Should perioperative anticoagulation be an integral part of the priapism shunting procedure?

We propose that post-shunting recurrence of ischemic priapism is a postoperative thromboembolic complication, similar to cases of postoperative thrombosis of veins (femoral or popliteal) or arteries (cerebral or coronary). Therefore, perioperative anticoagulation should be given to men undergoing these shunting procedures to prevent this complication. Two illustrative cases are presented herein. Case 1 The patient is a 22-year-old man with a history of schizophrenia, controlled with oral medications (olanzapine and valproic acid). Over the past two years, he had eight episodes of ischemic priapism, lasting between 4-14 hours, which all resolved spontaneously. The patient presented again to a local hospital with a chief complaint of painful erection for three days. The patient was immediately transferred to our center. A thorough history yielded only recent (and only intermittent) use of olanzapine as a possible causative factor for the ischemic priapism. He complained of severe, dull pain in his penis. On physical examination, his penis was rigid and tender. There were no signs of infection. His WBC count was normal. He was taken to the operating room, as he declined bedside procedure in the emergency department. On exam, the tip of the rigid corporal body was easily palpable at a shallow depth from the surface of the glans. A marking pen was used to make two vertical incision lines about 1 cm long, 0.5 cm lateral to urethral meatus. Local anesthetic (0.25% bupivicaine) was injected into the subepithelial layer (not the underlying spongy tissue) of the glans overlying the planned, T-shunt sites (Figure 1). Bilateral T-shunts were then performed using a 10-blade scalpel, in quick succession. Bilateral corporal tunneling was performed using 22-Fr. straight urethral sounds as previously described (1-3). With the sound oriented slightly laterally, the sound was passed gently to the crura without injury to the urethra. After the sound was removed, there was immediate drainage, of thick dark viscous blood. The penis was milked until blood draining forth from the shunt sites turned into a bright-red color. The T-shunt sites were closed with running-locking 4-0 chromic sutures. Care was taken to place each suture shallowly within glans tissue, so as to minimize incorporation of deeper glans tissue at the shunt site. The penis was moderately edematous, but remained non-erect throughout a 10-minute observation period and through the end of the surgery. A Foley catheter was placed which drained clear yellow urine. Following transfer to the recovery room, the patient …