High flow priapism following the insertion of an inflatable penile prosthesis mimicking autoinflation: a case report.

Penile prosthesis implantation is a surgical option for erectile dysfunction when other treatments fail or the patient prefers implantation. Although penile prosthesis is generally considered safe and effective, various complications have been reported in the literature. High-flow priapism, resulting from an arteriovenous fistula between the cavernosal artery and the corpora cavernosa, is a rare complication after penile prosthesis implantation. Managing the condition as autoinflation may lead to unfortunate complications. A 54-year-old male patient underwent a penile prosthesis implantation due to erectile dysfunction lasting for 5 years. Doppler ultrasound revealed arterial insufficiency that was refractory to oral and intracavernosal treatments. A 3-piece inflatable penile prosthesis (Coloplast - Titan) was implanted through a midline penoscrotal incision without any complications. The patient reported uncontrolled tumescence after activating the device, which led us to suspect autoinflation. The final diagnosis was high-flow priapism due to an arteriovenous fistula in the cavernosal artery. The patient was given an antiandrogenic medication and the prosthesis was deflated for 3 months. The fistula closed without any additional intervention. High-flow priapism is a rare but potential complication of penile prosthesis implantation. Careful evaluation and management of patients' symptoms are necessary for diagnosing and treating this condition. This case highlights the importance of considering high-flow priapism as a potential cause of uncontrolled tumescence after penile prosthesis implantation and the possibility of successful non-surgical management.

Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling?

Prolonged ischemic priapism presents a treatment challenge given the difficulty in achieving detumescence and effects on sexual function. To evaluate current practice patterns, an open, web-based multi-institutional survey querying surgeons' experience with and perceived efficacy of tunneling maneuvers (corporoglanular tunneling and penoscrotal decompression), as well as impressions of erectile recovery, was administered to members of societies specializing in male genital surgery. Following distribution, 141 responses were received. Tunneling procedures were the favored first-line surgical intervention in the prolonged setting (99/139, 71.2% tunneling vs. 14/139, 10.1% implant, p < .001). Although respondents were more likely to have performed corporoglanular tunneling than penoscrotal decompression (124/138, 89.9% vs. 86/137, 62.8%, p < .001), penoscrotal decompression was perceived as more effective among those who had performed both (47.3% Very or Extremely Effective for penoscrotal decompression vs. 18.7% for corporoglanular tunneling; p < .001). Many respondents who had performed both tunneling procedures felt that most regained meaningful sexual function after either corporoglanular tunneling or penoscrotal decompression (33/75, 44.0% vs. 33/74, 44.6%, p = .942). While further patient-centered investigation is warranted, this study suggests that penoscrotal decompression may outperform corporoglanular tunneling for prolonged priapism, and that recovery of sexual function may be higher than previously thought after tunneling procedures.

Erectile response profiles of men using PDE5 inhibitors combined with intracavernosal injections as part of a penile rehabilitation program after radical prostatectomy.

BACKGROUND: Phosphodiesterase type 5 (PDE5) inhibitor labeling states that these agents should not be used in conjunction with other erectogenic medications for fear of priapism occurring. AIM: We explored the risk of priapism and prolonged erections in men in our post-radical prostatectomy (RP) penile injection program who were using regular PDE5 inhibitor and intracavernosal injections (ICIs) as part of their rehabilitation program. METHODS: The study cohort included men on penile injection therapy who (1) were taking tadalafil 5 mg daily or taking sildenafil 25 mg on noninjection days, (2) had an RP, (3) were using their respective PDE5 inhibitor regularly at the time of penile injection training, and (4) complied with the program instructions regarding penile injection use. Demographics, comorbidity details, PDE5 inhibitor dose and utilization, and injection dose and utilization data were collected. All patients underwent in-office injection training and used trimix (papaverine/phentolamine/prostaglandin E1) as the intracavernosal medication. OUTCOMES: Priapism was defined as a patient self-reported penetration hardness erection ≥4 hours in duration, while prolonged erection was defined as a penetration hardness erection lasting ≥2 hours. RESULTS: A total of 112 tadalafil users and 364 sildenafil users were compared. Mean age and duration post-RP were 62 ± 14 years and 5.2 ± 12 months, respectively, and there was no difference between tadalafil and sildenafil groups. The mean trimix dose was tadalafil 24 ± 24 units and sildenafil 31 ± 37 units (P < .05). Priapism occurred in 2 (1.7%) of 112 tadalafil users and 5 (1.4%) of 364 sildenafil users (P = .47). Excluding those men experiencing priapism on any occasion, those with any reported penetration hardness erection lasting ≥2 hours were 7 (6.3%) of 112 tadalafil users and 12 (3.3%) of 364 sildenafil users (P < .01). A total of 53% of these prolonged erections occurred within the first 6 injections at home (no difference between tadalafil and sildenafil groups). CLINICAL IMPLICATIONS: We emphasize the need for continued monitoring and education on proper injection techniques to minimize the risk of adverse events in ICI and PDE5 inhibitor combination therapy. STRENGTHS & LIMITATIONS: This study has a relatively large patient population with a considerable follow-up time. Additionally, the rigorous training, education, and monitoring of the participants, as well as the use of formal definitions for priapism and prolonged erections, enhances the accuracy and reliability of the results. However, there are some limitations, such as social desirability, confounding factors, and recall bias. CONCLUSION: There is no significant difference in the incidence of priapism in an ICI program in which men combine ICI with tadalafil or sildenafil. However, tadalafil patients had a higher rate of prolonged erections, which was found to occur mostly early during the titration phase.

Penile implants in low flow priapism.

Priapism is a persistent or prolonged erection, in the absence of sexual stimulation, that fails to subside. Prolonged ischaemic or low flow priapism is defined as a full or partial erection persisting for more than 4 h and unrelated to sexual interest or stimulation, characterised by little or no cavernous blood flow. Low flow priapism leads to progressive corporal fibrosis, which could, in turn, lead to long-lasting erectile dysfunction if left untreated. Penile prosthesis implantation is recognised as a management option in refractory and delayed low flow priapism for restoring erectile function with high patient satisfaction rates. However, the ensuing corporal fibrotic scarring poses a surgical challenge to clinicians, given the higher complication rates in this patient subset. Postoperative patient satisfaction has been closely linked to preoperative expectations and perceived loss of penile length. Therefore, thorough patient counselling concerning the risk and benefits of penile implants should be a priority for all clinicians. Moreover, there is a lack of consensus on the ideal prosthesis choice and procedural timing in refractory low flow priapism. In this review, we will examine the existing literature on penile implants in patients with priapism and discuss the options for managing complications associated with penile prosthesis surgery.

Priapism in children: an experience of the modified Winter procedure.

BACKGROUND: Priapism in children is a rare disease, which seldom presents during the pediatric surgery practice. It is, however, a surgical and urological emergency. Early diagnosis and prompt management can prevent the devastating sequelae of this potentially fatal condition. MATERIALS AND METHODS: A prospective study was conducted between March 1st, 2007 and February 28th, 2019 at the Department of Pediatric Surgery, Khyber Teaching hospital, Peshawar. All the patients between 3 and 15 years of age, with the diagnosis of priapism, were enrolled in the study with ethical approval. RESULTS: A total of ten patients were enrolled in the study period from March 1st, 2007 to February 28th, 2019. The age ranged between 3 and 15 years and the mean age of presentation was 8 years. The mean duration of symptoms was 4 h. The mean hospital stay was 4 days. The modified Winter procedure by creating a corporoglanular shunt was performed in all cases. Successful detumescence was achieved in eight patients, while two patients needed further detumescence and manual evacuation. Symptomatic relief was achieved in all the children. CONCLUSION: Priparism in children is a rare urological emergency that can lead to permanent erectile dysfunction if prompt medical intervention is not done. The modified Winter procedure technically is a less invasive procedure to achieve satisfactory clinical outcome in terms of achieving good erectile functions.

Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism.

BACKGROUND: Corporal fibrosis is known to result from prolonged priapism; however, the impact of the timing of penile prosthesis placement after priapism on complication rates is poorly understood. AIM: We sought to evaluate the impact of timing of inflatable penile prosthesis (IPP) placement on complications in men with a history of ischemic priapism. METHODS: We performed a multicenter, retrospective cohort study of patients with a history of priapism undergoing IPP placement by 10 experienced implantation surgeons. We defined early placement as ≤6 months from priapism to IPP. We identified a 1:1 propensity-matched group of men without a history of priapism and compared complication rates between men who had early placement, late placement, and no history of priapism. OUTCOMES: Our primary outcome was postoperative noninfectious complications, and secondary outcomes included intraoperative complications and postoperative infection. RESULTS: A total of 124 men were included in the study with a mean age of 50.3 ± 12.7 years. A total of 62 had a history of priapism and 62 were matched control subjects. The median duration of priapism was 37 (range, 3-168) hours and the median time from ischemic priapism to IPP placement was 15 months (range, 3 days to 23 years). Fifteen (24%) men underwent early (≤6 months) IPP placement at a median time of 2 months (range, 3 days to 6 months) following the ischemic priapism event. The remaining 47 (76%) underwent placement >6 months following priapism at a median time of 31.5 months (range, 7 months to 23 years). The complication rate in the delayed placement group was 40.5% compared with 0% in the early placement group and control group. Cylinder-related complications such as migration or leak accounted for 8 (57%) of 14 of the postoperative noninfectious complications. Full-sized cylinders were used in all patients who had a cylinder related complication. CLINICAL IMPLICATIONS: Priapism patients should be referred to prosthetic experts early to decrease complication rates in those needing an IPP. STRENGTHS AND LIMITATIONS: This is a multicenter study from experienced prosthetic urologists but is limited by the retrospective nature and small number of patients in the early placement group. CONCLUSION: IPP complication rates are high in men with a history of ischemic priapism, especially when implantation is delayed beyond 6 months.

Bilateral Cavernosal Artery Ligation to Treat Ischemic Priapism Following Inflatable Penile Prosthesis Implantation.

OBJECTIVE: To describe the first known case of recurrent acute priapism after penile prosthesis implantation. MATERIALS AND METHODS: A 60-year-old gentleman with a history of recurrent ischemic priapism without hemoglobinopathy presented with refractory erectile dysfunction and underwent uncomplicated penile prosthesis placement. His course was complicated by early acute ischemic priapism confirmed via ultrasound. Due to his pain, attempts to relieve the priapism using ultrasound-guided phenylephrine injections were attempted but were unsuccessful. RESULTS: He subsequently underwent exploration with confirmation of distal ischemic priapism followed by brisk bright red blood from the proximal corpora upon device externalization. A perineal exploration was performed and the bilateral cavernosal arteries were suture ligated with immediate relief. The device was reimplanted and the patient recovered uneventfully. CONCLUSION: We report the first known case of ischemic priapism following inflatable penile prosthesis implantation. The details of this case challenge the dogma that priapism is a binary event and instead supports an imbalance between unopposed cavernosal artery inflow possibly due to vascular calcifications and compromised venous outflow due to the presence of the device. Prosthetic urologists should be aware of this rare phenomenon and consider all available approaches on an individualized case-by-case basis.

Insertion of Penile Implants in Patients with Priapism: When Is the Right Time?

Acute ischaemic priapism is a urological emergency that requires prompt intervention. Refractory cases result in the development of fibrosis in the corpus cavernosum, which results in erectile dysfunction. Early insertion of a penile prosthesis in refractory cases allows easier dilatation and maintains the penile length and girth.

A population-based analysis of predictors of penile surgical intervention among inpatients with acute priapism.

While consensus exists regarding risk factors for priapism, predictors of operative intervention are less well established. We assessed patient and hospital-level predictors associated with penile surgical intervention (PSI) for patients admitted with acute priapism, as well as length of stay (LOS) and total hospital charges using the National Inpatient Sample (2010-2015). Inpatients with acute priapism were stratified by PSI, defined as penile shunts, incisions, and placement of penile prostheses, exclusive of irrigation procedures. Survey-weighted logistic regression models were utilized to assess predictors of PSI. Negative binomial regression and generalized linear models with logarithmic transformation were used to compare PSI to LOS and total hospital charges, respectively. Among 14,529 weighted hospitalizations, 4,953 underwent PSI. Non-Medicare insurances, substance abuse, and ≥3 Elixhauser comorbidities had increased odds of PSI. Conversely, Black patients, sickle cell disease, alcohol abuse, neurologic diseases, malignancies, and teaching hospitals had lower odds. PSI coincided with shorter median LOS (adjusted IRR: 0.62; p < 0.001) and lower ratio of the mean hospital charges (adjusted Ratio: 0.49; p < 0.001). Additional subgroup analysis revealed penile incisions and shunts primarily associated with reduced LOS (adjusted IRR: 0.66; p < 0.001) and total hospital charges (adjusted Ratio: 0.49; p < 0.001). Further work is required to understand predictors of poor outcomes in these populations.

Novel treatment for glance necrosis due to priapism; presentation and review of literature.

INTRODUCTION: Glans necrosis in association with priapism is very rare and its appropriate treatment is not known. There is a secondary cause in most cases. CASE DESCRIPTION: We treated a 65-year-old man with priapism and glans necrosis using a closed shunt (Winter), continuous penile irrigation with normal saline, and heparin for 48 h and waited for the necrotic area to resolve spontaneously. The treatment outcome was much better compared to previous cases in whom open surgery, irrigation with pure normal saline, and/or resection of the necrotic area were performed. CONCLUSION: In cases with priapism and glans ischemia, we recommend treating the condition with continuous covernose irrigation with heparinized saline and avoiding open surgery.

Is urgent surgical management necessary for priapism in pediatric patients with hematologic conditions?

INTRODUCTION: Acute priapism is usually considered a medical emergency that warrants prompt urologic evaluation and treatment. Efforts have been made to determine the optimal management strategy for pediatric priapism. OBJECTIVE: The aim of this study is to assess differences in conservative, minimally-invasive, and operative management of acute priapism in the pediatric population. STUDY DESIGN: A retrospective study of pediatric patients with acute priapism from 2015 to 2021 at a single tertiary care children's hospital was conducted. Conservative, minimally-invasive, and operative approaches for the priapism episodes during these hospital encounters were analyzed. RESULTS: Thirty-nine patients were identified with a total of 61 cases of acute pediatric priapism were evaluated in the study period. Eight-three percent of patients were African-Americans, and 72% of patients had a history of sickle cell disease. Oxygen therapy (P = 0.001) and hydration with intravenous fluids (P = 0.00318) were more commonly utilized for hematologic-associated cases compared to other etiologies. For priapism episodes of hematologic etiology, 18 (40.0%) and 18 (40.0%) patients received phenylephrine injection and aspiration/irrigation (e.g., minimally-invasive therapy), respectively, while for the other causes of priapism, three (18.8%) and four (25.0%) received phenylephrine injection and aspiration/irrigation (e.g., minimally-invasive), respectively. Conservative and minimally-invasive treatment resulted in complete resolution of priapism in 27 (60%) and 16 (35.5%) patients with hematologic-associated priapism while 12 (75%) and 1 (6.3%) patients with other etiologies had resolution of priapism with conservative and minimally-invasive treatment, respectively. One patient received shunting in the hematologic group while two patients received shunting in the non-hematologic group (P = 0.1031). DISCUSSION: Hematologic disorders are the most common causes of priapism in children and adolescents. An overwhelming majority of priapism events in the pediatric population can be managed with conservative therapies including oxygenation and intravenous hydration as well as minimally-invasive procedures such as corporal aspiration, irrigation and/or injections. The utilization of corporal shunting, anesthesia, and hospital resources is infrequently necessary for pediatric priapism episodes. CONCLUSION: While urgent surgical management is often performed in the adult population, a minimally-invasive management strategy can be implemented in the pediatric population where an extended period of conservative management that avoids operative management and general anesthesia is effective.

Rare emergency in children: Priapism and stepwise treatment approach.

BACKGROUND: Priapism is a rare condition in children and the treatment algorithm is controversial in this age group. Herein, we report eight cases with low-flow priapism and our stepwise treatment approach in light of literature. METHODS: We present a simple stepwise treatment for low-flow priapism including five steps. Step 1: Cold compress and analgesia while evaluation the priapism and its etiology. Step 2: Corporal aspiration and adrenaline infusion in the ward. Step 3: Modified Winter shunt in the same place. Step 4: Ketamine application and caudal block in the operating room. Step 5: Sapheno-cavernous (Grayhack) shunt. Eight cases with low-flow priapism were reviewed retrospectively. Symptoms, duration of tumescence, the interventions, and step that provide detumescence were recorded. RESULTS: The mean age of patients was 8.5 years (1-17 y). The median time of the priapism before admission was 15 h (4-165 h). The etiological factors were sickle cell disease, hemodialysis due to chronic renal failure, and factor V Leiden mutation in three patients. Detumescence was achieved in one patient at Step 2, in two patients at Steps 3, 4, and 5, respectively. Rigidity of cavernous body was observed in one patient in long-term follow-up. CONCLUSION: Low-flow priapism is a urological emergency that may cause erectile dysfunction. Treatment options should be selected according to a protocol that prevents time loss and avoids more invasive treatment in unnecessary situations. Our algorithm with simple nature and its steps from less invasive to more invasive procedures may be an alternative for the treatment of low-flow priapism.

A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review.

BACKGROUND: In 2016, we reported the first case of high flow priapism and arteriocavernosal fistula caused by penile prosthesis insertion that mimicked device autoinflation. AIM: To raise awareness amongst implanters, we describe further cases from our institution and perform a systematic review of the literature to understand the rarity of this phenomenon. METHODS: Patient demographics, management and outcomes were extracted retrospectively. A systematic search of the EMBASE, PubMed and PubMed Central libraries for studies reporting arteriocavernosal fistula mimicking autoinflation since 1946 was performed. OUTCOMES: To identify and report all known cases of high flow priapism and arteriocavernosal fistula presenting as autoinflation of an inflatable penile prosthesis. RESULTS: Four patients in total (median age 56, range 46-60 years) were identified. Catastrophic bleeding (1.8L) occurred during revision surgery for presumed autoinflation in Patient 1 and subsequent ultrasound (US) confirmed a fistula which was embolized. Patient 2 redeveloped autoinflation following revision surgery. Ultrasound confirmed high flow priapism from an arteriocavernosal fistula. Patient 3 underwent penile magnetic resonance imaging (MRI) to investigate autoinflation and residual penile curvature. MRI showed a tumescent penis despite a deflated device and the fistula was embolized successfully. Patient 4 with sleep-related painful erections did not improve following insertion of penile prosthesis. Doppler US identified 2 fistulae that was embolized but with no resolution of symptoms. Subsequent embolization of both common penile arteries were done to control his symptoms. No other publications apart from the published abstract from 2016 reporting patient 1 was found. CLINICAL IMPLICATIONS: If considered prior to revision surgery, the fistula can be managed safely by minimally invasive percutaneous angioembolisation avoiding surgery which can potentially be associated with significant complications. STRENGTHS AND LIMITATIONS: The rarity of this phenomenon was supported by a systematic review. Our study however does present the findings from a small number of patients. CONCLUSION: Damage to the cavernosal artery during inflatable penile prosthesis insertion can create an arteriocavernosal fistula that mimics autoinflation, leading to catastrophic intra-operative bleeding or unnecessary surgery. Lee WG, Satchi M, Skrodzka M, et al. A Rare Cause of Autoinflation after Penile Prosthesis Insertion: Case Series and Systematic Review. J Sex Med 2022;19:879-886.

Immediate insertion of a soft penile prosthesis as a new option for a safe and cost-effective treatment of refractory ischemic priapism.

OBJECTIVE: The aim of this study is to assess the management of refractory ischemic priapism (IP) by the immediate insertion of a soft penile prosthesis (sPP). PATIENTS AND METHODS: We identified men affected by IP who underwent early sPP placement from May 2017 to October 2019. All patients underwent a detailed medical history review; intraoperative, postoperative features and adverse events were recorded. We evaluated the penile lengthening and bending, presence of complementary erection, ability to have sexual intercourse, postoperative sexual life satisfaction (International Index of Erectile Function [IIEF] questionnaire - question number 5). A cost-analysis was included. RESULTS: A total of six patients were identified. Median time (range) since onset was 78 (48-108) hours with a mean age (SD) of 33 (6.9) years. Median operative time (range) was 82 minutes (62-180). No complications were recorded. Median follow- up was 9 months (range 3-17). No significant loss of penile length, neither penile angulation was recorded. Despite a transient reduction of penile sensitivity, all patients reported satisfactory sexual intercourse (mean score question number 5 from IIEF-5 of 4). The cost of sPP was € 1769,00 with a surgeryrelated reimbursement fee from the National Health System of € 3856,75. CONCLUSIONS: The insertion of a sPP for patients with refractory IP results in immediate pain relief, preservation of sexual function and penile size, with a higher surgery reproducibility in an emergency. In addition to this, financial and resource burdens of IP on the health-care system can be potentially reduced.

Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis.

INTRODUCTION: Priapism is a urologic emergency that may require surgical intervention in cases refractory to supportive care. Exchange transfusion (ET) has been previously used to manage sickle cell disease (SCD), including in priapism; however, its utilization in the context of surgical intervention has not been well-established. AIM: To explore the utilization of ET, as well as other patient and hospital-level factors, associated with surgical intervention for SCD-induced priapism METHODS: Using the National Inpatient Sample (2010-2015), males diagnosed with SCD and priapism were stratified by need for surgical intervention. Survey-weighted regression models were used to analyze the association of ET to surgical intervention. Furthermore, negative binomial regression and generalized linear models with logarithmic transformation were used to compare ET vs surgery to length of hospital stay (LOS) and total hospital charges, respectively. MAIN OUTCOME MEASURES: Predictors of surgical intervention among patients with SCD-related priapism RESULTS: A weighted total of 8,087 hospitalizations were identified, with 1,782 (22%) receiving surgical intervention for priapism, 484 undergoing ET (6.0%), and 149 (1.8%) receiving combined therapy of both ET and surgery. On multivariable regression, pre-existing Elixhauser comorbidities (e.g. ≥2 Elixhauser: OR: 2.20; P < 0.001), other forms of insurance (OR: 2.12; P < 0.001), and ET (OR: 1.99; P = 0.009) had increased odds of undergoing surgical intervention. In contrast, Black race (OR: 0.45; P < 0.001) and other co-existing SCD complications (e.g. infectious complications OR: 0.52; P < 0.001) reduced such odds. Compared to supportive care alone, patients undergoing ET (adjusted IRR: 1.42; 95% CI: 1.10-1.83; P = 0.007) or combined therapy (adjusted IRR: 1.42; 95% CI: 111-1.82; P < 0.001) had a longer LOS vs. surgery alone (adjusted IRR: 0.85; 95% CI: 0.74-0.97; P = 0.017). Patients receiving ET (adjusted Ratio: 2.39; 95% CI: 1.52-3.76; P < 0.001) or combined therapy (adjusted Ratio: 4.42; 95% CI: 1.67-11.71; P = 0.003) had higher ratio of mean hospital charges compared with surgery alone (adjusted Ratio: 1.09; 95% CI: 0.69-1.72; P = 0.710). CONCLUSIONS: Numerous factors were associated with the need for surgical intervention, including the use of ET. Those receiving ET, as well as those with combined therapy, had a longer LOS and increased total hospital charges. Ha AS, Wallace BK, Miles C, et al. Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis. J Sex Med 2021;18:1788-1796.

Current Status for Semirigid Penile Prosthetic Devices.

PURPOSE OF REVIEW: The goal of this paper was to evaluate the current use of semirigid penile prosthesis (SRPP), surgical techniques for insertion of SRPP, and how to prevent and approach surgical complications. RECENT FINDINGS: SRPP is a valid option for those who are refractory to medical therapy for erectile dysfunction (ED) and even more appropriate for specific subsets of patient populations. It is important for urologists to know which patient population SRPP is preferred for. Several studies have shown good patient outcomes and patient satisfaction with those who underwent SRPP.

Effectiveness of the caverno-dorsal vein shunt (Barry shunt) on prolonged ischaemic priapism and its effect on the post-operative long-term erectile function.

Ischaemic priapism is the most common form of priapism and requires urgent treatment. In this study, we evaluated the effectiveness of the caverno-dorsal vein shunt on resolution of ischaemic priapism and on the post-operative long-term erectile function in patients presenting with priapism. The study included 10 patients admitted to our hospital for priapism between 2010 and 2018. The median age of the patients was 31 (24-66) years. The median priapism time was 13.5 (7-38) hours. The blood gas measurements were taken from the corpus cavernosum, and the drainage of the corpus cavernosum was performed as an emergency intervention. Then, the corpus cavernosum was irrigated with 0.01% adrenaline 5 times in 20-min intervals. The caverno-dorsal vein shunt procedure was performed in cases without regression of priapism. Two months after, the operation shunt was closed. Detumescence occurred in all patients. Eight of 10 patients maintained their erectile function. In 2 patients, severe erectile dysfunction occurred at post-operative 2 months following a priapism attack and penile prosthesis implantation was performed in these 2 patients. Our study showed that caverno-dorsal vein shunt procedure is effective in providing detumescence and maintaining potency in cases with ischaemic priapism. In our opinion, caverno-dorsal vein shunt can be considered as the first treatment of choice for refractory low-flow priapism.