The etiology and treatment of urethro-cavernosal fistula following surgical shunting procedure for low-flow priapism.

Priapism is an uncommon condition defined by prolonged erection in the absence of sexual excitement or desire. Although most cases are idiopathic, the majority of low flow priapism is associated with systemic diseases, in particular sickle cell disease and leukemia, or intracavernosal injection therapy for impotence. When the standard therapy of intracavernosal adrenergic agents with/without intracavernosal aspiration irrigation does not result in detumescence, a variety of surgical shunting procedures (proximal and distal approaches) have been used to direct blood from the corpora cavernosa into the low-pressure spongiosal system. A recognized complication involves inadvertent entry into the urethra at time of corpora-spongiosal shunt creation. Urethro-cavernosal fistulas are challenging complications that have resulted following shunting procedures. Multiple approaches have been used depending on the extent and location of the fistula. The following review encompasses two iatrogenic urethro-cavernosal fistulas and their surgical treatment. Two patients with low-flow priapism failed medical management (hydration, exchange transfusion, etc) and minimally invasive procedures (aspiration, *-adrenergic instillation, etc). They underwent bilateral cavernosal-spongiosal shunts. Follow-up revealed cavernosal-urethra fistulas. Repair was different in the two cases involving a fasciocutaneous tissue flap in one case while the other utilized a two-stage repair using a buccal flap. Prolonged low-flow priapism may need surgical management involving proximal bilateral corporo-spongiosal shunts (Quackles procedure). Overly aggressive incision into the corpora-spongiosum can result in corporo-spongiosal fistula formation. Surgical treatment of this complication involves careful repair using tissue flaps for successful resolution. Priapism is an uncommon condition defined by prolonged erection in the absence of sexual excitement or desire. Although most cases are idiopathic, the majority of low flow priapism is associated with systemic diseases, in particular sickle cell disease and leukemia, or intracavernosal injection therapy for impotence. When the standard therapy of intracavernosal adrenergic agents with/without intracavernosal aspiration irrigation does not result in detumescence, a variety of surgical shunting procedures (proximal and distal approaches) have been used to direct blood from the corpora cavernosa into the low-pressure spongiosal system. A recognized complication involves inadvertent entry into the urethra at time of corpora-spongiosal shunt creation. Urethro-cavernosal fistulas are challenging complications that have resulted following shunting procedures. Multiple approaches have been used, depending on the extent and location of the fistula. The following review encompasses two iatrogenic urethro-cavernosal fistulas and their surgical treatment. Two patients with low-flow priapism failed medical management (hydration, exchange transfusion, etc) and minimally invasive procedures (aspiration, *-adrenergic instillation, etc). They underwent bilateral cavernosal-spongiosal shunts. Follow-up revealed cavernosal-urethra fistulas. Repair was different in the two cases involving a fasciocutaneous tissue flap in one case while the other utilized a two-stage repair using a buccal flap. Prolonged low-flow priapism may need surgical management involving proximal bilateral corporo-spongiosal shunts (Quackles procedure). Overly aggressive incision into the corpora-spongiosum can result in corporo-spongiosal fistula formation. Surgical treatment of this complication involves careful repair using tissue flaps for successful resolution.

Jeffrey Bejma, Maurice Garcia, Jack McAninch, and Wayne J.G. Hellstrom. Tulane University School of Medicine, New Orleans, LA. San Francisco General Hospital, San Francisco, CA.