Abstract Introduction Ischaemic priapism is a urological emergency that threatens corporal smooth muscle viability and long-term erectile function. Prompt restoration of cavernosal perfusion is essential; management escalates from conservative measures to shunting and, when protracted, early penile prosthesis implantation (PPI). Prolonged ischaemia (72 h) or failure of shunting/decompression markedly increases the likelihood of irreversible erectile dysfunction (ED); in such scenarios, PPI is indicated to restore penetrative capacity and prevent progressive corporal fibrosis and penile shortening. When a shunt is required earlier (36 h window exceeded), deferred implantation at 6 weeks is a practical compromise: it allows resolution of oedema and inflammation while avoiding technically challenging late fibrosis. A malleable (semirigid) prosthesis is often preferred as the index implant in the post-priapism setting because it facilitates dilation in fibrotic corpora, shortens operative time, and mitigates infection risk; patients can be converted to an inflatable device later if desired. Early PPI when ischaemia is prolonged (72 h) or after unsuccessful shunt/decompression; in selected patients after shunt, defer to up to 6 weeks to simplify the field yet pre-empt dense fibrosis. Device selection, cylinder sizing and anchoring should anticipate scarring and potential distal erosion risks; meticulous antisepsis and antibiotic prophylaxis are mandatory. Counselling covers expectations (rigidity vs concealability), possible staged conversion to an inflatable system, and management of residual curvature or length changes. Objective The objective was to set a standard for timing and surgical management of ischaemic priapism. Methods A 53-year-old man, heavy smoker (≈20 cigarettes/day) with a history of benzodiazepine/cocaine abuse, empty sella syndrome and osteoporosis, presented with an episode of ischaemic priapism (March 2025). He underwent distal shunting after failure of conservative measures. Given the duration of ischaemia and anticipated fibrosis, an elective PPI was scheduled six weeks after shunting. Past surgeries included nasal septoplasty and a shoulder prosthesis. Results PPI was performed as scheduled 6 weeks after the priapism episode. After a penoscrotal incision and exposure of the corpora cavernosa, bilateral corporotomy was performed using the excavation technique. Dilation of the corpora cavernosa was executed first with Metzembaum scissors to break the fibrotic tissues, then with Hegar dilators and Rossello dilators after that. Malleable penile prosthesis was implanted. Operative time was 70 minutes. No intra-operative or post-operative complication happened. Sexual intercourse was possible 4 weeks after surgery. At 6 months follow-up, the patient expressed the desire of switching the device with an inflatable penile prosthesis. Conclusions This case underscores that timely shunting followed by planned, early prosthetic rehabilitation offers durable resolution of symptoms and restores sexual function in post-ischaemic priapism. A structured pathway, clear patient counselling, and staged prosthetic strategy optimise outcomes while containing the risks introduced by fibrosis and prior shunting. Disclosure No
Guadagni et al. (2026) studied this question.