Urologic Emergencies - Beyond the Abstract
For AUR related to BPH for which a foley has been placed, men are often started on an α-blocker for several days prior to attempting decatheterization and a trial of void. The addition of an α-blocker has been shown to increase the percentage of men subsequently passing a trial of void from 47.9% to 61.9% versus placebo1. However, AUR is often a sign of end-stage BPH that may be refractory to such medical therapy. Other, earlier signs include gross hematuria, recurrent urinary tract infections, renal failure, and bladder stone formation.
While many therapies exist, the most common are monopolar and bipolar transurethral resection of the prostate (TURP). Meta-analyses of randomized controlled trials found no difference in most objective criteria between the monopolar and bipolar TURP2,3, but monopolar was associated with increased complications such as bleeding, transfusion, and hyponatremia4. GreenLightTM Photoselective Vaporization of the Prostate (Boston Scientific, Marlborough, MA) has been linked to decreased intraoperative complications, hospital length of stay, and time with catheter while still having similar improvements in objective criteria as TURP5. However, it is associated with higher rates of dysuria, urge, and re-treatment for residual adenoma. Other therapies, some still emerging, include holmium laser enucleation of the prostate, prostatic urethral lift with the Urolift device (NeoTract, Pleasanton, CA), and Rezum water vapor therapy (Maple Grove, MN).
For urethral stricture disease, work-up can include serum creatinine, urine culture, post void residual, renal ultrasound, Uroflow, and cystoscopy and retrograde urethrogram. Treatment can include urethral dilation, direct visual internal urethrotomy, or urethroplasty with or without use of grafts or flaps.
Priapism: For refractory ischemic priapism, surgical intervention may be necessary with distal or proximal shunts. Distal shunts should be attempted first because they’re technically easier, less invasive, and some can be performed under local anesthetic6.
More conservative distal shunts include the Winter’s (a biopsy needle through the glans to excise cores from the distal corpora), Ebbehoj (an 11-blade scalpel through the glans with multiple punctures through the distal corpora), and unilateral T-shunt (a 10-blade scalpel through the glans into the distal tip of the corpora, then a 90-degree rotation away from the urethra, removal of the scalpel, and glans closure with absorbable suture once bright red blood is visualized)7. If the priapism persists or recurs, a second T shunt can be performed on the opposite side. More aggressive distal shunts, for priapism of longer duration, include a bilateral T-shunt (using a 20/22Fr straight urethral sound or Hegar dilator to tunnel into the corpora down to the penile base) and the Al-Ghorab shunt (a 2cm transverse incision into the dorsal glans, 1cm distal to the coronal sulcus, with excision of the distal portion of the tunica albuginea from each corpora).
Finally, proximal shunts can be attempted when necessary. In the Quackel’s shunt, the corpora spongiosum and cavernosal are incised and anastomosed through a perineal or shaft incision. In the Grayhack shunt, the saphenous vein is anastomosed in an end-to-side fashion to the corpora cavernosa at the penile base. Because untreated or refractory priapism will inevitably lead to fibrosis and complete erectile dysfunction, some advocate for immediate penile prosthesis implantation to preserve penile length and make for a technically easier insertion. Men who had early penile prosthesis insertion after refractory ischemic priapism were found to have greater satisfaction and ability to have intercourse than men who had delayed implantation8.
Written by: Adarsh S Manjunath, MD, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL
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References
1. McNeill SA, Hargreave TB, Roehrborn CG, Alfaur study g. Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. Urology. 2005;65(1):83-89; discussion 89-90.
2. Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. European urology. 2010;58(3):384-397.
3. Omar MI, Lam TB, Alexander CE, et al. Systematic review and meta-analysis of the clinical effectiveness of bipolar compared with monopolar transurethral resection of the prostate (TURP). BJU international. 2014;113(1):24-35.
4. Issa MM. Technological advances in transurethral resection of the prostate: bipolar versus monopolar TURP. J Endourol. 2008;22(8):1587-1595.
5. Al-Ansari A, Younes N, Sampige VP, et al. GreenLight HPS 120-W laser vaporization versus transurethral resection of the prostate for treatment of benign prostatic hyperplasia: a randomized clinical trial with midterm follow-up. European urology. 2010;58(3):349-355.
6. Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology / editor-in-chief, Alan J. Wein ; [editors, Louis R. Kavoussi ... et al.]. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012.
7. Brant WO, Garcia MM, Bella AJ, Chi T, Lue TF. T-shaped shunt and intracavernous tunneling for prolonged ischemic priapism. The Journal of urology. 2009;181(4):1699-1705.
8. Zacharakis E, Garaffa G, Raheem AA, Christopher AN, Muneer A, Ralph DJ. Penile prosthesis insertion in patients with refractory ischaemic priapism: early vs delayed implantation. BJU international. 2014;114(4):576-581.