# Management of Intraoperative Erection in Endourology: A Systematic Review of Techniques and Interventions

## TL;DR

This review examines techniques to manage unexpected erections during urological surgeries, finding that injections of certain drugs are most effective but more research is needed.

## Contribution

The study systematically evaluates interventions for intraoperative erection, identifying phenylephrine as a top option and highlighting the need for standardized protocols.

## Key findings

- Intracavernosal sympathomimetic agents like phenylephrine show high success rates (93-100%) for rapid detumescence.
- Current management strategies lack high-quality evidence, relying mostly on low-level data and anecdotal reports.
- Systemic sympathomimetics like terbutaline and ketamine have variable efficacy and potential side effects.

## Abstract

Intraoperative penile erection is an uncommon but significant complication encountered during endourological procedures, such as Transurethral Resection of the Prostate (TURP), Transurethral Resection of the Bladder Tumour (TURBT), and ureteroscopy, with incidence rates varying by anaesthetic technique. This phenomenon can impede surgical access, compromise patient safety, and increase the risk of urethral injury and long-term sequelae. Existing practice for its management is shaped by limited evidence and lacks standardised protocols. This review aims to systematically examine the literature on management strategies for intraoperative erection during endourological surgery and to evaluate the efficacy and safety of various interventions, providing evidence-based recommendations for clinical management.

The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, analysing studies from PubMed, EMBASE®, and the Cochrane Library. Search terms included “intraoperative erection” and related phrases. Eligible studies addressed pharmacological or non-pharmacological management of intraoperative erection, excluding those on erectile dysfunction, non-human studies, or non-English articles. Two independent assessors reviewed studies to minimise bias, and quality appraisal was performed using the JBI tool and Oxford Centre for Evidence-Based Medicine grading.

Nineteen studies reporting management of intraoperative erection in more than 122 cases over a 40-year period (1983-2023) were included. The majority were case series (n=12) and letters to the editor (n=4), with three case reports. Intracavernosal sympathomimetic agents, particularly phenylephrine (93-100% success rate), ephedrine (100% success rate), and epinephrine (100% success rate), demonstrated the highest efficacy with rapid detumescence (1-5 minutes) and minimal complications. Intravenous sympathomimetics showed variable success rates, with terbutaline achieving 100% success but causing systemic side effects, while ketamine demonstrated inconsistent results (0-78%). Alternative approaches, including dorsal nerve block and cold saline compresses, were effective but less commonly reported.

The findings underscore the lack of robust, high-quality evidence for managing intraoperative erection, with current strategies being largely anecdotal or adapted from other contexts. While intracavernosal injection of sympathomimetic agents, particularly phenylephrine, is the most effective first-line management based on available evidence, this is predominantly supported by low-level data (Oxford Level 4-5). The review highlights the urgent need for comprehensive prospective studies, especially randomised controlled trials, to establish standardised, evidence-based treatment protocols. Given the clinical significance of this complication, it also warrants greater attention, including explicit inclusion in preoperative consenting discussions.