Pediatric Case Reports Epidural blockade for alternative management of priapism: A case report of child with T-cell acute lymphoblastic leukemia Ahmet Gokce, Deniz Gul, Mehmet Fatih Orhan, Mustafa B€ uy€ ukavci, Gurkan Demir, and Serbulent Gokhan Beyaz Priapism is a clinical condition that rarely presents with leukemia in childhood. Management of priapism treatment can become more complex and difficult when accompanied by acute leukemia. We presented a 16 years old child with t-cell acute lymphoblastic leukemia (ALL) who developed priapism. Due to the failure of conservative methods and intracaver- nosal drainage, we performed epidural blockade which has limited data reported with successful results in the literature before shunt surgery. UROLOGY 00: 1-3, 2021. © 2021 Elsevier Inc. P riapism is a pathological condition representing a true disorder of penile erection that persists for more than 4 hours and is beyond, or is unrelated to, sexual interest or stimulation and remains despite orgasm. 1 Basically, 3 main types of priapism are used in classification and ischemic priapism accounts for 95% of all cases. 2 Compartment syndrome in ischemic priapism requires urgent medical intervention and irreversible con- sequences such as corporal fibrosis and erectile dysfunc- tion may occur if not treated quickly. 3,4 In terms of pathophysiology (Table 1), ischaemic pria- pism has been identified as idiopathic in most cases. 2 Ischemic priapism is relatively more common (0.4%- 35%) after intracavernous injection of papaverine, phen- tolamine and/or prostaglandin E1, but has also been asso- ciated with sickle cell anemia (SCA), hematologic dyscrasias, and neoplastic syndromes. 2,5,6 Leukemia is an important but relatively less common cause of priapism in childhood. Most cases of leukemia -associated priapism are chronic myeloid leukemia. 7 In the literature, acute lymphoblastic leukemia (ALL) lead- ing to priapism is very rare. In this report, we presented a case of a 16 years old child who diagnosed as a T-cell ALL and developed priapism and our alternative management in priapism treatment. CASE PRESENTATION A sixteen-years-old, 66-kg male patient was admitted to the emergency service with sudden blurred vision and widespread rash on the body. Retinal bleeding was detected in the fundoscopic examination. Laboratory evaluation revealed 271 £ 10 9 /L of white blood cell (WBC) and 97% of blast cell on peripheral blood smear. T-cell ALL was diagnosed by flow cytometric analysis (CD5: 93%, CD7: 55%, CD34: 43.6%, cCD3: 28.6%). No blast was observed in cerebrospinal fluid. Brain MRI and testicular ultrasound were normal. Prednisolone was started in accordance with the ALL IC BFM 2009 proto- col. On the 3 day of the treatment, priapism developed with penile pain and rigidity. Although leukemia is thought to be the most likely cause of priapism, hemoglobin electro- phoresis was performed to exclude SCA, which is the most common disease in priapism etiology. Conservative treatment as ice-pack, exercise, ejaculation and cold bath were recommended at first-line immediately. As a result of these conservative methods failed and priapism persisted, twelve hours later, intracavernous drainage was planned under sedation in the operating room. Lateral (3/9 o’clock) mid-shaft corporal needle access was performed, avoiding the urethra or dorsal neurovascular bundle with 19G butterfly needle. In the first blood gas sample results, pH:7.22, pCO 2 :63 mmHg and pO 2 :25 mmHg were deter- mined and was consistent with ischemic priapism. After the aspiration and irrigation, it couldn't achieve detumes- cence, so intracavernosal epinephrine injection (2 mL of 1/100000 epinephrine solution with five times over a 20- Disclosure: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. From the Department of Urology, Sakarya University, Faculty of Medicine, Sakarya, Turkey; the Department of Pediatric Hematology&Oncology, Sakarya University, Fac- ulty of Medicine, Sakarya, Turkey; the Department of Anesthesiology and Reanimation, Sakarya University, Faculty of Medicine, Sakarya, Turkey; and the Department of Anesthesiology and Reanimation, Istinye University, Faculty of Medicine, Istanbul, Turkey Address correspondence to: Ahmet Gokce, M.D., Department of Urology, Sakarya University School of Medicine, Sakarya, Turkey E-mails: aagokce@yahoo.com; gokce@sakarya.edu.tr Submitted: March 31, 2021, accepted (with revisions): June 17, 2021 1 https://doi.org/10.1016/j.urology.2021.06.017 0090-4295 © 2021 Elsevier Inc. All rights reserved. ARTICLE IN PRESS