Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis

Abstract

ABSTRACT Introduction Ischemic priapism is a common acute complication among males with sickle cell disease (SCD), with an estimated lifetime prevalence of 2% to 35%. The management of priapism has traditionally followed a stepwise algorithm, starting with conservative and minimally invasive measures such as therapeutic aspiration and injection of sympathomimetic agents to alleviate corporal hypoxia and minimize tissue necrosis; complementary intravenous hydration, alkalization, supplemental oxygen, and pain control are also employed. In cases of prolonged ischemic time or in priapism refractory to conservative measures, definitive surgical intervention via corpora cavernosal shunting and/or placement of inflatable penile prosthesis (IPP) is considered. While efficacious in addressing priapism, such procedures are not without complications. Exchange transfusion (ET) has been previously used to manage sickle cell disease (SCD), including in priapism; however, its utilization in the context of priapism management has not been well-established. Objective To explore the utilization of ET, as well as other patient and hospital-level factors, associated with surgical intervention for SCD-induced priapism Methods Using the National Inpatient Sample (2010-2015), a cross sectional descriptive analysis of males with SCD-related priapism was performed and stratified by surgical intervention. Given the paucity of known risk factors for surgical intervention in SCD-induced priapism, especially in the context of other SCD-related complications, backwards elimination Akaike Information Criterion (AIC) was used to construct a survey-weighted multivariable logistic regression model. Additional survey-weighted regression models were constructed to compare ET, surgery, and conservative treatment with length of hospital stay (LOS), and total hospital charges. An exploratory analysis was additionally performed to compare the utilization of ET, surgery, and supportive care in the presence of priapism +/- other coexisting SCD-related complications. Results A weighted total of 8,087 hospitalizations for SCD-related priapism were identified, with 1,782 (22%) receiving surgery, 464 (6.0%) undergoing ET, and 149 (1.8%) undergoing combined ET and surgery. On multivariable regression, numerous factors were associated with surgery (Figure 1), particularly those with other forms of insurance, ≥2 Elixhauser comorbidities, and ET having increased odds. In contrast, Black race and the presence of other co-existing SCD complications reduced such odds; a prior history of erectile dysfunction was not associated with surgical intervention. In addition, surgical intervention was most often utilized among patients presenting only with priapism; however, it was generally reduced in the presence of other acute SCD complications (e.g. pulmonary complications) (Figure 2). Finally, compared to supportive care alone, patients with ET (adjusted IRR: 1.42; 95% CI: 1.10-1.83; p=0.007) or combined therapy (adjusted IRR: 1.42; 95% CI: 1.11-1.82; p=0.006) had significantly longer LOS vs. surgery (adjusted IRR: 0.85; 95% CI: 0.74-0.97; p=0.017), as well as a higher ratio of mean hospital charges in the ET (adjusted Ratio: 2.39; 95% CI: 1.52-3.76; p <0.001) and combined group (adjusted Ratio: 4.42; 95% CI: 1.67-11.71; p <0.001) vs. surgery group (adjusted Ratio: 1.09; 95% CI: 0.69-1.72; p = 0.710). Conclusions Numerous factors were associated with surgical intervention for SCD-related priapism, including the use of ET. Other factors such as co-existing complications of SCD (e.g. pulmonary complications) may reduce odds of surgery. Healthcare disparities such as black race and certain forms of insurance may also affect receipt of surgical intervention. ET or combined therapy was associated with longer LOS and greater total hospital charges vs. surgical intervention. Future research comparing the therapeutic efficacy of ET vs. surgery for SCD-related priapism will further validate these associations. Disclosure No