shunt,” therefore creating a small defect in the distal corporal tip, but crucially, without violating the integrity of the glans penis. Thus, the “internal” shunt is created while sparing the glans. The corporotomy is then closed. Visualization of the glans penis becoming engorged with blood after closure of the corporotomy confirms that the cavernosal-spongiosal shunt has been created. These steps can then be repeated on the contralateral side if necessary to achieve complete detumescence.

Results
The DeSIST technique was utilized on two patients who presented with priapism of &gt;36 hours and who failed aspiration/irrigation in the emergency room and did not want immediate penile prosthesis placement. Both patients underwent the DeSIST procedure unilaterally and achieved immediate detumescence. 3 month follow up revealed adequate return of post-surgery erectile function aided by PDE5 inhibitors. Both patients evaluated the cosmetic appearance of the glans and subcoronal scar as excellent.

Conclusions
The DeSIST technique offers a promising alternative for the surgical management of acute ischemic priapism. This technique effectively balances the need for immediate detumescence and the establishment of an outflow shunt while significantly reducing morbidity associated with glans scarring. Further studies with larger sample sizes and long-term follow-up are warranted to establish the definitive benefits and potential limitations of this novel approach.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Andrew Sun - Consultant for Boston Scientific, Marius Pharma, Endo Pharma. Paurush Babbar - Consultant for Boston Scientific.