Al-Ghorab open distal shunt for ischaemic priapism

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play through the eight steps, or use Back and Next. Watch the glans open, a window cut from each dorsal tip, dark clot give way to bright blood, and the drainage path stay open under the closed glans. The triggers show a firm penis the next morning, a ventral excision and a dusky glans.

Operative steps

1. Refractory ischaemia: the indication A man in his thirties with ischaemic priapism, confirmed on corporal blood gas, after repeated aspiration and irrigation, phenylephrine under monitoring, and a percutaneous distal shunt that did not hold. The corpora are dark and rigid; the glans and spongiosum are soft because they drain separately. The two healed puncture marks lateral to the meatus are the history of the failed percutaneous attempt. The alternatives are named before the knife: another percutaneous distal shunt with tunnelling, the Burnett modification with retrograde dilators through the windows, and an early prosthesis conversation when the episode is delayed or refractory.
   where it bites: the indication is failure of the ladder, not a first choice; the European guideline ranks no distal shunt technique above another.
2. Tourniquet and set-up Supine, prepared and draped, antibiotics given. A tourniquet goes round the base of the penis so the excision is done in a still field; it stays on until the glans is closed. A urethral catheter is optional: it marks the urethra, which lies ventral to everything that follows, and makes a ventral wander obvious at once.
   where it bites: the urethra is ventral; everything in this operation happens on the dorsum.
3. Transverse dorsal glans incision A transverse incision in the dorsum of the glans, distal to the corona, taken down sharply through the dartos and Buck's fascia to the tunica albuginea. The lips part and the white dorsal tips of both corpora cavernosa lie in the floor of the wound, with the glans spongy tissue round them.
   where it bites: a transverse glans incision can compromise the glans arterial supply; it stays transverse, dorsal and no longer than it needs to be.
4. Excise the first segment: the patient's left tip Allis forceps lift the dorsal tunica of the first corporal tip. A segment of tunica is excised with scissors, leaving a round window with a cut rim; dark stagnant blood follows at once. The excised segment leaves the field. The window is on the dorsal tip, away from the septum and well away from the ventral spongiosum.
   where it bites: excise from the dorsal tip; a segment taken ventrally is an excision toward the urethra.
5. Excise the second segment: the patient's right tip The same on the other corpus, grasped the same way and excised to the same depth. Two windows now sit side by side, one in each tip, with the intercavernous septum intact between them. The excision is bilateral, as both the operative text and the guideline describe it: one window per corpus.
   where it bites: symmetry and the same depth on both sides; the septum between the windows is left alone.
6. Evacuate: compression from base to tip External pressure on the corpora, milked from the base toward the tip, pushes the stagnant dark blood and clot out through both windows. The colour at the windows is the endpoint: dark, then dusky, then bright red as arterial inflow returns, and the shaft softens with it. If clot will not come, a dilator passed through each window into the corpus clears the channel (the Burnett modification).
   where it bites: bright blood at the windows is the sign of restored inflow; softening alone can be emptying without reperfusion.
7. Close the glans; tourniquet off The glans incision is closed with interrupted absorbable sutures over the open windows; a running closure is also described. The windows are not closed: the shunt is the open window under the closed glans, a path from each corpus through its window into the glans spongy tissue, which drains freely. The tourniquet comes off and haemostasis is checked with the shunt working.
   where it bites: the windows stay open; closing the tunica closes the shunt.
8. Reassess and counsel A loose dressing, the penis supported against the abdomen to limit swelling. A firm penis afterwards may be oedema or reactive hyperaemia rather than persistent ischaemia, so the decision to go further rests on a repeat corporal blood gas or direct observation, not on feel or colour Doppler alone. Before discharge the conversation is honest: duration drives smooth muscle death and fibrosis, erectile function may not recover, and in a delayed or refractory episode an early prosthesis is discussed rather than waiting for dense fibrosis.
   where it bites: judge success by gas or direct observation; a prosthesis after a shunt is delayed, and in the delayed or refractory case it is raised early.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Priapism. Not a workplace-based assessment and not evidence of competence.