DANGLE ET AL.

Surgery Illustrated Focus on Details

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A modified surgical approach to the Al-Ghorab
shunt an anatomical basis
Pankaj P. Dangle, Mitesh B. Patel, Lopa K. Pandya and Casimir F. Firlit*
Department of Surgery, Division of Urology, Saint Louis University School of Medicine; and *Pediatric/Fetal
Urology, Neuro-Urology, Cardinal Glennon Hospital, Saint Louis, MO, USA

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

KEYWORDS
priapism, Al-Ghorab, shunt, surgical access
INTRODUCTION
Priapism, although rare, is a well identified
entity seen in the Emergency Department.
Its presentation, types and management
are well discussed in the literature [1].
Acute management is stepwise; with
surgical intervention required once more
conservative approaches fail to correct
the underlying cause. Surgical shunts, e.g.
the Winter and the Ebbehoj, have variable
success rates of 30100% [2]. The success
of these procedures is dependent on the
cause, duration, previous episodes, and
number of previous surgical interventions.
In stuttering priapism, both the Winter and
Ebbehoj shunts can occlude secondary to
frequent clotting and fibrosis. A surgically
established shunt, e.g. the Al-Ghorab, has
a proven success rate shown by persistent
detumescence [2,3]. The traditional surgical
approach for the Al-Ghorab shunt is a
dorsal sub-coronal incision, which can
surgically incise the dorsal nerve of the
penis (DNP) and thereby denervate the
glans penis.
Herein, we describe a modified surgical
approach to the Al-Ghorab shunt with the
intention of avoiding surgical incision to the
dorsal nerve bundle innervating the dorsal
aspect of glans penis.
PATIENT AND METHODS
A 17-year-old male with a known history
of recurrent priapism presented to the
Emergency Department with another
episode lasting for a period of 36 h. The
patient reported previous multiple episodes
over the last 5 years with at least three
interventions in the form of bedside
aspirations at another institute. On detailed
history, he denied previous trauma, sickle
cell disease, and drug abuse, confirmed
by urine analysis. The patient had a
significant psychiatric history and had
been treated with several antipsychotic
and antidepressant medications including
ziprasidone, divalproex, lithium carbonate
and citalopram. Antipsychotic medications,
including ziprasidone and lithium, have been
reported causes of ischaemic priapism [4,5].
After failed conservative management, a
decision was made to perform a distal
Al-Ghorab (corporoglandular) shunt. A
penile block preceded surgical intervention.
Instead of a classical dorsal incision, we
elected to modify the surgical access
through bilateral ventral sub-coronal
incisions lateral to the urethra [6]. The
decision to modify the incision was based
on the detailed anatomical illustrations of
Yang and Bradley [7]. According to the
authors the axons innervating the glans
were constant in a dorsal, midline location
along most of the penile shaft, with
abundant branching within the glans
and paucity of nerves on the ventral
aspect of the penis (Fig 1a). Based on the
findings, the authors proposed that the
pattern of innervation of the glans supports
its role as a sensory structure for sexual
function [7].
As a standard approach, a Foley catheter
was placed to identify and consequently to
avoid injury to the urethra. Further
dissection was carried out until the distal
ends of the corpora cavernosa were
identified. The tips of the corporal bodies
were incised in a stellate fashion to create
the corporoglandular shunts on each side
(Fig 1b and c). Both corporal bodies were
flushed using a 1015 cm 21 G spinal
needle with heparinised saline,
detumescence was achieved and
haemostasis was confirmed. A Penrose
tourniquet was used throughout the
procedure at the base of the penis.

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 FOCUS ON DETAILS

Figure 1

a) Dorsal aspect of the penile shaft

demonstrating the subcoronal section with
complex neurovascular innervation.
b) Ventral aspect of the penis (subcoronal
section) with sparse neural innervation.
c) Subcoronal incision on the ventral aspect
of the penis guarding the urethra medially.

a b

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DANGLE ET AL.
DISCUSSION
Ischaemic priapism is a urological
emergency and if untreated can lead to
progressive ischaemia, acidosis, and
corporeal fibrosis [8]. Management of
priapism is dependent on the presenting
type. Based on American Urological
Association guidelines, treatment of
ischaemic priapism should be stepwise
beginning with intracavernosal injection of
an -adrenergic sympathomimetic agent,
with or without evacuation of old blood,
and lastly surgical shunting if conservative
means of management have failed [3].
Several shunting procedures have been
described in the literature to allow for
alternative drainage with distal shunts being
the first choice. Shunting can be performed
with a large biopsy needle (Winter), a scalpel
inserted percutaneously through the glans
(Ebbehoj) or by excising a piece of each
corpus cavernosum (Al-Ghorab). Success
with these shunts varies in terms of
achieving detumescence. Of the distal
shunts, the Al-Ghorab has been reported
effective and can be performed even if the
other distal shunts fail to resolve erection.
Nixon et al. [2] reported success in 12 of 13
patients who underwent an Al-Ghorab
shunt, while 12 of 14 who underwent
Winter shunt procedures required a second
surgical shunt within 2436 h.
In a classical Al-Ghorab shunt a surgical
incision is made on the dorsal surface of the
glans. We describe a novel modification to
the Al-Ghorab shunt in which incisions are
made on the ventral aspect of the glans in
an effort to prevent destruction and
preserve the sensations to the glans penis.
CRITICAL ANATOMY
The DNP is critical for normal sexual
functioning. Yang and Bradley [7] described
the neuroanatomy of the DNP and showed
that the DNP travels along the dorsal aspect
of the shaft and provides lateral branches
that supply the sensory pathway of the
ventral and lateral shaft. Furthermore, the
DNP terminates with dorsal branching
extending into the glans penis.
The anatomical dissection by the authors
revealed two different populations of axons
comprising the DNP. While one group travels
along the dorsal midline and terminates in
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the glans, the second group radiates over
the lateral aspect to supply the ventral
aspect of the penis. Furthermore, ventral
dissection revealed a scarcity of nerves. At
12 cm proximal to the glans the DNP
divides into two to three bundles, which
enter straight into the glans to form the
medial and ventrolateral glanular branches.
Immediately after entering the glans, these
nerves branch and radiate towards the
urethral meatus and the glanular epithelium.
Bors and Comarr [9] described patients who
had total loss of erectile and ejaculatory
function after bilateral pudendal
neurectomy. The nerves in the glans penis
may play an important role in erectile
function. Vibratory stimulation of the glans
has been shown to induce ejaculation in
men with spinal cord injuries [10,11]. Nerve
branching becomes increasingly intricate at
the distal end of the shaft and no specific
neurovascular bundle exists, complicating
surgical procedures involving the glans penis
and leading to numbness and erectile
dysfunction secondary to incision of the
delicate nerves. We chose a ventral approach
for our corporoglandular shunt to avoid the
sensory neural branching that occurs on the
dorsal aspect of the glans.
Based on the anatomical illustrations of
Yang and Bradley [7], the present
modification may reduce the neural injury
created by surgical incision through the
dorsal aspect. Long-term follow-up is
essential to evaluate the benefits of our
modification over the classically described
dorsal approach. The close proximity of the
urethra by the ventral approach may pose
risks of urethral injury. Preoperative urethral
catheterisation and laterally directed
dissection with vigilance may avoid
inadvertent urethral injury.
CONCLUSION
The Al-Ghorab shunt has been shown to be
an effective and reproducible technique for
the management of ischaemic priapism. This
case highlights our success in management
of priapism and the potential to decrease
injury to the DNP at the glans with a
surgical access modification. Randomised
clinical trials and their long-term follow-up
will better define the value of this
modification for secondary (sensory) erectile
dysfunction.
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Correspondence: Pankaj P. Dangle,
Department of Surgery, Division of Urology,
3635 Vista Avenue at Grand Boulevard,
3rd Floor N, Desloge Towers, St. Louis MO
63110-0250, USA.
e-mail: pankajdangle@gmail.com
Abbreviation: DNP, dorsal nerve of the penis.
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