Infections Versus Penile Implants: The War on Bugs

Prevention of Penile Prosthesis Infection

INTRODUCTION

Management protocols for treatment of severe erectile dysfunction have changed little in the last 20 years. Most algorithms consider penile prostheses as the last option of treatment in patients who have failed medical management. Despite multiple advances in current devices, prosthetic infection remains the most feared complication by implanting surgeons and patients. This report tries to make a compilation of the factors that can be impacted to prevent penile implant infections, and to make penile implantation a safer and more reliable way to solve an erection deficit.

PURPOSE OF REVIEW

List events related to the surgical act (pre-operative, intra-operative, and post-operative) that are related to the risk of infection to contextualize possible actions/measures used to avoid prosthetic infection.

RECENT FINDINGS

The impact of coated implants on reduction of infection rates. The recommendation to use chlorhexidine-based solutions over iodine solution for preoperative skin preps. Appears to be no difference in infection rates according to the approach chosen by the surgeon (infrapubic vs penoscrotal). The change in the microbial colonies that are colonizing implants in recent years are dramatic. Lack of evidence of which solutions to use for salvage or revision washout surgery: Chemical eradication or mechanical lavage cleansing?. Despite the importance of metabolic control in the literature, there is a disparity in exact glycemic values ​prior to the intervention in our literature. Factors such as preparation of the operative site, presence of comorbidities or previous surgeries, surgical time, or additional maneuvers during surgery can negatively impact the final result of penile prosthetic surgery.

HbA1c over 8.5% is not predictive of increased infection rate following penile prosthesis implant surgery in diabetic patients with erectile dysfunction

Diabetes mellitus is associated with increased risk of erectile dysfunction. Penile prosthesis implantation is an efficient therapeutic option for erectile dysfunction, but not without risk, as infection remains a prominent concern. This study investigates diabetes mellitus as a risk factor for penile prosthesis implantation infection and the relationship between haemoglobinA1c levels and infection rates. All diabetic patients with erectile dysfunction who underwent penile prosthesis implantation surgery between January 2012 and November 2019 at Hamad Medical Corporation, Qatar, were included in this retrospective observational study. A total of 599 diabetic patients with erectile dysfunction had penile prosthesis implantation. Mean age was 59.69 ± 31.19. Penile prosthesis implantation infection rate was 0.83% (5/599), while the mean haemoglobinA1c level was 7.58 ± 1.45 mmol/l (range: 4.1-12.6). A comparison between diabetic patients with penile prosthesis implantation infection and those without infection revealed no significant difference in the level of haemoglobinA1c between the two groups with mean haemoglobinA1c in patients with infected implants 7.14 and 7.59 for noninfected (p = 0.491). Limitations include retrospective single-centre design and low-infection rates reducing sample number. Penile prosthesis implantation infection rate in a large series of diabetic patients was low with no significant association between haemoglobinA1c level and penile prosthesis implantation infection observed.

Case - Conservative management of deep penile skin infection post-three-piece penile prosthesis implantation

Not required

Unexpected nuances of the penoscrotal inflatable penile prosthesis

The inflatable penile prosthesis was first implanted with a large vertical suprapubic incision. Nowadays, three surgical approaches are utilized: penoscrotal, infrapubic, and subcoronal. Globally the penoscrotal approach is used most often. Our first author describes nuances of the high transverse scrotal incision technique gained over 48 years of experience. Many of these methods will interest the reader because they are divergent from the common practice of implanters across the world. These distinctions are designed to diminish the risk of infection, speed up the surgery, and improve outcomes for both the patient and his surgeon.

Risk factors associated with penile prosthesis infection: systematic review and meta-analysis

PURPOSE

The aim of this study was to identify the factors associated with infection in patients who undergo penile prosthesis implantation.

METHODS

We performed a systematic review/meta-analysis, including clinical trials, quasi-experiments, retrospective and prospective cohort studies, and case-control studies. Searching was done in CENTRAL, MEDLINE, and EMBASE databases. Participants were patients who had erectile dysfunction, regardless of the etiology, and underwent penile prosthesis implantation. Two researchers reviewed each reference by title and abstract. The statistical analysis was performed using Review Manager 5.3 (RevMan® 5.3).

RESULTS

A total of 513 studies were found with the search strategies. After excluding duplicates, 40 studies with a total of 175,592 patients were included in the qualitative and quantitative analysis. Among patient characteristics, we found that diabetes mellitus and immunosuppression appear to have increase odds of infection. Related to the procedure, infection-retardant-coated penile prosthesis and primary (first) surgery appear to lower odds of infection.

CONCLUSIONS

Diabetes mellitus and immunosuppression were associated with increased infection rates; infection-retardant coating of the prosthesis and primary surgery were associated with reduced infection rates.

A 3-piece penile prosthesis salvage in the presence of late-onset infected hematoma: Clinical, radiological and intraoperative findings-A case report

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Penile prosthesis infection is a serious complication often managed radically.

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In selected patients, infected prosthesis can be salvaged without removal.

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Wound washout with antimicrobials and antiseptics is a key component of the management.

Introduction

Erectile dysfunction (ED) is a common health problem affecting 30% of young men worldwide. Despite the availability of non-invasive lines of management, penile prosthesis insertion is considered as a definite solution for ED. Despite strict perioperative measures, infection still complicates around 3% of penile prosthesis surgeries.

Presentation of case

This is a case of a 36-year-old male who had an infected scrotal hematoma that led to prosthesis malfunction due to the inability to locate the pump to activate and deactivate the device. Intraoperatively, the prosthesis was salvaged after hematoma evacuation and ensuring a good device functionality.

Discussion and conclusion

Infected penile prostheses are usually either removed completely with a new device insertion a few months later or exchanged at the same setting with vigorous wound washout. We suggest salvaging penile implants which are surrounded by infected hematomas in selected patients who don’t manifest systemic signs of infection. This approach will help in cost reduction and avoiding further intraoperative complications.

The Role of Orientation of Surface Bound Dihydropyrrol-2-ones (DHP) on Biological Activity

Quorum sensing (QS) signaling system is important for bacterial growth, adhesion, and biofilm formation resulting in numerous infectious diseases. Dihydropyrrol-2-ones (DHPs) represent a novel class of antimicrobial agents that inhibit QS, and are less prone to develop bacterial resistance due to their non-growth inhibition mechanism of action which does not cause survival pressure on bacteria. DHPs can prevent bacterial colonization and quorum sensing when covalently bound to substrates. In this study, the role of orientation of DHP compounds was investigated after covalent attachment by 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC)/N-hydroxysuccinimide (NHS) coupling reaction to amine-functionalized glass surfaces via various positions of the DHP scaffold. The functionalized glass surfaces were characterized by X-ray photoelectron spectroscopy (XPS) and contact angle measurements and tested for their in vitro biological activity against S. aureus and P. aeruginosa. DHPs attached via the N-1 position resulted in the highest antibacterial activities against S. aureus, while no difference was observed for DHPs attached either via the N-1 position or the C-4 phenyl ring against P. aeruginosa.

Local Treatment of Penile Prosthesis Infection as Alternative to Immediate Salvage Surgery

INTRODUCTION

Penile prosthesis (PP) is the established treatment for patients with erectile dysfunction (ED) who do not respond to phosphodiesterase inhibitors and intracavernosal injections. In general, these devices have been largely successful but there are not free of serious complication such as PP infection (PPI). PPI requires immediate surgical removal or salvage rescue of the PP.

AIM

In this report, we present two clinical cases with inflatable PP (IPP) treated locally with antibiotic and high pressure irrigation and then avoid the PP removal or salvage rescue.

METHODS

We present two patients with PPI in our institution and literature review.

MAIN OUTCOME MEASURES

Resolution of the two cases.

RESULTS

Patient A (A) was 44 years old and patient B (B) 51 years old presented PPI after three weeks (A) and eight weeks (B). Both patients were diabetic. Physical exploration revealed an open scrotal incision at its margin with a clear discharge. The rest of the incision and scrotum were clean and dry. They had not scrotum pain/tenderness or systemic/septic symptoms. The bacterial culture of the incisional drainage revealed a Staphylococcus aureus (A) and Staphylococcus epidermidis (B). In both cases, we performed an excision of the tissue around the pump with a high pressure pulsed irrigation (Interpulse; Stryker Corp, Kalamazoo, MI, USA). For the irrigation we used three different solutions that included povidone-iodine, antibiotics (gentamicin plus vancomicin), and hydrogen peroxyde. Finally, we performed a multilayered surgical closure with the use of aspirate drainage over 24 hours and intravenous antibiotics. The patients had a total resolution of its symptoms after 20 months (A) and 36 months (B), and the IPP worked properly.

CONCLUSION

This treatment could be an option for to perform specific patients with local IPP infection without systemic symptoms instead of surgical removal.

Emerging rules for effective antimicrobial coatings

In order to colonize abiotic surfaces, bacteria and fungi undergo a profound change in their biology to form biofilms: communities of microbes embedded into a matrix of secreted macromolecules. Despite strict hygiene standards, biofilm-related infections associated with implantable devices remain a common complication in the clinic. Here, the application of highly dosed antibiotics is problematic in that the biofilm (i) provides a protective environment for microbes to evade antibiotics and/or (ii) can provide selective pressure for the evolution of antibiotic-resistant microbes. However, recent research suggests that effective prevention of biofilm formation may be achieved by multifunctional surface coatings that provide both non-adhesive and antimicrobial properties imparted by antimicrobial peptides. Such coatings are the subject of this review.