Penile implant infections: prevention and treatment

Artificial Urinary Sphincter Complications: A Narrative Review

Stress urinary incontinence is a financially burdensome and socially isolating problem and can be experienced by men as a result of radical prostatectomy, radiation therapy, or other urologic surgery. Artificial urinary sphincter (AUS) placement for stress urinary incontinence is considered the 'gold standard' for male stress urinary incontinence. While initially only placed by specialized prosthetic surgeons, changes in urologic training have made implantation of the device by general urologists more widespread. Additionally, even though a minority of urologists place the majority of implants, many urologists may find themselves caring for patients with these devices even if they have never placed them themselves. For this reason, it is paramount that the urologic surgeon implanting the device and those caring for patients with prostheses are familiar with the various perioperative and postoperative complications of AUS implantation. This review discusses the most commonly reported complications of AUS implantation as well as those that are rarely described. Knowledge of these potential complications is necessary in order to care for patients with urologic implants.

Narrative review of penile prosthetic implant technology and surgical results, including transgender patients

Over the past 40 years, the technological and surgical advancements in penile prostheses have led to increased patient satisfaction rates and decreased complication and infection rates. In cis males with erectile dysfunction (ED), these technological improvements tremendously improve quality of life. In female to male transgender patients, prostheses provide the ability to engage in penetrative intercourse and to urinate standing. This review evaluates technological and surgical advancements in penile prosthetics in the context of documented patient satisfaction and complication rates from prosthesis surgeries. Retrospective studies of penile implant usage in female to male gender-affirming surgeries report that infection and complication rates are higher than those seen in cis males. There are newer prostheses developed specifically for female to male reassignment surgeries, but outcome data is limited. Continued research and development are needed to develop more efficacious penile implantation options for gender affirmation surgery.

A novel approach for removal of an inflatable penile prosthesis reservoir using laparoscopic instruments

In the setting of an infected inflatable penile prosthesis (IPP), removal of the reservoir is a surgical challenge. We describe a novel technique for IPP reservoir removal at the time of IPP explantation utilizing laparoscopic instruments. We present two cases of infected IPPs requiring complete removal of all components of the implant. The corporal cylinders and scrotal pump were removed via a single penoscrotal incision. Through the same incision, a lighted, hand-held retractor was used for visibility, and laparoscopic instruments were utilized to dissect the tissue surrounding reservoir and the attached tubing until free. Then, a completely intact reservoir was easily removed. Infected IPP reservoirs were successfully removed in this fashion without any complication. This new technique not only facilitated the safe removal of the reservoir, but also enhanced surgical efficiency by eliminating the need for additional incisions. We performed a review of current literature concerning techniques and indications for removal of IPPs and the reservoir. In the setting of an infected penile prosthesis, all components of the implant should be removed. Removal of the reservoir has been surgically difficult due to its location, either deep in the space of Retzius or high in the abdomen between the muscular fascias. Our new technique provides an innovative solution for reservoir removal with the use of laparoscopic instruments via a single penoscrotal incision. We have found that this technique overcomes the challenge of a cumbersome blind dissection and the need for the second incision.

Use of BioPatch® (Protective Disk with Chlorhexidine Gluconate) in Closed-Suction Drainage for Penile Implant Surgery

BACKGROUND

The use of closed-suction drains after penile implant surgery remains controversial. The use of BioPatch®, a protective disk with chlorhexidine gluconate, may reduce the incidence of drain-related infections, one of the feared complications of drains. The aim of this study is to describe a novel use of BioPatch® in penile implant surgery as well as additional techniques that may potentially minimize infection rates.

METHODS

A description of operative technique and a review of the literature will be presented. A novel approach to penile implant surgery that may reduce infection rates is described.

RESULTS

A simple technique is described for surgeons considering implementation of closed-suction drains after penile implant surgery.

CONCLUSION

Although randomized controlled studies looking at drain placement following penile implant surgery are lacking, the addition of BioPatch® and the implementation of surgical techniques as described are potentially helpful in preventing infection following this surgery.

Three-piece Inflatable Penile Prosthesis: Surgical Techniques and Pitfalls

Penile prosthesis surgery plays a vital role in the treatment of erectile dysfunction (ED). As far as outcome is concerned, it is one of the most rewarding procedures for both patients and surgeons. We describe our surgical technique for implantation of the three-piece inflatable penile prosthesis and point out the major surgical pitfalls accompanying this procedure and their specific management. The psychological outcome of penile prosthesis surgery is also discussed. Different surgical approaches are available when performing the procedure. A number of procedure-related problems can be encountered and a thorough knowledge of these is of paramount importance. Penile prosthesis surgery has a favorable psychological outcome. Surgery for implantation of an inflatable penile prosthesis is a rewarding procedure, with a high yield of patient satisfaction. Urologists should have thorough understanding of the surgical pitfalls peculiar to this procedure and their management.

Inflatable penile prosthesis and salvage protocol for mechanical failure: is it really necessary?

INTRODUCTION

Penile prosthesis patients with mechanical failure who wish continued treatment require device removal and replacement. Infection rates as high as 18% have been reported for procedures involving replacement of malfunctioning penile prosthesis compared with 2% for primary implantation.

AIM

The aim of this study is to compare the outcomes of patients who have had a penile prosthesis replacement for mechanical failure to determine if those who had a mini-salvage washout procedure had better outcomes than those who did not.

METHODS

A retrospective chart review was performed of all patients undergoing inflatable penile prosthesis replacement for mechanical failure from 1997 to 2010. Demographics, past medical history, reason for device failure, type of device, time from original implantation to failure, operative details, culture results, and follow-up data were analyzed.

MAIN OUTCOME MEASURES

Infection rates for penile implant revisions with and without mini-salvage washout.

RESULTS

Forty-two patients underwent a mini-salvage procedure for mechanical failure and 87 patients underwent standard sterile replacement. There were no infections in the mini-salvage group and two (2.3%) in the standard sterile group (P=1.00). In patients with culture data available, two patients in each group had coagulase negative staphylococcus on culture, but none of these patients developed an infection. One patient who developed an infection had an intraoperative culture, which revealed no growth. The other patient with an infection did not undergo intraoperative culture testing. Operating room (OR) time was longer with the mini-salvage procedure (156 ± 36 minutes vs. 131 ± 31 minutes, P<0.001).

CONCLUSIONS

Performing a mini-salvage procedure for patients undergoing penile prosthesis replacement for mechanical failure adds to operative time but did not significantly change the infection rate and may not be indicated. Furthermore, intraoperative culture results were not predictive of postoperative infection.

Vascularized cadaveric fibula flap for treatment of erectile dysfunction following failure of penile implants

INTRODUCTION

Postpriapism erectile dysfunction in patients with sickle cell disease is a particularly devastating condition. Where penile implants have failed, there is no good surgical alternative at present. Free tissue transfer is fraught with risks in patients with sickle cell disease and are not the best option for treatment.

AIM

To describe a new surgical technique involving prefabrication of a bone flap for treatment of erectile dysfunction in a patient with sickle cell disease.

METHODS

The descending branch of the lateral circumflex femoral artery was isolated and implanted within a cadaveric bone segment. The prefabricated flap was then transferred 2 months later as a neophallus for penile autoaugmentation.

RESULTS

Bone scan showed viability of the bone flap after transfer. The patient was able to have vaginal intercourse and successfully achieve orgasm 2 months after the second stage surgery.

CONCLUSIONS

Prefabrication of a cadaveric bone flap and subsequent transfer is a novel and effective technique for treatment of erectile dysfunction refractory to medical management. This technique may be particularly useful for "implant cripples," who have no other surgical option.

Is a closed-suction drain advantageous for penile implant surgery? The debate continues

INTRODUCTION

The debate about leaving a closed-suction drain during penile implant surgery remains unsolved. What is the current thinking about the pros and cons of leaving a scrotal drain for inflatable penile implant (IPP) surgery?

AIMS

The aim of this study is to explore the fund of existing information, and formulate a point and counterpoint debate analyzing the drain issue for implant surgery.

METHODS

Two differing points of view are given to answer the question of benefit vs. risk drains in implant patients.

MAIN OUTCOME MEASURES

To facilitate the debate about a longstanding urologic question.

RESULTS

There are two conflicting points presented in this manuscript, one supporting drain placement, the other opposing it in light of the risks and benefits.

CONCLUSIONS

Without prospective randomized controlled trials specifically looking at drain placement following IPP, it is unclear whether or not this intervention is beneficial. Until a study of this type is performed, leaving a drain will largely remain a surgeon preference.

What is new for inflatable penile prostheses?

PURPOSE OF REVIEW

Although the first inflatable penile prosthesis was introduced over 30 years ago for the treatment of erectile dysfunction, technological innovations have continually improved these penile implants since that time. This review will highlight outcomes reported in peer-reviewed literature during the past 5 years related to several recent advancements in three-piece inflatable penile prosthesis technology of interest to surgeons who implant these devices.

RECENT FINDINGS

Research findings reported during the past 5 years have been related to improvements in cylinder and pump design to provide more reliable performance with good device concealment and a normal look and feel, to ease inflation and deflation, and to reduce infection complications with inflatable prostheses.

SUMMARY

It is important for all physicians, who implant life-changing penile prosthetics, to understand the most recent advances in technology in order to best serve their patients.