Priapism Shunts & Decompression

For diagnosis and nonsurgical management, see Priapism.

The organizing principle is simple: ischemic priapism is a corporal compartment syndrome. Medical therapy evacuates and pharmacologically contracts the corpora; shunt surgery creates outflow when aspiration, irrigation or phenylephrine fails. Current practice favors distal corporoglanular shunts with tunneling, and glans-sparing decompression is an emerging alternative. Proximal shunts are mostly historical: the combined AUA/SMSNA 2022 guideline states that evidence is inadequate to quantify their benefit after distal shunting , and the EAU systematic review concluded that they should be abandoned.^{[1][2][3][53]}

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Algorithmic Placement

Clinical setting	Preferred operative move	Avoid
Persistent ischemic priapism after aspiration / irrigation / phenylephrine	Distal corporoglanular shunt, usually T-shunt or Al-Ghorab depending on setting and surgeon experience	Repeating ineffective bedside aspiration for hours while ischemic time accumulates
Prolonged priapism with thick clot or failed simple distal shunt	Add corporal tunneling (Burnett snake maneuver) or proceed to PSD	Tiny needle shunts that cannot clear organized proximal clot
Failed distal shunt / failed tunneling	PSD or early penile prosthesis, based on duration, corporal viability, patient goals, and local expertise	Proximal shunt as reflex salvage
Very late presentation, nonviable corpora, or failed decompression	Acute malleable penile prosthesis or planned early prosthesis strategy	Delayed implantation without counseling about fibrosis and length loss

For ischemic priapism lasting at least 36 hours, non-surgical management is associated with a high retreatment burden. In a 2026 retrospective single-center cohort of 76 patients (38 non-surgical, 38 surgical), reported readmission or reintervention rates were 66.7% with non-surgical care versus 10.4% with surgical care (p < 0.01).^[4]

Predicting who will need a shunt. Two retrospective cohorts identify factors associated with progression to surgical shunting after failed medical therapy. In a series of 169 ischemic-priapism encounters, 74% related to intracavernosal injections, duration (odds ratio 1.05 per hour) and prior priapism (odds ratio 3.15) predicted shunting; a 24-hour cutoff had 77% sensitivity and 90% specificity in this cohort.^[50] In a separate cohort of 147 patients presenting with a first episode of ischemic priapism, a total phenylephrine dose above 950 mcg or an erection duration beyond 15.5 hours were each associated with a significantly higher likelihood of requiring corporoglanular shunting.^[51]

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Distal Corporoglanular Shunts

Distal shunts create a communication between the distal corpus cavernosum and the glans / corpus spongiosum. They are first-line surgical procedures because they are fast, anatomically accessible, and can often be performed under local anesthesia with dorsal penile nerve block plus ring block.^[1][5] AUA/SMSNA 2022 recommends a distal corporoglanular shunt, with or without tunneling, after intracavernosal phenylephrine and aspiration, with or without irrigation, fail . Consider tunneling for persistent ischemia after a distal shunt .^[3][53]

Winter Shunt

Feature	Detail
Mechanism	Percutaneous needle core through the glans into the distal corpus cavernosum, removing a core of tunica albuginea to create a small corporo-spongiosal communication
Instrument	Tru-Cut or large-bore core biopsy needle
Shunt window	Small (circular core)
Strength	Simplest bedside shunt under local anaesthesia; minimal equipment
Weakness	Small opening; prone to closure; highest failure rate among distal shunts in the Nixon series, where 92% of reoperated patients had initially undergone a Winter shunt[48]
Best use	Early refractory ischemic priapism (< 24 h) when a simple distal decompression is reasonable

Winter is the least invasive distal shunt but also the easiest to occlude.^[1][5] Multiple passes may be made bilaterally to increase the shunt size. The small window may be insufficient for adequate drainage in prolonged priapism with thick, gelatinous, or organised clot; the Burnett "Snake" maneuver cannot be combined with the Winter shunt because the window is too small to accept a Hegar dilator.^[1][8]

Efficacy. In the Nixon retrospective series (n = 28), 13 patients (46.4%) required more than one operation for failed detumescence after cavernosa-to-spongiosum shunts, and 12 of the 13 (92.3%) had initially undergone a Winter shunt.^[48] Reoperation was uncommon after Al-Ghorab or Quackels shunts in the same series.^[48] Brant and colleagues reported a 13-patient T-shunt series.^[6] Across studies in the EAU systematic review, distal-shunt resolution ranged from 18.7–100% and potency from 20–100%, with heterogeneous priapism durations.^[1]

Ebbehoj Shunt

Feature	Detail
Mechanism	Percutaneous scalpel stab through the glans into the distal corpus cavernosum; blade rotated or withdrawn to create a linear incision (rather than a core biopsy)
Instrument	No. 11 scalpel blade
Shunt window	Moderate (linear incision) — slightly larger than Winter
Strength	Slightly larger opening than Winter while remaining simple; no tissue removal
Weakness	Still a small distal opening; urethral injury risk if directed too ventrally; not easily combined with the Snake maneuver (window too small for dilator passage)
Best use	Early refractory cases where a percutaneous blade shunt is preferred over needle coring

First described by Ebbehoj 1974 as a modification of the Winter shunt that uses a scalpel blade rather than a biopsy needle to create the corporo-spongiosal fistula.^[1] Conceptually similar to Winter but creates a larger tunical defect; the blade should be directed into the distal corporal tip and kept away from the ventral urethra.^[1][5]

Efficacy. Most outcome studies group the Ebbehoj with other distal shunts; individual efficacy data are limited. Its window is intermediate in size between the Winter and Al-Ghorab shunts; comparative efficacy data are lacking. A persistent glans-cavernosum fistula can itself cause ED from venous leak; restoration of full erections after closure of a persistent fistula 5 years after shunting has been described in a single case.^[18]

T-Shunt (Lue)

Feature	Detail
Mechanism	Scalpel inserted percutaneously through the lateral glans (2 o'clock or 10 o'clock, avoiding the urethra ventrally and the dorsal NVB), advanced into the distal corpus cavernosum; rotated 90° to create a cruciate (T-shaped) opening in the tunica albuginea
Instrument	No. 10 scalpel blade
Shunt window	Large (cruciate) — significantly larger than Winter or Ebbehoj
Strength	Wider, more durable distal opening; compatible with the Burnett Snake maneuver (7–8 mm Hegar dilator); allows simultaneous corporal biopsy for smooth-muscle viability assessment; bedside under local anaesthesia
Weakness	More tissue disruption; urethral injury risk if trajectory is wrong (mitigated by lateral glans entry + Foley catheter); urethrocutaneous-fistula risk with Snake maneuver[10]
Best use	Commonly used percutaneous distal shunt for refractory cases, especially when tunneling will be needed

The T-shunt was designed to create a larger and more durable distal corporal exit than Winter or Ebbehoj. In the Brant / Lue 2009 original retrospective series (n = 13), cavernous blood flow was restored in 12 of 13 (92%) and one further patient needed a second procedure. All but 2 recovered erectile function, and 6 patients had previously undergone unsuccessful distal or proximal shunt procedures.^[6]

Step-by-step (Brant–Lue):^[6]

1. Local anaesthesia (dorsal penile-nerve block and ring block) suitable for bedside or ED use.
2. Foley catheter placed to identify the urethra and prevent urethral injury.
3. No. 10 blade inserted through lateral glans at 2 o'clock or 10 o'clock, advanced into distal corpus cavernosum, penetrating the tunica albuginea.
4. Rotate the blade 90° laterally away from the urethral meatus and withdraw it in that position to create the distal tunical opening.^[49]
5. Dark deoxygenated blood expressed; manual compression facilitates drainage.
6. If rigidity persists after the first shunt, repeat the procedure on the opposite side.^[49]
7. Optional tunneling through the T-shunt. A 20–22 Fr straight urethral sound or dilator is passed through the T-shunt opening toward the crus to clear stagnant corporal blood.^[6][55] The 7–8 mm Hegar dilator is described for the Al-Ghorab Snake technique.^[8][53][55]
8. Optional corporal biopsy. Necrotic smooth muscle on biopsy is highly predictive of severe ED and shunt failure and may guide early prosthesis decisions.^[7]
9. Closure with absorbable sutures; compressive dressing.

Efficacy:

• Brant / Lue 2009. Blood flow restored in 12 of 13 patients.^[6]
• Zacharakis 2014 T-shunt and Snake (n = 45). Resolution occurred in all patients with priapism < 24 h and in 30% of those with priapism > 48 h. At median six-month follow-up, mean IIEF-5 decreased from 24 to 7.7. All patients with priapism > 48 h had necrotic cavernous smooth muscle on biopsy and severe ED requiring prosthesis.^[7]
• Ortaç 2019 T-shunt ± tunneling (n = 25). All had rapid resolution (median duration 58 h); among 19 with erectile-function follow-up, 16 (84.2%) reported postoperative ED, 3 (15.8%) achieved unaided intercourse, 6 (31.5%) required PDE5i, and 9 (47.4%) had severe ED.^[19]
• Unal / Burnett 2024 Snake versus no Snake (n = 82, retrospective). Single-intervention resolution was 24/26 (92.3%) with Snake versus 30/56 (53.6%) without (p < 0.001); among initial responders, recurrence was 1/24 (4.2%) versus 8/30 (26.6%).^[10]

Outcomes by priapism duration (T-shunt ± Snake):

Duration	Resolution	Erectile function	Smooth-muscle biopsy
< 24 h	100% resolution	ED in about 50%; mild to moderate cases treated with PDE5i	Not stated[7]
24–48 h	Not reported separately	Not reported separately	Not reported separately
> 48 h	30% resolution	Severe ED in all, requiring prosthesis	Necrotic smooth muscle in all[7]

Source: Zacharakis 2014.^[7]

T-shunt and proximal shunts. Brant and Lue suggested that the T-shunt with tunneling could make proximal shunts obsolete.^[6]

Al-Ghorab Shunt

First described by Al-Ghorab in 1973. Among the distal shunts, the Al-Ghorab produces the largest tunical window because the tunica albuginea is excised under direct vision rather than punctured or incised. It was the original platform on which Burnett later developed the Snake maneuver.^[5][8][9]

Feature	Detail
Approach	Open (not percutaneous)
Instrument	Scalpel + scissors / sharp dissection — excises a disc of tunica under direct vision
Shunt window	Largest (excised ~ 5 × 5 mm disc of distal tunica)
Visualization	Direct — glans tissue dissected to expose distal tunical tips
Snake compatible	Yes — originally described here
Anesthesia	Local (dorsal-nerve + ring block), regional, or general
Reoperation rate	Uncommon in the Nixon series
Best use	Failed percutaneous shunt, prolonged clot burden, or primary distal procedure when open access is preferred

Step-by-step (Al-Ghorab):^[5][9]

1. Anaesthesia: local (dorsal-nerve and ring block), regional, or general.
2. Transverse or dorsal glans incision (circumcoronal or dorsal-glans approach) exposing the distal corpora cavernosa. A transverse glans incision may compromise arterial flow because the distal deep dorsal arteries run longitudinally.^[49]
3. Dissect glans tissue to expose the distal tips of the tunica albuginea bilaterally.
4. Excise a disc or cone of tunica albuginea (about 5 × 5 mm) from each corporal tip under direct vision.
5. Express dark deoxygenated blood; manual shaft compression facilitates drainage.
6. Optional Snake maneuver. 7–8 mm Hegar dilator passed retrograde through the excised window to the crus, bilaterally.^[8][9][53]
7. Blunt cavernosotomy salvage (Shiraishi–Matsuyama). For very prolonged (5–7 d) priapism refractory to T-shunt and Snake, Pean forceps may be used through the Al-Ghorab window to bluntly excise necrotic or fibrotic cavernosal tissue, enlarging the drainage route.^[20]
8. Optional corporal biopsy: necrotic smooth muscle predicts severe ED and may justify early prosthesis.^[7]
9. Close glans incision with absorbable sutures; compressive dressing.

Efficacy:

• Nixon 2003 (n = 28). Across cavernosa-to-spongiosum shunts 46.4% required reoperation, and 92.3% of those had initially undergone a Winter shunt, while reoperation after Al-Ghorab or Quackels was uncommon. As many as 90% of patients with follow-up had ED; only 2 of 20 (10%) preserved pre-morbid erectile function.^[48]
• Burnett / Pierorazio 2009 (original Snake-with-Al-Ghorab, n = 3). 2-, 5-, and 6-day priapism refractory to all prior management; 3/3 resolved.^[9]
• Segal / Burnett 2013 (retrospective, n = 10, mean follow-up 6.7 months). Mean duration 75 h (24–288 h); 6/10 had failed prior surgery; 8 of 10 resolved with no recurrence; 2 with recurrent priapism were treated with IPP; 2 of the 6 men with normal preoperative EF had at least partial postoperative EF.^[8]
• Shiraishi / Matsuyama 2013 salvage (n = 2, 5- and 7-day priapism refractory to T-shunt and Snake): Al-Ghorab and blunt cavernosotomy with Pean forceps achieved immediate resolution in both; pathology confirmed fibrotic or necrotic corporal tissue; one patient achieved partial erection on sildenafil.^[20]
• Unal / Burnett 2024 distal shunt ± Snake (n = 82): single-intervention resolution 24/26 (92.3%) with Snake versus 30/56 (53.6%) without (p < 0.001); among initial responders, recurrence was 1/24 (4.2%) versus 8/30 (26.6%).^[10]

Distal-shunt comparison:

Feature	Winter	Ebbehoj	T-Shunt	Al-Ghorab
Approach	Percutaneous	Percutaneous	Percutaneous	Open
Instrument	Tru-Cut needle	No. 11 blade	No. 10 blade + 90° rotation	Scalpel + excision under direct vision
Window	Small (core)	Moderate (linear)	Large (cruciate)	Largest (excised disc)
Visualization	Blind	Blind	Blind	Direct
Snake compatible	No	No	Yes	Yes (originally described)
Reoperation (Nixon series)	Most reoperations followed Winter	Not reported	Not reported	Uncommon

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Burnett Snake Maneuver

The Burnett "Snake" maneuver is a corporal tunneling adjunct to distal shunt surgery for ischemic priapism. Burnett and Pierorazio described it at Johns Hopkins in 2009 as a modification of the Al-Ghorab shunt, and it was later extended to the T-shunt.^[9] It is used with a shunt and not alone. It addresses a limitation of a distal window: opening the corporal tip does not clear the clotted or sludged blood filling the full length of the corporal body. A 7–8 mm Hegar dilator passed retrograde from window to crus mechanically disrupts that column and restores a patent intracorporal lumen.^[8][9]

Step-by-step (Burnett–Pierorazio):^[9]

1. Prerequisite: adequate distal shunt window. Originally described with the Al-Ghorab; now also performed through the T-shunt. Winter and Ebbehoj windows are too small to accept a Hegar dilator.^[5][9]
2. Anaesthesia per the underlying shunt (local and dorsal-nerve and ring block at the bedside, or regional or general anesthesia in the OR).
3. 7–8 mm Hegar cervical dilator (smooth, blunt, graduated metal) inserted retrograde through the distal tunical window into the corporal tip.
4. Dilator advanced proximally through the full length of the corpus cavernosum to the crus at the ischiopubic ramus; the serpentine advancement is the eponymous "snake."
5. Procedure performed bilaterally.
6. Dark deoxygenated, clotted blood expressed; manual shaft compression assists drainage.
7. Confirm that the dilator passes smoothly along the full corporal length and assess detumescence. Postoperative Doppler may assess cavernosal flow, but reperfusion hyperemia can complicate interpretation; if rigidity persists or recurs, obtain a corporal blood gas or color duplex Doppler before repeat surgery.^[49][53]
8. Optional corporal biopsy: necrotic smooth muscle predicts severe ED and may guide early-prosthesis decisions.^[7]
9. Close the shunt site (glans incision or stab wounds) with absorbable suture; compressive dressing.

Shunt-compatibility matrix:

Shunt	Snake-compatible?	Rationale
Winter (Tru-Cut needle)	No	Core too small for Hegar dilator
Ebbehoj (No. 11 blade)	No	Linear stab still too narrow
T-Shunt (No. 10 + 90° rotation)	Yes	Cruciate window accommodates dilator
Al-Ghorab (open excision)	Yes — original platform	Largest window; ideal dilator passage

Efficacy across the Snake literature:

Series	n	Setting	Resolution	Erectile function / note
Burnett / Pierorazio 2009 (Al-Ghorab + Snake)	3	2-, 5-, 6-day refractory priapism after failed prior shunting	3/3 (100%)	Meaningful EF recovery assessable in 1[9]
Segal / Burnett 2013 (Al-Ghorab + Snake)	10	Mean duration 75 h (24–288 h); 6/10 prior failed surgery	8/10 (80%) with no recurrence; 2 with recurrence treated with IPP	2/6 with normal preop EF achieved at least partial postop EF[8]
Zacharakis 2014 (T-shunt + Snake)	45	Refractory ischemic priapism	100% if < 24 h; 30% if > 48 h	IIEF-5 24 to 7.7 (p < 0.0005); all > 48 h had necrotic smooth muscle on biopsy and required prosthesis[7]
Ortaç 2019 (T-shunt ± tunneling)	25	Median duration 58 h	Rapid resolution in all (1 recurrence at 12 h)	ED in 16 of 19 with follow-up (84.2%); 15.8% unaided intercourse; 31.5% PDE5i; 47.4% severe ED[19]
Unal / Burnett 2024 (distal shunt ± Snake)	82 (26 Snake vs 56 no Snake)	Comparative Johns Hopkins cohort	Single-intervention resolution 24/26 (92.3%) vs 30/56 (53.6%) (p < 0.001)	Among initial responders, recurrence 1/24 (4.2%) vs 8/30 (26.6%) (p < 0.001); among those with documented sexual-function follow-up, functional erections 6/14 (42.8%) vs 13/26 (50%; p = .66)[10]

In this retrospective single-center comparison, the Snake maneuver was associated with higher single-intervention resolution (24/26 [92.3%] vs 30/56 [53.6%]) and lower recurrence among initial responders (1/24 [4.2%] vs 8/30 [26.6%]). Among patients with documented sexual-function follow-up, functional erections did not differ significantly (6/14 [42.8%] with Snake vs 13/26 [50%] without; p = .66).^[10]

Complications (Segal / Burnett series, n = 10):^[8]

• Wound infection with skin necrosis: 2/10 (one also had urethral injury and fistula)^[8]
• Intraoperative urethral injury with subsequent urethrocutaneous fistula: 1/10^[8]
• Corporal perforation: theoretical (not reported in published series)
• Penile shortening or deformity: prolonged ischemia and surgical treatment may both contribute.^[53]

Salvage modification: Al-Ghorab and blunt cavernosotomy (Shiraishi–Matsuyama 2013). For very prolonged priapism (5–7 d) refractory to T-shunt and Snake, Pean forceps are used through the Al-Ghorab window to bluntly excise necrotic or fibrotic corporal tissue. Both reported patients achieved immediate resolution; one recovered partial sildenafil-responsive EF.^[20]

Practice pattern. In a survey with 141 responses from members of societies for male genital surgery, 99/139 (71.2%) favored tunneling procedures as first-line surgery for prolonged ischemic priapism; 124/138 (89.9%) had performed corporoglanular tunneling, versus 86/137 (62.8%) who had performed penoscrotal decompression.^[14]

Pearls:

• Use blunt, controlled pressure; false passage or tunical perforation defeats the purpose.
• Tunnel only after a real distal exit has been made; forcing a dilator through a tiny puncture increases urethral- and tunical-injury risk.
• Persistent erection after shunting or tunneling requires corporal blood gas or color duplex Doppler before repeat surgery to distinguish persistent ischemia from reactive hyperemia or conversion to non-ischemic priapism .^[53]

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Penoscrotal Decompression

Penoscrotal decompression (PSD) is a glans-sparing surgical strategy for prolonged or refractory ischemic priapism, first described by Fuchs, Shakir, McKibben et al. in 2018.^[11] Instead of communicating the corpus cavernosum with the corpus spongiosum through the glans, PSD makes direct corporotomies through a penoscrotal or proximal shaft incision, evacuating thrombosed blood from the mid-shaft and proximal corpora through a surgical field familiar to surgeons who perform penile-fracture repair or prosthesis implantation. Small retrospective series report detumescence after PSD and document later prosthesis placement; a surgeon survey records perceived effectiveness, but no direct patient-outcome comparison establishes superiority over corporoglanular tunneling.^{[11][12][13][14][49]}

Rationale. PSD was developed to address three weaknesses of the distal-shunt and Snake paradigm:^[11]

• In the Zacharakis T-shunt-plus-Snake series, resolution occurred in only about 30% of patients with priapism > 48 h; corporoglanular tunneling may still leave heavily thrombosed mid-shaft and proximal corpora incompletely decompressed.^[7]
• In Fuchs's small, nonrandomized comparison after failed distal shunts, 3/8 MPP recipients required eight revision operations over median 41.5 months; distal extrusion accounted for four and impending lateral extrusion for two of those eight revision indications.^[11]
• A penoscrotal or proximal-shaft approach gives direct access to the mid-shaft corpora through a familiar plane and spares the glans, preserving future prosthesis options.

Step-by-step:^[11][12][13]

1. Regional or general anaesthesia in an OR setting.
2. Penoscrotal incision (Fuchs original) at the penoscrotal junction, similar to implant exposure, or a proximal penile shaft incision (Basile 2025 modification) familiar from penile-fracture repair, which avoids the penoscrotal junction and may facilitate quicker bilateral exposure and later IPP placement.^[13]
3. Foley catheter; dissect through dartos to expose tunica albuginea of both corpora cavernosa; incise Buck's fascia.
4. Bilateral longitudinal (or transverse) corporotomies in the tunica albuginea.
5. Evacuate dark, clotted blood; the EAU-described PSD technique passes a suction tip proximally and distally through each corporotomy to clear the corporal bodies. Manual shaft compression and saline irrigation assist evacuation.^[49]
6. Unilateral and bilateral decompression have been described. In Baumgarten’s retrospective series, priapism recurred after 2/10 unilateral PSDs and 0/15 primary bilateral PSDs.^[12]
7. Close tunical incisions primarily with absorbable suture (3-0 PDS or Vicryl).
8. Layered wound closure; compressive dressing.

Efficacy and outcomes:

Series	n	Duration	Key outcomes
Fuchs 2018 (PSD vs MPP after failed distal shunt)	6 PSD / 8 MPP	Median 61 h	PSD: 6/6 resolution and immediate pain relief, with no additional intervention; MPP: 3/8 patients (37.5%) underwent eight revisions over median 41.5 months, including 4/8 revision indications for distal extrusion and 2/8 for impending lateral extrusion[11]
Baumgarten 2020 (multi-institutional)	25 (27 procedures)	Mean 71 h; 48% had failed prior corporoglanular shunting	Bilateral PSD 0/15 recurrence vs unilateral 2/10 (20%), both salvaged with bilateral PSD; 9/15 (60%) with documented sexual-function follow-up reported spontaneous erections adequate for penetration; median IIEF-5 drop 3.5 points; 2/25 went on to uneventful IPP[12]
Basile 2025 (proximal-shaft PSD)	26 (22 bilateral, 4 unilateral)	Median 47 h (IQR 36.5–58.8); half > 48 h	96% immediate detumescence, 92% complete pain relief, 18/26 (69%) success defined as pain resolution without recurrence (73% for bilateral); 2/26 (8%) complications; among 21 with documented sexual function at median 10.4-month follow-up, 86% reported satisfactory EF with or without PP; 2/13 PP recipients had infection requiring explantation; earlier and bilateral PSD were associated with better outcomes[13]
VanDyke 2023/2024 surgeon survey	141 responses	Perception study	Among surgeons who had performed both, 47.3% rated PSD "Very/Extremely Effective" vs 18.7% for corporoglanular tunneling (p < 0.001); perceived meaningful sexual recovery was 33/74 (44.6%) for PSD vs 33/75 (44.0%) for corporoglanular tunneling; practice experience was 124/138 (89.9%) for corporoglanular tunneling vs 86/137 (62.8%) for PSD[14]

Comparison across surgical options:

Feature	Distal shunts	Snake (corporoglanular tunneling)	PSD	Immediate MPP after failed shunt
Approach	Through glans	Through glans	Penoscrotal / proximal shaft	Penoscrotal
Glans-sparing	No	No	Yes	Yes
Resolution / success (different cohorts)	Distal shunts: 18.7–100% resolution across mixed durations[1]	Snake: 24/26 (92.3%) single-intervention resolution[10]	PSD: 18/26 (69%) resolution of pain without recurrence; 6/6 detumescence after failed distal shunt[13][11]	Prostheses: 100% priapism resolution across reviewed studies[1]
Recurrence	Variable	1/24 (4.2%) among initial Snake responders[10]	0/15 after primary bilateral PSD[12]	Not reported as a comparable endpoint
Erectile function	Distal shunts: 20–100% potency across heterogeneous studies[1]	Snake: 6/14 (42.8%) functional erections with or without PDE5i among those with follow-up[10]	PSD: 9/15 (60%) spontaneous erections adequate for penetration among those with follow-up[12]	N/A (prosthesis-dependent)
Further treatment after index procedure (different endpoints)	Variable	2/10 Segal Snake patients with refractory recurrence underwent IPP[8]	0/6 Fuchs PSD patients required additional intervention to achieve detumescence[11]	3/8 (37.5%) Fuchs MPP patients underwent eight revision operations over median 41.5-month follow-up[11]
Complication rate	Not reported separately in EAU review (all shunts: 0–42.5%)[1]	2/10 (20%) in Segal Snake series[8]	2/26 (8%) in Basile PSD series[13]	0–13.6% across pooled penile-prosthesis studies, not immediate post-shunt MPP specifically[1]
Preserves future prosthesis	Yes	Yes	Yes (uneventful IPP documented)	N/A

Complications. Postoperative complications occurred in 8% (2 patients) in the Basile series, and no urethral injuries or wound infections were reported in these small PSD series. The Segal Snake series (n = 10) had two patients with wound infection and skin necrosis; one also had an intraoperative urethral injury with subsequent fistula.^[8] In the Segal Al-Ghorab Snake series, 2 of 6 men with normal preoperative erectile function achieved at least partial postoperative function.^[8] Among PSD patients, Baumgarten reported ED in 6/15 (40%) with documented sexual-function follow-up, while Basile reported ED in 38% after successful PSD versus 57% after failed PSD among 21 with documented status.^[12][13]

Prosthesis preservation. Because PSD avoids the glans entirely and closes the corporotomy primarily, future IPP placement remains feasible; Baumgarten documented two uneventful subsequent IPPs, and Basile reported 86% satisfactory EF (with or without PP) among 21 patients with documented sexual-function status at median 10.4-month follow-up, although 15% (2/13) of PP recipients required explantation for infection.^[12][13]

Place in the algorithm. AUA/SMSNA 2022 makes no PSD-specific recommendation; the EAU 2026 guideline says PSD may be used as an alternative first surgical option instead of distal shunting .^[49][53] A later 26-patient retrospective cohort studied this approach, but neither it nor the pooled PSD literature establishes superiority over distal shunting in a direct patient-outcome comparison.^{[13][49][53][54]} The sequence below combines AUA/SMSNA guidance, the EAU systematic review, the Schifano 2025 review and PSD series.^{[1][3][11][12][21][53]}

1. Intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as combined first-line therapy .^[53]
2. Distal shunt (T-shunt or Al-Ghorab) ± Snake.
3. PSD when distal shunting fails to fully detumesce, and increasingly considered as a primary alternative to corporoglanular tunneling in prolonged priapism.^[13][14]
4. Early penile prosthesis when smooth-muscle necrosis is confirmed or duration / clinical signs argue against any decompression attempt.

EAU 2026 guideline positions. The EAU guideline (distinct from its 2024 systematic review) recommends proceeding to surgery only after aspiration and sympathomimetic injection have failed , distal shunting first with tunneling if necessary , and penoscrotal decompression as an alternative first-line option . It states that no shunt type has been shown superior and that distal shunts are less invasive with lower ED rates; that proximal shunts are more invasive with higher ED rates; and that shunting beyond 36–48 hours may only relieve pain. Tunneling with a 7 mm sound or 7/8 Hegar dilator is described as necessary when priapism has lasted over 48 hours. For PSD it cites a 2025 systematic review of 62 patients (detumescence about 89%, erectile function preserved in about 55%, nearly half after failed distal shunts) and the Basile series, and cautions that PSD in refractory cases may delay prosthesis placement. The EAU describes perioperative antithrombotic prophylaxis (aspirin 325 mg preoperatively, heparin 5,000 IU intraoperatively, aspirin 81 mg with clopidogrel 75 mg for five days). In one observational shunt subgroup, recurrence was 11% in 9 patients given heterogeneous antithrombotic therapy versus 69% in 13 without it, an 84% relative decrease (level 3).^[49]

Limitations. Evidence consists of small retrospective cohorts, case reports and abstracts, with no RCTs. A nine-publication review (62 patients) reported detumescence in 89.3%, recurrence in 12.7%, and erectile function preserved in 54.8% of those with follow-up; 46.7% had undergone prior distal shunting.^[54] The pooled PSD estimates lack a shunt or prosthesis comparator.^[54] Efficacy is still time-dependent (better outcomes within 36 h in the Basile series), PSD requires an OR rather than a bedside setting, and 62.8% of surveyed male-genital-surgery society members had personally performed the procedure.^[13][14]

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Proximal and Venous Shunts

Proximal shunts were historically used after distal shunt failure. They are now largely de-emphasized or abandoned because distal shunts with tunneling, PSD, and early prosthesis have clearer roles and lower anatomic morbidity. The EAU Sexual and Reproductive Health Guidelines Panel systematic review concluded that proximal or venous shunts should be abandoned because of their morbidity and ED rates.^[1][2][5] AUA/SMSNA 2022 advises counseling that evidence is inadequate to quantify the benefit of a proximal shunt after distal failure . Its discussion permits selected proximal shunting after distal shunting and tunneling fail, according to surgeon experience, duration and baseline erectile function.^[3][53]

Quackels Shunt

First described by Quackels in 1964 as a proximal cavernospongiosal shunt: a direct side-to-side anastomosis between the corpus cavernosum and the adjacent corpus spongiosum at the proximal penile shaft or perineum, where the two structures lie in immediate anatomic apposition. The original rationale was that in prolonged priapism, the distal corpora may be so heavily thrombosed that distal shunts fail to drain the proximal corporal bodies; opening a window at the proximal level was meant to bypass the thrombosed distal tissue.^[5][22]

Step-by-step (Quackels):^[5]

1. General or regional anaesthesia (cannot be performed under local alone, unlike most distal shunts).
2. Lithotomy position for perineal and proximal-shaft access; Foley catheter to protect the urethra.
3. Perineal or penoscrotal-junction incision exposing the proximal corpora cavernosa and bulbar corpus spongiosum.
4. Dissect through Buck's fascia to expose the tunica albuginea of the corpus cavernosum and the adjacent corpus spongiosum.
5. Excise an elliptical or circular window from the apposed walls of corpus cavernosum and corpus spongiosum; suture the tunical edges together with absorbable suture to create a watertight side-to-side anastomosis.
6. Unilateral or bilateral; bilateral is more commonly performed for maximum drainage.
7. Express thrombosed blood through the new fistula into the spongiosum / systemic venous return.
8. Layered closure over a urethral catheter.

Quackels versus Grayhack, the two classic proximal shunts:

Feature	Quackels	Grayhack
Year	1964	1964
Drainage pathway	Corpus cavernosum → corpus spongiosum	Corpus cavernosum → saphenous vein
Anastomosis	Direct side-to-side corporospongiosal	Pedicled saphenous vein to corpus cavernosum, end-to-side[49]
Vein harvest	No	Yes (saphenous from thigh)
Technical complexity	Moderate	High (vein harvest + microvascular anastomosis)
Urethral-injury risk	Higher (direct manipulation of spongiosum / urethra)	Lower
Pulmonary-embolism risk	Comparative rate unknown	Reported after corpus–saphenous shunting; comparative rate unknown[49]
Pooled potency rate	11.1–77.2% across proximal shunts; Quackels-specific rate not given[1]	11.1–77.2% across proximal shunts; Grayhack-specific rate not given[1]

Efficacy:

• Cosgrove / LaRocque 1974 (early review of 100 shunt cases). Overall potency 61% across shunt types; little difference between Grayhack and Quackels; unilateral saphenous-vein shunts performed slightly better than bilateral; outcomes similar whether performed early or late.^[23]
• Nixon 2003 (n = 28). Reoperation was uncommon after Al-Ghorab or Quackels (92.3% of reoperated patients had had a Winter shunt); as many as 90% had ED at follow-up; only 10% (2 of 20) preserved pre-morbid EF and 15% achieved partial unaided erection.^[48]
• Tabibi 2010 (small comparative, 16 treated: 5 Winter / 7 Al-Ghorab / 4 Grayhack; erectile-function results for 14 at ≥ 2-yr follow-up). Mean duration 51 h; Grayhack 2/4 impotent, 1 potent, 1 sildenafil-responsive; no surgical complications; sample too small for firm conclusions.^[24]
• Zheng 2013 (n = 9 prolonged priapism, mixed shunt types incl. 1 Grayhack). 100% resolution but 66.7% postoperative ED; > 72 h cases had no response to PDE5i; authors recommended early prosthesis instead.^[25]
• EAU systematic review 2024. Proximal shunts (n = 209): resolution 5.7–100%, potency 11.1–77.2%; distal shunts (n = 274): resolution 18.7–100%, potency 20–100%; prostheses (n = 194): 100% resolution, satisfaction 60–100%. The panel concluded that proximal or venous shunts should be abandoned.^[1]

Quackels-specific complications. Beyond the duration-driven ED that affects all priapism surgery, Quackels carries distinctive risks from corporospongiosal manipulation:^[26][27][28]

• Urethral injury. Direct dissection of the spongiosum places the urethra at risk.
• Urethrocavernous fistula. Robbins 1984 reported a late-developing urethrocavernous fistula 3 months post-cavernospongiosum shunt.^[27]
• Combined urethrocutaneous and urethrocavernous fistula. Manjunath 2015 reported simultaneous urethrocutaneous and urethrocavernous fistulae after proximal corporospongiosal shunt requiring suprapubic urinary diversion.^[26]
• Persistent ("permanent open") shunt with venous leak. Among 26 patients with impotence or impaired potency after priapism shunt surgery who underwent cavernosography because an open shunt was suspected, Kulmala 1995 found a permanent open shunt in 5/26 (19.2%); impotence in all 5 was cured by shunt closure, suggesting that a subset of post-shunt ED is mechanically reversible if recognized. The 26 patients had undergone various shunt operations.^[28]
• Wound infection, cavernositis, penile shortening from corporal fibrosis.

Current status. The Quackels shunt is largely obsolete in contemporary practice:

• Burnett / Brant–Lue T-shunt and Snake provide proximal corporal decompression through a distal approach and may reduce the need for proximal shunting.^[6][9]
• Penoscrotal decompression drains the proximal corpora without a corporospongiosal anastomosis. Small series report detumescence and erectile outcomes; comparative morbidity and erectile recovery versus Quackels remain unestablished.^{[11][13][21][49]}
• Penile prosthesis series in the EAU systematic review (n = 194, not stratified here by timing or device type) reported 100% priapism resolution and 60–100% patient satisfaction.^[1][17]

Alnajjar and Muneer (2022) describe proximal Quackels and Grayhack shunts as no longer routinely performed.^[57] Quackels remains a procedure to recognize in historical literature and to consider only where modern techniques (Snake, PSD, prosthesis) are unavailable.

Grayhack Shunt

First described by Grayhack, McCullough, O'Conor, and Trippel in 1964 as a proximal cavernovenous shunt: a segment of great saphenous vein is mobilized, tunneled subcutaneously, and anastomosed end-to-side to the corpus cavernosum so that corporal blood drains into the systemic venous circulation rather than into an adjacent penile structure.^[5][29] Conceptually distinct from Quackels (which drains into the adjacent corpus spongiosum), the Grayhack offers a high-capacity venous conduit but at the cost of vein harvest, microvascular anastomosis, donor-site morbidity, and the unique risk of a persistently patent graft causing venous-leak ED.

Step-by-step (Grayhack):^[5][29]

1. General or regional anaesthesia; supine, ipsilateral leg prepped to access the saphenous vein.
2. Great saphenous vein identified at the groin / proximal medial thigh; mobilize an adequate pedicled length, divide and ligate it distally while preserving the proximal saphenofemoral connection, then flush the free end with heparinised saline before anastomosis.^[59]
3. Separate penoscrotal-junction or proximal-shaft incision to expose the tunica albuginea of the corpus cavernosum.
4. Small elliptical or circular corporotomy in the tunica.
5. The mobilized, proximally connected saphenous vein is tunneled subcutaneously from the groin to the penile incision and anastomosed end-to-side to the corpus cavernosum with interrupted 5-0 or 6-0 suture.^[49]
6. Unilateral preferred over bilateral. Cosgrove / LaRocque found unilateral saphenous-vein shunts performed better than bilateral.^[23]
7. Confirm free flow of dark deoxygenated blood from corpus to graft to systemic venous return.
8. Layered closure at both sites; compressive penile dressing; urethral catheter optional.

Efficacy:

Series	n	Setting	Resolution	Erectile function / note
Cosgrove / LaRocque 1974 (literature review)	100 cases (mixed shunts)	Early shunt literature	—	Overall potency 61%; little difference between Grayhack and Quackels; unilateral > bilateral saphenous-vein shunts; outcomes similar early vs late[23]
Resnick / Grayhack 1975 (pediatric)	2 boys (trauma; idiopathic)	Bilateral corporosaphenous	Both effectively treated	One of the earliest pediatric Grayhack reports[30]
Moloney 1975 (saphenocavernous bypass)	11 over 10 yr	Priapism treated with saphenocavernous bypass	—	Functional results were uniformly good when bypass was performed within 36 h; prior aspiration/irrigation appeared to extend that window. Persisting graft patency was associated with impotence — recommended graft ligation if no erection by 3 mo[31]
Richard 1979	12 (8 saphenocavernous)	French series	7/8 (87.5%) detumescence	5/8 (62.5%) potency preserved; earlier operation = lower secondary impotence[32]
Nixon 2003	28 (mixed)	Refractory low-flow	46.4% reoperation overall; uncommon after Al-Ghorab or Quackels (proximal venous shunts not separately stratified)	As many as 90% had ED[48]
Kulmala 1995	26 with post-shunt impotence or impaired potency	Cavernosographic survey for suspected open shunt	—	5/26 (19.2%) had a permanent open shunt; all 5 cured by shunt closure — directly relevant to Grayhack persistent-graft physiology[28]
Zheng 2013	9 (1 Grayhack after failed Winter)	Prolonged ischemic priapism	100% (mixed)	66.7% ED; > 72 h cases unresponsive to PDE5i[25]
EAU systematic review 2024	Proximal-shunt studies, n = 209	Mixed proximal procedures	5.7–100%	Potency 11.1–77.2%; panel: abandon proximal / venous shunts[1]

Grayhack versus Quackels, head to head:

Feature	Grayhack	Quackels
Year	1964	1964
Drainage	Corpus cavernosum → saphenous vein (systemic venous)	Corpus cavernosum → corpus spongiosum
Vein harvest	Yes (saphenous)	No
Surgical complexity	High (vein harvest + vascular anastomosis)	Moderate
Urethral-injury risk	Lower (no urethral manipulation)	Higher (direct spongiosum dissection)
Persistent-shunt / venous-leak risk	Higher (vein graft may stay patent)	Present but lower
Pulmonary-embolism risk	Reported after corpus–saphenous shunting; comparative rate unknown[49]	Comparative rate unknown
Unilateral vs bilateral	Unilateral preferred (Cosgrove)	Bilateral often performed

Grayhack-specific complications.^{[1][10][28][31]}

• Persistent ("permanent open") graft with venous-leak ED. The defining Grayhack-physiology risk. Kulmala found an open shunt on cavernosography in 5/26 (19.2%) patients with post-shunt impotence or impaired potency examined because an open shunt was suspected; Moloney recommended ligating a saphenous-bypass shunt if erection had not returned within 3 months.^[28][31]
• Graft thrombosis. The saphenous graft may occlude, leaving the shunt non-functional.
• Pulmonary embolism. A case has been reported after a corpus–saphenous shunt.^[49][56]
• Donor-site morbidity. Wound infection, hematoma, seroma, lymphocele at the groin; loss of the saphenous segment for future CABG or vascular reconstruction.
• Duration-driven ED, penile shortening / fibrosis, multi-site wound infection.

Modern cavernovenous variants (kept brief; see Barry section below for caverno-dorsal-vein detail):

• Barry shunt (1976). Corpus cavernosum to dorsal penile vein; smaller surgical field, no saphenous mobilization, cannot cause urethrocutaneous fistula; can convert to Grayhack or Quackels without repositioning if unsuccessful.^[33]
• Chiou 2009 cavernosal-dorsal-vein shunt. Saphenous-vein graft connecting corpus cavernosum to the deep dorsal vein. In 16 patients (10 with prior failed shunts), priapism resolved or improved in all; 9 of 13 adults with ischemic priapism and follow-up (69%) had erections (6 with intercourse); Doppler confirmed graft patency and restored cavernosal arterial flow in 12/13 studied.^[34]
• Kilinc 2009 temporary cavernosal-cephalic vein shunt. Minimally invasive angiocath and serum-set construct to the cephalic vein; 13/15 (86.7%) detumescence; the 2 failures required formal saphenocavernous shunting; 3/13 ED at 12 mo.^[35]

Current status. The Grayhack is largely obsolete:

• The EAU systematic review concluded that proximal or venous shunts should be abandoned.^[1]
• T-shunt or Al-Ghorab and Snake achieves proximal corporal decompression through a distal approach, removing the original rationale.^[6][9]
• Penoscrotal decompression drains the proximal corpora without vein harvest; comparative morbidity and erectile recovery versus Grayhack remain unestablished.^[11][13][49]
• Penile prosthesis series in the EAU systematic review (n = 194, not stratified here by timing or device type) reported 100% priapism resolution and 60–100% patient satisfaction.^[1][17]

The Grayhack and its variants persist mainly in historical literature and as the conceptual ancestor of the Barry (caverno-dorsal-vein) shunt, which the recent Soydaş 2025 algorithm and Micoogullari 2021 series have proposed as a possible niche option. Micoogullari's series used elective shunt closure at 2 months to address persistent shunt patency.^[15][16]

Barry / Caverno-Dorsal Vein Shunt

First described by John M. Barry in 1976 as a simpler, smaller-field cavernovenous alternative to the Grayhack, using the dorsal vein of the penis (deep or superficial) as the drainage target rather than the saphenous vein.^[33] The original Barry technique uses a smaller field than Grayhack, avoids saphenous-vein harvest, and avoids the direct spongiosal dissection of Quackels; Chiou’s later graft modification reintroduces saphenous-vein harvest.^[33][34] Recent series, particularly the Micoogullari 2021 planned-closure construct and the Chiou 2009 saphenous-graft modification, have driven a measured resurgence of interest, with some authors advocating Barry shunting as a first-line surgical option for refractory ischemic priapism.^[15][16][34]

Relevant venous anatomy. The penis drains via three distinct systems:

• Superficial dorsal vein. Subcutaneous; drains skin and prepuce into the external pudendal, then femoral or saphenous, veins.
• Deep dorsal vein (DDV). In the midline dorsal groove between the corpora cavernosa, deep to Buck's fascia; drains glans and all three corpora via emissary and circumflex veins into Santorini's preprostatic plexus. Principal drainage of the flaccid corpus cavernosum and the target of the standard Barry shunt.
• Cavernosal (crural) veins. Emerge from each crus and drain only the corpora into the internal pudendal vein.

In ischemic priapism the veno-occlusive compression of emissary veins is pathologically sustained; the Barry shunt bypasses that obstruction by creating a direct corpus-cavernosum-to-dorsal-vein communication and restoring venous outflow.

Step-by-step (original Barry, 1976):^[33]

1. General or regional anaesthesia; supine.
2. Dorsal mid-shaft penile incision. Single small field; no patient repositioning required.
3. Identify and mobilize the deep dorsal vein (between Buck's fascia and tunica) and/or the superficial dorsal vein.
4. Small corporotomy in the tunica adjacent to the mobilized vein.
5. Ligate the chosen dorsal vein distally; anastomose the proximal end end-to-side to the corpus cavernosum with fine suture.
6. Confirm free flow of dark deoxygenated blood from corpus to dorsal vein to systemic return; detumescence.
7. Layered closure; compressive dressing.

If the Barry shunt is unsuccessful, a Grayhack or Quackels can be performed without repositioning, a deliberate practical advantage of Barry's original design.^[33]

Modifications:

• Micoogullari 2021: planned closure at 2 months.^[15] Protocol: emergency aspiration and corporal blood gas, then 0.01% adrenaline irrigation × 5 at 20-min intervals, then Barry shunt if priapism persists, then elective shunt closure at 2 months. This planned closure addresses the Grayhack-era "permanent open shunt" problem discussed by Kulmala and Moloney; separately, a 2024 systematic review by the EAU Sexual and Reproductive Health Guidelines Panel concluded that proximal or venous shunts should be abandoned because of morbidity and erectile dysfunction rates.^[1][28][31]
• Chiou 2009: DDV and saphenous-vein-graft interposition.^[34] Hybrid construct using the dorsal vein as drainage target (Barry) but a saphenous-vein graft as the conduit (Grayhack); larger-caliber lumen at the cost of reintroducing vein harvest.
• Kilinc 2009: temporary external cavernosal-cephalic shunt.^[35] Angiocaths and serum sets bridging the corpora to a forearm cephalic-vein angiocath; bedside, no OR required.
• Soydaş 2025 algorithm. Proposes incorporating caverno-dorsal-vein shunting into a prolonged-priapism algorithm.^[16]

Efficacy:

Series	n	Setting	Resolution	EF / note
Barry 1976 (original)	2	6-day (DDV) and 3.5-day (superficial DV) priapism	2/2 resolved	"Anatomically sound, small surgical field, no saphenous mobilization, cannot cause urethrocutaneous fistula"[33]
Chiou 2009 (DDV + SVG)	16 (age 15–65; duration 32 h–8 d; 10/16 had prior failed shunting)	Mixed primary and salvage (10 with prior shunts)	Resolved or improved in 16/16	69% (9/13) had erections at ≤ 6.5 yr (5 of 16 returned questionnaires); 6 with intercourse; Doppler-confirmed patent shunt in all studied and restored cavernosal arterial flow in 12/13[34]
Micoogullari 2021 (Barry + planned closure)	10	Median duration 13.5 h (range 7–38)	100% (10/10)	80% (8/10) maintained EF; 2/10 → IPP; shunt electively closed at 2 mo[15]
Kilinc 2009 (temporary cephalic-vein)	15	Bedside angiocath construct	13/15 (86.7%)	2 failures → saphenocavernous shunt; 3/13 ED at 12 mo[35]

Barry versus Grayhack: what Barry was designed to fix:

Feature	Barry	Grayhack
Drainage target	Dorsal penile vein	Saphenous vein
Vein harvest	No (original)[33] / yes (Chiou modification)[34]	Yes (Grayhack saphenous-vein shunt)[49]
Surgical field	Small (dorsal penis only)	Large (groin + penis)
Donor-site morbidity	None (original)	Present (thigh wound)
Urethrocutaneous-fistula risk	None	None
Surgical complexity	Low–moderate	High
Patient repositioning	Not required	May be required
Escalation if it fails	Can proceed to Grayhack/Quackels without repositioning	—

Complications. The defining cavernovenous-shunt risk, persistent ("permanent open") shunt with venous-leak ED, applies to Barry as much as to Grayhack. Among 26 patients with impotence or impaired potency after priapism shunting who underwent cavernosography for suspected open shunt, Kulmala found a permanent open shunt in 5/26 (19.2%) and reported impotence cured after closure in all five; Moloney recommended ligating a saphenocavernous bypass if erection had not returned by 3 months.^[28][31] Micoogullari's ten-patient series used planned shunt closure at two months; 8/10 maintained erectile function after a median priapism duration of 13.5 hours.^[15] Barry-specific reports document no urethrocutaneous fistulae, no saphenous donor-site morbidity (original technique), and no recurrence in the Micoogullari and Chiou series.^[15][33][34]

Current status and algorithmic placement. The EAU review based its conclusion that proximal or venous shunts should be abandoned on series of several proximal-shunt types (209 patients; potency 11.1–77.2% across studies).^[1] The Barry-shunt series are small and uncontrolled (Chiou: 16 patients, priapism resolved or improved in all, and erections in 9/13 [69%] adults with ischemic priapism followed for up to 6.5 years; Micoogullari: 10 patients, detumescence in all and EF maintained in 8/10 [80%]).^[34][15] Micoogullari suggests the Barry shunt could be considered as a first treatment for refractory low-flow priapism. AUA/SMSNA 2022 includes Barry shunts in its proximal-shunt evidence discussion but does not endorse Barry as a first surgical treatment.^[53] It recommends counseling about uncertain benefit after distal shunt failure .^[53]

The clearest pragmatic niches:

• After failed distal shunting. Chiou's 16-patient cavernosal-dorsal-vein graft series included 10 patients with previous shunt surgery; priapism resolved or improved in all 16, without a separate complete-resolution rate. Chiou's series describes salvage without a comparator.^[34]
• When saphenous harvest is undesirable. Original Barry preserves the saphenous segment.^[33]
• When planned closure is feasible. Micoogullari et al. described elective closure at two months in 10 patients with median ischemia duration 13.5 hours; 8/10 maintained erectile function, without a comparator showing benefit from closure.^[15]
• As a stepping stone. Failure converts to Grayhack or Quackels without repositioning.^[33]

All-shunt summary

Shunt	Year	Type	Approach	Resolution	Potency	Current status
Winter	1976	Distal	Percutaneous needle	Distal-shunt series (not a named-shunt estimate): 18.7–100%[1]	Distal-shunt series (not a named-shunt estimate): 20–100%[1]	Used; highest reoperation rate in the Nixon series
Ebbehoj	1974	Distal	Percutaneous blade	Distal-shunt series (not a named-shunt estimate): 18.7–100%[1]	Distal-shunt series (not a named-shunt estimate): 20–100%[1]	Used; few individual outcome data
T-Shunt (Lue)	2009	Distal	Percutaneous (90° rotation)	Distal-shunt series (not a named-shunt estimate): 18.7–100%[1]	Distal-shunt series (not a named-shunt estimate): 20–100%[1]	Widely used; Snake-compatible
Al-Ghorab	1973	Distal	Open excision	Distal-shunt series (not a named-shunt estimate): 18.7–100%[1]	Distal-shunt series (not a named-shunt estimate): 20–100%[1]	Largest distal window; Snake-compatible
Quackels	1964	Proximal	Open corporospongiosal	Proximal-shunt series (not a named-shunt estimate): 5.7–100%[1]	Proximal-shunt series (not a named-shunt estimate): 11.1–77.2%[1]	Largely abandoned
Grayhack	1964	Proximal	Open with saphenous-vein graft	Proximal-shunt series (not a named-shunt estimate): 5.7–100%[1]	Proximal-shunt series (not a named-shunt estimate): 11.1–77.2%[1]	Largely abandoned
Barry	1976	Venous	Open to dorsal penile vein	Detumescence in all (n = 10, Micoogullari)	80% (n = 10)	Niche / planned-closure construct
Chiou cavernosal-dorsal-vein	2009	Venous	Saphenous-graft to deep dorsal vein	Resolved or improved in all (n = 16, 10 prior failed)	69% of 13 adults	Salvage option after failed shunting

---

Early Malleable Penile Prosthesis for Refractory Ischemic Priapism

EAU advises discussing penile prosthesis implantation for ischemic priapism with delayed presentation (>48 hours) or refractory to injection therapy and distal shunting , and its text recommends immediate malleable penile prosthesis (MPP) insertion to avoid the difficulty and complications of delayed implantation in fibrotic corpora;^[49] a penile prosthesis may also be considered for untreated acute ischemic priapism >36 hours .^[53] It treats the priapism and the ED that follows prolonged corporal ischemia in one operation. In Ralph's UCLH series of 50 patients with smooth-muscle necrosis, 42 resumed intercourse, satisfaction was 96%, and no patient reported penile shortening.^{[2][17][36][37]}

Pathophysiological rationale. Corporal smooth-muscle damage is time-dependent and ultimately irreversible: by > 48 h all biopsied patients in the Zacharakis T-shunt series had necrotic smooth muscle, and EF recovery is unlikely even if shunting achieves detumescence.^[5][17][36] Implantation in the acute soft-corpora window, before fibrotic remodeling consolidates, accomplishes four things at once:

1. Mechanical detumescence. The prosthesis displaces the trapped blood.
2. Length preservation. The cylinder functions as an internal stent or tissue expander during fibrotic remodeling.
3. ED treatment. Addresses the low likelihood of erectile recovery after prolonged confirmed ischemia; AUA/SMSNA advises this counseling after >36 hours .^[53]
4. Avoidance of the dense-fibrosis surgery. Zacharakis showed 80% of delayed implants require a second corporotomy and downsized cylinders due to fibrosis.^[38]

Imaging-guided patient selection with contrast-enhanced penile MRI. T2-weighted gadolinium-enhanced penile MRI differentiates viable from nonviable corporal smooth muscle. Ralph 2010 reported 100% sensitivity for MRI-predicted nonviable smooth muscle among 23 patients with paired MRI and corporal biopsy; among 15 additional patients without biopsy, 10 MRI-nonviable patients developed ED and 5 MRI-viable patients maintained EF.^[39] MRI findings may inform prosthesis counseling in prolonged cases, but AUA/SMSNA states that MRI is unlikely to have a role in the initial diagnostic and treatment phase. In acute ischemic priapism with a persistent erection after shunting, clinicians should perform a corporal blood gas or color duplex Doppler before repeat surgery .^[39][47][53] In the ISSM survey (251 respondents; 11.6% response rate), fewer than 40% currently used MRI or corporal biopsy in this setting.^[40]

Guideline positioning.

• EAU panel systematic review (2024). The review favors prosthesis implantation for ischemic priapism >48 hours and concludes that proximal or venous shunts should be abandoned; these are review conclusions.^[1]
• AUA/SMSNA 2022. A prosthesis may be considered for untreated acute ischemic priapism >36 hours or refractory disease after shunting, with or without tunneling .^[53] For patients with acute ischemic priapism considering a penile prosthesis, discuss the risks and benefits of early versus delayed placement .^[53] The discussion defines early placement as within two weeks and calls for confirming the ischemic timeline, including intermittent detumescence.^[3][53]
• EAU 2026. Discuss prosthesis after delayed presentation (>48 hours) or failed injection/distal-shunt therapy ; delay implantation after a shunt to reduce infection and erosion . AUA/SMSNA discusses those risks without prescribing a fixed post-shunt delay.^[49][53]
• Pang 2025 / Calopedos 2025. These narrative reviews favor early prosthesis for RIP.^[2][36]

Why malleable over inflatable in the acute setting:^[17][36][37]

Feature	Malleable (semi-rigid)	Inflatable (3-piece IPP)
Acute / early implantation	More often used in AUA-reviewed early series	Also an option; choice depends on patient goals and surgical expertise[53]
Surgical complexity	Lower	Higher (reservoir + pump)
Operative time	Shorter	Longer
Comparative infection risk	No established superiority in the AUA review	No established superiority in the AUA review[53]
Corporal dilation	Minimal — soft necrotic tissue	Same, but precise sizing critical
Acts as internal stent / tissue expander	Yes	Yes (more complex)
Concealment	Poor	Better
Elective exchange to IPP later	Yes (~ 6–12 mo)	N/A
Cost	Lower	Higher

Step-by-step (early MPP for refractory ischemic priapism):^[37][41][42]

1. Confirm ischemic priapism with corporal blood gas (dark blood, pO₂ <30 mmHg, pH <7.25); MRI may inform viability in selected prolonged cases but must not delay initial treatment. After shunting, obtain blood gas or Doppler before further surgery.^[39][53]
2. Counsel about permanent loss of native erections in exchange for detumescence, length preservation, and restored ability to have intercourse.
3. Broad-spectrum antibiotic prophylaxis; select a malleable implant and prepare it according to its model-specific instructions.
4. Penoscrotal or subcoronal incision.
5. Bilateral corporotomies. The necrotic corpora are soft and dilate with minimal force; full Hegar progression is rarely needed.
6. Evacuate residual thrombosed blood; irrigate.
7. Measure full corporal length distally and proximally. Choose cylinder length with distal-tip integrity in mind after shunting; in one retrospective early-implant cohort, malleable cylinders were routinely downsized by 0.5 cm and fixed to the tunica, particularly after T-shunt.^[58]
8. Insert malleable rods bilaterally, with proximal tip seated in crura, distal tip beneath the glans.
9. Salem sling-suture distal-erosion prophylaxis (especially after prior distal shunting that has weakened the tunica): nonabsorbable suture taken through the cylinder and the edges of the opened tunica fixes the cylinder to the corporotomy edges. In Salem's 12-patient series (11 with prior failed shunts) this construct yielded 0% distal erosion at median 15-mo follow-up.^[42]
10. Close corporotomies with 2-0 / 3-0 absorbable.
11. Layered wound closure; compressive dressing.
12. Discharge within 24 h is typical.^[41]

Clinical evidence:

Series	n	Setting	Outcome
Ralph 2009 UCLH	50 (13 prior failed shunts)	Acute ischemic priapism; 86% malleable, 14% IPP	84% successful intercourse (42/50; median follow-up 15.7 mo); 96% satisfaction; no patient reported shortening; 6% infection; 12% further revision; 12% elective MPP-to-IPP exchange[37]
Zacharakis 2014 UCLH (early vs delayed)	95 (68 early at median 7 d vs 27 delayed at median 5 mo)	Refractory ischemic priapism	Satisfaction 96% early vs 60% delayed; 80% of delayed required second corporotomy + downsized cylinders due to dense fibrosis; significant shortening was the main driver of delayed-group dissatisfaction[38]
Barham 2023 multicenter (IPP)	62 priapism (15 early, 47 delayed) + 62 controls (no priapism)	Early (≤ 6 mo) vs delayed (> 6 mo) IPP	Postoperative noninfectious complications: 0% early vs 40.5% delayed; all reported cylinder-related complications occurred with full-sized cylinders — supports early referral to prosthetic experts[43]
Tausch 2015 cost-effectiveness	14	RIP at urban safety-net hospital	Mean preop 82 h of RIP, 4 ER visits, 2 admissions, 1.5 shunts, 5 irrigation/drainage, 5 hospital days, estimated preop cost US $83,818; all discharged ≤ 24 h after MPP[41]
Salem 2010 distal-erosion prevention	12 (11 prior failed shunts)	Median duration 120 h	100% successful insertion; 0% distal erosion and 0% infection with sling-suture construct; 100% intercourse and satisfaction at median 15 mo[42]
Dighero 2025 long-term QoL (QoLSPP)	39 of 167 post-priapism implants	Median 9 yr post-priapism	Satisfactory scores on 7/16 QoLSPP items; 100% would not regret the prosthesis; 100% satisfied to live the rest of life with device in situ; no significant difference malleable vs inflatable[44]
Butaney 2019 ISSM survey	251 ISSM members	Practice patterns	70.9% more comfortable with MPP than shunt, yet ~ 80% still favor shunts first-line; experience higher with prostheses than shunts — points to underutilization gap[40]

Malleable-to-inflatable exchange. A main advantage of acute MPP is the option for elective exchange to a 3-piece IPP at 6–12 months once corporal remodeling has stabilized; Ralph reported elective exchange in 6 of 50 patients (12%), and the corporal space maintained by the malleable rod makes the later IPP insertion considerably easier than a primary delayed IPP into densely fibrotic tissue.^[37][38]

Complications. Early MPP series and retrospective early-versus-delayed implant cohorts describe infection, erosion, revision, and shortening; none establishes a lower complication rate than shunt surgery.^{[1][17][37][38][42][43][46]} In a 2026 retrospective mixed-device cohort (n = 166), delayed placement was associated with more revisions after adjustment for device type (OR 3.74, 95% CI 1.22–11.44); infection and reported shortening did not differ significantly.^[58]

• Infection: 3/50 (6%) after immediate implantation in Ralph’s mixed-device cohort (43 malleable, 7 inflatable; median follow-up 15.7 months), versus 0/12 in Salem’s malleable sling-suture series (median follow-up 15 months); Ralph’s infections were managed by explantation and delayed reinsertion.^[37][42] Antibiotic-coated cylinders reduce this risk.^[46] Antibiotic-coated cylinders reduce this risk.
• Distal cylinder erosion or protrusion: particular risk when prior shunting has weakened the distal tunica; no distal erosion occurred with the Salem sling suture in 12 patients.^[42]
• Intraoperative corporal perforation: 1/12 patients (8.3%) in Salem’s small series; the affected patient had sickle cell disease, and the perforation was managed intraoperatively.^[42]
• Curvature: from asymmetric fibrosis or malposition; infection and curvature were the reasons for revision in the Zacharakis early group.^[38]
• Mechanical failure: relevant to IPPs only; malleable rods have no mechanical components.
• Penile shortening: none of Ralph’s 50 immediate-implant patients reported it; Zacharakis reported subjective shortening in 3% of 68 early-implant versus 40% of 27 delayed-implant patients, with shortening driving delayed-group dissatisfaction.^[37][38]

Three-piece IPP in the acute setting. Both malleable and inflatable devices are options; AUA/SMSNA does not mandate one device type.^[53] Clavijo 2017 detailed techniques for IPP placement into fibrotic corpora including cutting cavernotomes and narrow-base cylinders (Coloplast Titan narrow-base).^[45] In Barham’s retrospective multicenter cohort, postoperative noninfectious complications occurred in 0% of 15 men receiving an IPP within 6 months of ischemic priapism versus 40.5% of 47 men receiving it later; the study supports early referral.^[43] A narrative review of 8 studies reported total complication rates of 3.37% with early IPP placement versus 37.23% with delayed placement among the studies reporting complications, supporting early referral to a prosthetic surgeon when an IPP is planned.^[52]

Special populations.

• Sickle cell disease (4 of 13 in the Tausch cohort). The single corporal perforation in the Salem series occurred during dilation in a sickle cell patient. Perioperative hydration and transfusion are managed with hematology.^[41][42]
• Prior failed shunt surgery. Weakened distal tunica; use the Salem sling suture.^[42]

Algorithmic placement and biases. Per current evidence:^{[2][3][21][36]}

1. Intracavernosal phenylephrine and corporal aspiration, with or without irrigation, as combined first-line therapy .^[53]
2. Distal shunt (T-shunt or Al-Ghorab) ± Snake, for shorter-duration disease with likely-viable corpora.
3. Consider PSD after failed distal shunting; EAU 2026 also permits it as an alternative first surgical approach in selected cases . Discuss early prosthesis without requiring PSD first.^[49]
4. Consider a penile prosthesis for untreated acute ischemic priapism >36 h or persistent ischemia after shunting, with or without tunneling ; an early malleable device may be chosen when MRI or biopsy suggests nonviable corpora or the patient prefers definitive treatment with length preservation. After a shunt, delay implantation to reduce infection and erosion .^[49][53]

Situation	Bias
Shorter duration, viable corpora, patient strongly wants native EF chance	Distal shunt with tunneling or PSD
Failed shunt / failed PSD	Confirm persistent ischemia and evaluate for prosthesis; after recent shunting, plan insertion after wound healing to reduce infection and erosion.[49][53]
Duration > 36–48 h, MRI / biopsy with necrotic corpora	Early MPP (length-preserving)
Borderline duration (36–48 h) with patient strongly desiring native-EF chance	Discuss both options with the patient; MRI may inform the choice
Patient medically unstable or infected field	Temporize safely; defer implant if risk outweighs length preservation
Prior shunting with weakened distal tunica	If an MPP is selected, size and protect the distal tip; a 12-patient series (11 after failed shunts) described sling-suture fixation, while a later retrospective cohort routinely downsized early malleable cylinders by 0.5 cm and fixed them to the tunica, particularly after T-shunt.[42][58]

Penile prosthesis versus shunt (ranges from the EAU systematic review; not head-to-head data):^{[1][37][38][41]}

Parameter	Early prosthesis	Distal shunts	Proximal shunts
Resolution	100% across reviewed prosthesis series (timing and device types pooled)	18.7–100% across distal-shunt series	5.7–100% across proximal-shunt series[1]
Potency / functional intercourse	26.3–100% across prosthesis series (timing and device types pooled); 42/50 (84%) resumed intercourse in Ralph’s immediate mixed-device cohort after a median follow-up of 15.7 months	20–100% across distal-shunt series	11.1–77.2% across proximal-shunt series[1][37]
Satisfaction	96% in Ralph’s immediate mixed-device cohort (50 patients; median follow-up 15.7 months); the review’s 60–100% range includes prosthesis series with differing timing	Not systematically reported	Not systematically reported[1][37][38]
Complications	0–13.6% across reviewed penile-prosthesis series (not an early-only estimate)	0–42.5% across shunt series, not distal-specific	0–42.5% across shunt series, not proximal-specific[1]
Length preservation	Yes	Variable	Variable
Treats ED proactively	Yes	No	No
Comparative cost-effectiveness	Not established by the cited studies	Not established by the cited studies	Not established by the cited studies

Limitations. The choice is irreversible (native erectile function is permanently lost), which is a meaningful concern in borderline 36–48 h windows where some residual EF recovery might still occur.^[17][36][40] The evidence base is retrospective with no RCTs; availability of prosthetic surgical expertise on emergency call is not universal.^[17][36][40]

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Procedure Summary Table

Procedure	Category	Approach	Best for / indication	Key risk
Winter Shunt	Distal corporoglanular	Percutaneous Tru-Cut needle through glans	Simplest distal shunt for early refractory ischemic priapism	Small shunt closes; poor clot evacuation in prolonged priapism; highest failure rate among distal shunts
Ebbehoj Shunt	Distal corporoglanular	No. 11 blade stab through glans	Simple percutaneous blade shunt with larger opening than Winter	Urethral injury if directed too ventrally; still small; not Snake-compatible
T-Shunt (Lue)	Distal corporoglanular	No. 10 blade rotated 90° to create T-shaped distal tunical opening	Percutaneous distal shunt when a wider window and tunneling access are needed	Glans-based injury; urethral injury if trajectory wrong; urethrocutaneous fistula with Snake
Al-Ghorab Shunt	Distal corporoglanular	Open glans incision with distal tunical window	Large open distal shunt for failed percutaneous shunt or prolonged clot burden	Glans injury, urethral injury, cavernosospongiosal fistula
Burnett Snake Maneuver	Tunneling adjunct	size 7/8 Hegar dilator[55] passed proximally through distal shunt window (T-shunt or Al-Ghorab)	Disrupts full-length corporal clot after T-shunt or Al-Ghorab; single-intervention resolution 24/26 (92.3%) with Snake vs 30/56 (53.6%) without Snake (Unal/Burnett 2024)[10]	False passage or corporal perforation if forced
Penoscrotal Decompression	Glans-sparing decompression	Penoscrotal or proximal shaft corporotomies	Direct proximal evacuation / irrigation for prolonged priapism or failed distal shunt	Requires open exposure; erectile recovery duration-dependent
Quackels Shunt	Proximal / historical	Perineal cavernospongiosal shunt	Historical salvage after distal failure	Urethral injury, fistula, cavernositis, ED
Grayhack Shunt	Proximal / historical	Saphenous vein to corpus cavernosum	Historical caverno-venous drainage	Technical burden, pulmonary embolism concern, ED
Barry / Caverno-Dorsal Vein	Proximal / niche	Corpus cavernosum to dorsal penile vein	Small-series / niche venous-drainage option	Limited data; not mainstream algorithm
Early Malleable Penile Prosthesis	Definitive salvage	Acute corporal dilation and malleable cylinder placement	Length-preserving definitive option for nonviable corpora, failed shunts, or very late priapism	Implant infection / erosion in inflamed ischemic tissue

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Podcasts

Managing Ischemic Priapism: Surgical Approaches & Outcomes

BackTable Urology, Ep. 265 (2025) · Maia VanDyke, Juan Andino

backtable.com

References

1. Milenkovic U, Cocci A, Veeratterapillay R, et al. Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines Panel. Int J Impot Res. 2024;36(1):36-49. doi:10.1038/s41443-022-00604-1

2. Pang KH, Alnajjar HM, Lal A, Muneer A. An update on mechanisms and treatment options for priapism. Nat Rev Urol. 2025. doi:10.1038/s41585-025-01069-9

3. Bivalacqua TJ, Allen BK, Brock G, et al. Acute ischemic priapism: an AUA/SMSNA guideline. J Urol. 2021;206(5):1114-1121. doi:10.1097/JU.0000000000002236

4. El-Achkar A, Arbuiso A, Marquardt Filho N, et al. Non-surgical vs surgical management for major ischemic priapism of 36 hours duration. J Sex Med. 2026;23(1):qdaf362. doi:10.1093/jsxmed/qdaf362

5. Johnson MJ, Kristinsson S, Ralph O, Chiriaco G, Ralph D. The surgical management of ischaemic priapism. Int J Impot Res. 2020;32(1):81-88. doi:10.1038/s41443-019-0197-9

6. Brant WO, Garcia MM, Bella AJ, Chi T, Lue TF. T-shaped shunt and intracavernous tunneling for prolonged ischemic priapism. J Urol. 2009;181(4):1699-1705. doi:10.1016/j.juro.2008.12.021

7. Zacharakis E, Raheem AA, Freeman A, et al. The efficacy of the T-shunt procedure and intracavernous tunneling (snake maneuver) for refractory ischemic priapism. J Urol. 2014;191(1):164-168. doi:10.1016/j.juro.2013.07.034

8. Segal RL, Readal N, Pierorazio PM, Burnett AL, Bivalacqua TJ. Corporal Burnett "snake" surgical maneuver for the treatment of ischemic priapism: long-term followup. J Urol. 2013;189(3):1025-1029. doi:10.1016/j.juro.2012.08.245

9. Burnett AL, Pierorazio PM. Corporal "snake" maneuver: corporoglanular shunt surgical modification for ischemic priapism. J Sex Med. 2009;6(4):1171-1176. doi:10.1111/j.1743-6109.2008.01176.x

10. Unal S, Karakus S, Du Comb W, Burnett AL. Clinical outcomes of the Burnett "snake" maneuver shunt modification for ischemic priapism. J Sex Med. 2024;21(8):723-728. doi:10.1093/jsxmed/qdae078

11. Fuchs JS, Shakir N, McKibben MJ, et al. Penoscrotal decompression-promising new treatment paradigm for refractory ischemic priapism. J Sex Med. 2018;15(5):797-802. doi:10.1016/j.jsxm.2018.02.010

12. Baumgarten AS, VanDyke ME, Yi YA, et al. Favourable multi-institutional experience with penoscrotal decompression for prolonged ischaemic priapism. BJU Int. 2020;126(4):441-446. doi:10.1111/bju.15127

13. Basile G, Ralph D, Wardak S, Sangster P, Christopher N, Lee WG. Penoscrotal decompression should be considered for prolonged ischaemic priapism. J Sex Med. 2025;22(11):2072-2078. doi:10.1093/jsxmed/qdaf229

14. VanDyke ME, Smith WJ, Holland LC, et al. Current opinions on the management of prolonged ischemic priapism: does penoscrotal decompression outperform corporoglanular tunneling? Int J Impot Res. 2024;36(1):62-67. doi:10.1038/s41443-023-00808-z

15. Micoogullari U, Unal S, Alijla A, et al. Effectiveness of the caverno-dorsal vein shunt (Barry shunt) on prolonged ischaemic priapism and its effect on the post-operative long-term erectile function. Andrologia. 2021;53(2):e13945. doi:10.1111/and.13945

16. Soydaş T, Tunç OE, Uzundal H, et al. Barry shunt in prolonged ischemic priapism: a novel treatment algorithm. J Sex Med. 2025;22(11):2070-2071. doi:10.1093/jsxmed/qdaf240

17. Yassin M, Chen R, Ager M, Desouky E, Minhas S. Penile implants in low flow priapism. Int J Impot Res. 2023;35(7):651-663. doi:10.1038/s41443-023-00787-1

18. Stein RJ, Patel AS, Benoit RM. "Treatment of postpriapism erectile dysfunction by closure of persistent distal glans-cavernosum fistulas 5 years after shunt creation." Urology. 2005;65(3):592. doi:10.1016/j.urology.2004.09.035

19. Ortaç M, Çevik G, Akdere H, Ermeç B, Kadıoğlu A. Anatomic and functional outcome following distal shunt and tunneling for treatment ischemic priapism: a single-center experience. J Sex Med. 2019;16(8):1290-1296. doi:10.1016/j.jsxm.2019.05.011

20. Shiraishi K, Matsuyama H. Salvage management of prolonged ischemic priapism: Al-Ghorab shunt plus cavernous tunneling with blunt cavernosotomy. J Sex Med. 2013;10(2):599-602. doi:10.1111/j.1743-6109.2012.02973.x

21. Schifano N, Capogrosso P, Baldini S, et al. Current evidence on the management of ischaemic priapism post-shunting: a narrative review. Int J Impot Res. 2025. doi:10.1038/s41443-025-01078-7

22. Quackels R. Cure of a patient suffering from priapism by cavernospongious anastomosis. Acta Urol Belg. 1964;32:5-13.

23. Cosgrove MD, LaRocque MA. Shunt surgery for priapism: review of results. Urology. 1974;4(1):1-4. doi:10.1016/0090-4295(74)90098-3

24. Tabibi A, Abdi H, Mahmoudnejad N. Erectile function and dysfunction following low flow priapism: a comparison of distal and proximal shunts. Urol J. 2010;7(3):174-177. PMID 20845293

25. Zheng DC, Yao HJ, Zhang K, et al. Unsatisfactory outcomes of prolonged ischemic priapism without early surgical shunts: our clinical experience and a review of the literature. Asian J Androl. 2013;15(1):75-78. doi:10.1038/aja.2012.63

26. Manjunath AS, Mazur DJ, Han JS, Gonzalez CM. Simultaneous urethrocutaneous and urethrocavernous fistula after proximal corporospongiosal shunt for priapism. Urology. 2015;85(3):e13-e14. doi:10.1016/j.urology.2014.12.018

27. Robbins DM, Crawford ED, Lackner HL. Late development of a urethrocavernous fistula after cavernospongiosum shunt for priapism. J Urol. 1984;132(1):126-127. doi:10.1016/s0022-5347(17)49496-1

28. Kulmala RV, Lehtonen TA, Lindholm TS, Tammela TL. Permanent open shunt as a reason for impotence or reduced potency after surgical treatment of priapism in 26 patients. Int J Impot Res. 1995;7(3):175-180. PMID 8750051

29. Grayhack JT, McCullough W, O'Conor VJ Jr, Trippel O. Venous bypass to control priapism. Invest Urol. 1964;1:509-513. PMID 14130594

30. Resnick MI, Holland JM, King LR, Grayhack JT. Priapism in boys. Management with cavernosaphenous shunt. Urology. 1975;5(4):492-495. doi:10.1016/0090-4295(75)90073-4

31. Moloney PJ, Elliott GB, Johnson HW. Experiences with priapism. J Urol. 1975;114(1):72-76. doi:10.1016/s0022-5347(17)66946-5

32. Richard F, Fourcade R, Le Guillou M, Jardin A, Kuss R. Etiological aspects and interest of early surgical management of priapism. Eur Urol. 1979;5(3):179-181. doi:10.1159/000473100

33. Barry JM. Priapism: treatment with corpus cavernosum to dorsal vein of penis shunts. J Urol. 1976;116(6):754-756. doi:10.1016/s0022-5347(17)58998-3

34. Chiou RK, Aggarwal H, Mues AC, Chiou CR, Broughton FL. Clinical experience and sexual function outcome of patients with priapism treated with penile cavernosal-dorsal vein shunt using saphenous vein graft. Urology. 2009;73(3):556-561. doi:10.1016/j.urology.2008.10.025

35. Kilinc M. Temporary cavernosal-cephalic vein shunt in low-flow priapism treatment. Eur Urol. 2009;56(3):559-562. doi:10.1016/j.eururo.2008.10.009

36. Calopedos R, Trubbia D, Ralph D, Lee WG. Early penile prosthesis implantation in refractory ischaemic priapism: a narrative review. Int J Impot Res. 2025. doi:10.1038/s41443-025-01199-z

37. Ralph DJ, Garaffa G, Muneer A, et al. The immediate insertion of a penile prosthesis for acute ischaemic priapism. Eur Urol. 2009;56(6):1033-1038. doi:10.1016/j.eururo.2008.09.044

38. Zacharakis E, Garaffa G, Raheem AA, et al. Penile prosthesis insertion in patients with refractory ischaemic priapism: early vs delayed implantation. BJU Int. 2014;114(4):576-581. doi:10.1111/bju.12686

39. Ralph DJ, Borley NC, Allen C, et al. The use of high-resolution magnetic resonance imaging in the management of patients presenting with priapism. BJU Int. 2010;106(11):1714-1718. doi:10.1111/j.1464-410X.2010.09368.x

40. Butaney M, Thirumavalavan N, Rodriguez D, Gross MS, Munarriz R. Current practice in the management of ischemic priapism: an anonymous survey of ISSM members. Int J Impot Res. 2019;31(6):404-409. doi:10.1038/s41443-019-0120-4

41. Tausch TJ, Zhao LC, Morey AF, et al. Malleable penile prosthesis is a cost-effective treatment for refractory ischemic priapism. J Sex Med. 2015;12(3):824-826. doi:10.1111/jsm.12803

42. Salem EA, El Aasser O. Management of ischemic priapism by penile prosthesis insertion: prevention of distal erosion. J Urol. 2010;183(6):2300-2303. doi:10.1016/j.juro.2010.02.014

43. Barham DW, Chang C, Hammad M, et al. Delayed placement of an inflatable penile prosthesis is associated with a high complication rate in men with a history of ischemic priapism. J Sex Med. 2023;20(7):1052-1056. doi:10.1093/jsxmed/qdad075

44. Dighero I, Naylor K, Looney A, et al. Quality of life outcomes following penile prosthesis insertion in the post-ischaemic priapism setting. Int J Impot Res. 2025. doi:10.1038/s41443-025-01073-y

45. Clavijo RI, Sávio LF, Prakash NS, et al. Three-piece penile prosthesis implantation in refractory ischemic priapism — tips and tricks. Urology. 2017;106:233-235. doi:10.1016/j.urology.2017.04.032

46. Cocci A, Capogrosso P, Minhas S, et al. Penile prosthesis implantation: a systematic review of intraoperative and postoperative complications. Int J Impot Res. 2025. doi:10.1038/s41443-025-01108-4

47. von Stempel C, Walkden M, Kirkham A. Review of the role of imaging in the diagnosis of priapism. Int J Impot Res. 2024. doi:10.1038/s41443-024-00928-0

48. Nixon RG, O'Connor JL, Milam DF. Efficacy of shunt surgery for refractory low flow priapism: a report on the incidence of failed detumescence and erectile dysfunction. J Urol. 2003;170(3):883-886. doi:10.1097/01.ju.0000081291.37860.a5

49. EAU. Guidelines on Sexual and Reproductive Health, Limited Update March 2026, sections 10.1.3.b and 10.1.4 (surgical management and recommendations for ischemic priapism).

50. Zhao H, Dallas K, Masterson J, et al. Risk Factors for Surgical Shunting in a Large Cohort With Ischemic Priapism. J Sex Med. 2020;17(12):2472-2477. doi:10.1016/j.jsxm.2020.09.007

51. Palka J, DuComb W, Begun E, Soto-Aviles O. Factors Associated With Corporoglandular Shunting for Patients With First-Time Ischemic Priapism. Urology. 2021;154:191-195. doi:10.1016/j.urology.2021.03.030

52. Abou Chawareb E, Hammad MAM, Barham DW, et al. Early Inflatable Penile Prosthesis Implantation Offers Superior Outcomes Compared to Delayed Insertion Following Ischemic Priapism: A Narrative Review. Int J Impot Res. 2025;37(1):27-32. doi:10.1038/s41443-024-00900-y

53. American Urological Association/Sexual Medicine Society of North America. The Diagnosis and Management of Priapism: an AUA/SMSNA Guideline. 2022. Full guideline, statements 7–15 and discussion. Companion publication: Bivalacqua TJ, Allen BK, Brock GB, et al. The Diagnosis and Management of Recurrent Ischemic Priapism, Priapism in Sickle Cell Patients, and Non-Ischemic Priapism: An AUA/SMSNA Guideline. J Urol. 2022;208(1):43–52. doi:10.1097/JU.0000000000002767

54. Mubarak M, Isa Q, Hayes J, Pearce I, Modgil V. "The efficacy of penoscrotal decompression for refractory ischaemic priapism: a systematic review and meta-analysis." Int J Impot Res. 2026;38(9):662-668. doi:10.1038/s41443-025-01044-3

55. Kovac JR, Mak SK, Garcia MM, Lue TF. "A pathophysiology-based approach to the management of early priapism." Asian J Androl. 2013;15(1):20-26. doi:10.1038/aja.2012.83

56. Kandel GL, Bender LI, Grove JS. "Pulmonary embolism: a complication of corpus-saphenous shunt for priapism." J Urol. 1968;99(2):196-197. doi:10.1016/S0022-5347(17)62672-7

57. Alnajjar HM, Muneer A. "Recent advances in understanding and treating priapism." F1000Res. 2022;11:23. doi:10.12703/r/11-23

58. Tong KS, Pang KH, Lau JTY, Ralph DJ, Muneer A, Alnajjar HM. "Comparative Outcomes of Early versus Delayed Penile Prosthesis Insertion in Patients With Ischaemic Priapism-Long-Term Outcome Experience From a Single High-volume Centre." Andrology. 2026. doi:10.1111/andr.70309

59. Nguyen J, Abdoli S, Ochoa C. "Caverno-saphenous shunt for recurrent priapism." J Vasc Surg Cases Innov Tech. 2023;9(4):101359. doi:10.1016/j.jvscit.2023.101359