(111) Clinical Practice Patterns for Surgical Shunts and Penile Prosthesis Placement in Men with Priapism – A Retrospective Claims Database Analysis
Authors: Sury K , Kohn T , Bivalacqua T 
Published: May 2023

Abstract

Introduction
New AUA/SMSNA guidelines for management of acute ischemic priapism have been released, but actual practice patterns can be difficult to assess as overall incidence is low and men often seek care at multiple institutions.

Objective
To assess the rates of surgical shunting and prosthetic placement for acute ischemic priapism using a large multi-institutional claims database.

Methods
A US claims database network (TriNetX Diamond Network) was queried from 2010 to 2020. We constructed a cohort of men ages ≥16 years old with 1) a diagnosis of priapism (ICD-10: N48.4) and 2) who had undergone an irrigation of the corpora cavernosa for priapism (CPT: 54220). We assessed the number of men who then had a surgical penile shunt (corpora cavernosa-glans penis fistulation [CPT: 54435], corpora cavernosa-corpus spongiosum shunt [CPT: 54430], or corpora cavernosa-saphenous vein shunt [CPT: 54420]) or penile prosthesis placement (insertion of penile prosthesis inflatable and self-contained [CPT: 54401], insertion of semi-rigid penile prosthesis [CPT 54400], or insertion of multiple component inflatable penile prosthesis [CPT: 54405]). Time to surgical procedure and order of procedures were collected, as well as background information including age, race, diabetes status (ICD-10: E11), hyperlipidemia status (ICD-10: E78), sickle cell status (ICD-10: D57.0-1), and if men were classified to have drug-induced priapism (ICD-10: N48.33).

Results
6,392 men were identified with the diagnosis of priapism and the procedure of corpora cavernosa irrigation. Of these men, 693 (11%) proceeded to surgical shunt (94 had corpora cavernosa-glans penis fistulation, 321 men had corpora cavernosa-corpus spongiosum shunt, and 78 men had corpora cavernosa-saphenous vein shunt). 144 men (2%) underwent initial penile prosthesis placement (Figure 1). Of the men undergoing initial penile prosthesis 94 (65%) occurred within the first year of the initial corpora cavernosal irrigation with the majority (81 of 94, 86%) being 3-piece inflatable penile prostheses and the majority in a “delayed” manner between 3 to 12 months after initial priapism irrigation (Table 1). Men who underwent initial penile prosthesis placement were older (55.1±13.0 vs 43.0±13.7 years, p&lt;0.0001) and more often white (23% vs 16%, p=0.03), with higher rates of erectile dysfunction (56% vs 9%, p&lt;0.0001), type 2 diabetes (32% vs 13%, p&lt;0.0001), and hyperlipidemia (47% vs 20%, p&lt;0.0001) when compared to men who underwent initial penile shunt procedure (Table 2). Finally, when assessing choice of initial shunts versus initial penile prosthesis pre- and post-2015, overall rates of initial shunt (10.0% vs 8.5%, p&lt;0.0001) and initial prosthesis (3.1% vs 2.1%, p&lt;0.0001) were significantly lower after 2015 when compared with rates prior to 2015.

Conclusions
In this US claims-based analysis of men presenting with ischemic priapism and treated with initial irrigation, we found that a small percentage (11%) continued to surgical shunting. Only 2% were managed with an initial prosthesis, most often a 3-piece device in a delayed manner. Men receiving initial prostheses were more likely to have more comorbidities, and overall surgical management of priapism has decreased overtime. In the setting of the new AUA/SMSNA guidelines, this data provides real-world practice patterns.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Urogen Pharma, Janssen Global Services, Regeneron Pharmaceuticals