Dear Editor,

High-flow priapism is a persistent erection, usually caused by blunt perineal trauma, resulting in pathologically increased arterial inflow to the corpora cavernosa [1].The therapeutic strategy of high-flow priapism, although codified, leaves room for a wide choice of techniques, ranging from conservative management, selective arterial embolization to surgical management [2].The aim of this letter was to report an alternative approach of percutaneous embolization by direct puncture for the treatment of high-flow priapism.

A healthy 26-year-old military man had perineal trauma during an exercise session.He developed penile tumescence 1 week later.The patient was referred to our institution 48 h after the onset of priapism.Physical examination revealed uncomfortable but not painful priapism, and the erection was not completely rigid.Color duplex ultrasonography showed a pseudoaneurysm of the right corpus cavernosum.A magnetic resonance imaging study was then performed for an accurate topographic diagnosis of the vascular lesion(Fig.1).After approval from the French Society for Genitourinary Imaging, we chose to perform the first case of first-line percutaneous embolization of pseudoaneurysm by direct puncture.Patient’s approval was obtained for the treatment and publication of the data.

Figure 1 Pseudoaneurysm of the right corpora cavernosa.(A) Pseudoaneurysm of the right corpora cavernosa identified on ultrasound; (B) Cavernous artery velocities with high diastolic flow on Doppler study; (C) Axial T1 with fat saturation after gadolinium injection showing a heterogeneous vascular lesion of the right corpora cavernosa; (D) Axial T2 with fat saturation showing heterogeneous vascular lesion of the right corpora cavernosa.

Figure 2 Percutaneous embolization by direct puncture and outcomes.(A) Percutaneous puncture of the pseudoaneurysm;(B) Ultrasound-guided puncture of the pseudoaneurysm using a 18-gauge (1.7 mm × 45.0 mm) catheter; (C) Fluoroscopically monitored gelatin sponge injection;(D)Ultrasound study at 3-month follow-up showing complete restoration of right corpora cavernosa vascularization.

The procedure was performed by an experienced uroradiologist (AndrM) under local anesthesia.The vascular lesion was targeted with a linear ultrasound probe(12 MHz).A direct percutaneous puncture of the cavernous body was first performed using an 18 gauge needle (CATHLON®, Smiths Medical, Minneapolis, MIT, US) under ultrasound guidance.After mixing gelatin sponge (Curaspon®,Cura Medical B.V.,Assendelft,Netherlands)with saline and iodine, the hemostatic agent was injected under fluoroscopic guidance(Fig.2).The procedure was uneventful and immediate detumescence was observed.No recurrence nor erectile dysfunction was reported at 6-month follow-up.

Treatment of high-flow priapism is challenging.Non-ischemic priapism is not a urologic emergency.The European Association of Urology recommends conservative and non-operative management for the treatment of high-flow priapism [1].Spontaneous resolution has been documented to occur in up to 62%of patients[3].Currently,angiography with trans-arterial embolization is considered as the standard of care for persistent high-flow priapism[1].A recent non-systematic review of the literature reported success rates ranging between 61.7%and 83.3%,and erectile dysfunction rates from 0% to 33.3% after the first arterial embolization [3].Moreover, besides the general risks associated with angiography, there were also rare complications specific to embolization such as penile gangrene, gluteal ischemia, and purulent cavernositis [4].

To overcome some of these disadvantages, Tokue et al.[5]recently described the first case of percutaneous direct puncture embolization for priapism recurrence after conventional trans-arterial embolization.This approach has several advantages including shorter duration, direct treatment of the vascular lesion, emancipation from the angiographic difficulties, and most importantly, the simultaneous treatment of different arterial afferents, especially contralateral or occluded pathways, only revealed after occlusion of the main vessel.Thus, we consider that percutaneous embolization by direct puncture is a new alternative that may be useful when conventional embolization is technically impossible or fails, to avoid invasive surgical treatments in selected patients.Further studies are needed to assess the relevance and benefits of this approach.

Author contributions

Study concept and design: Quentin Holay, Marc Andr,Pierre-Henri Savoie.

Data acquisition: Quentin Holay, Marc Andr.

Data analysis: Quentin Holay, Marc Andr.

Drafting of manuscript:Quentin Holay,Marc Andr,Pierre-Henri Savoie.

Critical revision of the manuscript: Michael Baboudjian,Eric Lechevallier.

Conflicts of interest

The authors declare no conflict of interest.