Infection Retardant Coated Inflatable Penile Prostheses Decrease the Incidence of Infection: A Systematic Review and Meta-Analysis

Penile prosthesis for erectile dysfunction in France: A six-year nationwide database analysis

INTRODUCTION

Urological consultations for erectile dysfunction (ED) are increasing worldwide. Penile prosthesis (PP) implantations are performed when other treatments are unsuccessful. However, there is no data regarding PP implantations in France beyond the year 2016.

OBJECTIVES

This study aimed to describe the changes in the number and type of PP implants used for the treatment of ED in France from 2016 to 2021 and the hospitalization rates following implantation using French national data from the Program for the Medicalization of Information Systems (PMSI).

MATERIALS AND METHODS

We analyzed data on PP implantations in all France hospitals. PPs were coded into three types according to the Common Classification of Medical Procedures (CCAM). The number of patients admitted to hospital with complications twelve months after implantation was also recorded.

RESULTS

During the study period, 3675 men received 3868 PPs in France. A gradual increase in the total number of implanted PPs was observed, with an overall increase of 33.8%. In 2020, there was a sharp decline in the number of implanted PPs, primarily owing to the COVID-19 pandemic. The most commonly used implant was PPs with an extracavernous compartment, comprising 85% of all PPs. Twelve months after implantation, only 1-2% of the patients were rehospitalized.

CONCLUSION

PP implantation surgeries are highly reproducible and have a low incidence of complications, in terms of rehospitalization after one year of placement (1.8%). Moreover, there was an increase in the demand for penile prosthesis implantations in France between 2016 and 2021.

LEVEL OF EVIDENCE

4: Descriptive epidemiological study.

50 years of inflatable penile implants: Where do we stand in France?

INTRODUCTION

With 50 years' experience, inflatable penile implants are the preferred option for erectile dysfunction refractory to pharmacological and mechanical treatment. Technical and surgical improvements have optimized patient success and satisfaction. However, multi-factorial dissatisfaction persists.

OBJECTIVE

The aim of this study is to provide an overview of available technological improvements and innovations, as well as the perioperative management and complications of inflatable penile implant surgery.

METHOD

A literature review was carried out over the last twenty years to answer 4 questions: what are the different inflatable penile implants available in 2023, for which indications, results and complications.

RESULTS

Four companies propose inflatable penile implants in France. The main improvements have been in the various components of the prosthesis with better cylinder extension, more ergonomic reservoirs, and more manageable pumps, leading to a better durability. Indications have been extended to patients suffering from Peyronie's disease and in emergency cases of priapism. In response to demand from the transgender population, specific phalloplasty implants have been developed. New options are being developed for difficult cases of retracted penis. Results show a high satisfaction rate. Currently the main challenge is the management of infection with the development of rescue protocols using antibiotics to preserve implants - or replace them in a single operation.

CONCLUSION

After 50years' experience, improvements in penile implants led to effective, satisfactory and safe treatment and can be proposed in new indications. Further development is sill necessary to offer solutions in difficult cases.

Salvage procedures for infected penile implants: A comprehensive review and analysis of functional outcomes

BACKGROUND

The salvage procedure for infected penile implants (IPs) has been a subject of interest since its inception in the late 1980s, yet its widespread adoption remains limited. The aim of this study was to realize a systematic literature review to provide a comprehensive analysis of salvage techniques for IPs and assess their efficacy, specifically focusing on functional success.

METHODS

A systematic literature review was conducted using PubMed, employing Mesh terms related to penile prosthesis, penile implant, infection, and salvage procedures. Articles in French or English were considered for the final analysis, with exclusion of literature reviews.

RESULTS

Fifteen articles detailing various salvage techniques for IPs were identified. Mulcahy's initial technique was described in 1996, and consisted of complete removal of infected components, extensive lavage, and subsequent replacement with a similar implant. Success rates ranged from 80% to 100%, with emerging trends favoring the use of malleable implants during salvage. Unfortunately, functional data remained limited. When salvage penile prosthesis placement involved a malleable prosthesis, between 20% and 33% of patients underwent conversion to hydraulic prosthesis.

CONCLUSION

The salvage procedure for infected penile implants is a reliable method, with success rates surpassing 80%. The need for comparative studies assessing the type of implant used during salvage is required to tailor conservative management strategies for optimal patient outcomes. Finally, few data have been published regarding subsequent conversions from malleable penile implants to hydraulic penile implants after salvage.

Infection rate of penile prosthesis implants in men with spinal cord injury: a meta-analysis of available evidence

The risk of penile prosthesis implants (PPIs) infection in men with spinal cord injury (SCI), empirically theorized to be high, is widely variable among the studies. We performed a meta-analysis to define the pooled PPI infection rate and its possible risk factors in men with SCI. A thorough search of PubMed, Scopus and Web of Science was performed. The eighteen included studies provided information on 1079 implantation procedures, determining a pooled PPI infection rate of 8.0% (95% CI: 5.0-11.0%), with significant heterogeneity (I² = 67.0%). Trim-and-fill adjustment for publication bias had a small effect on the pooled estimate (adjusted odds ratio: 6.3%, 95% CI: 2.5-10.0%) with a substantial reduction in heterogeneity (I2 = 32.4%). The PPI infection rate was higher for inflatable PPIs than for malleable PPIs (16.4% vs 8.9%, p = 0.027). No differences were found between the different levels of SCI. In conclusion, the risk of PPI infection in SCI would be higher than that reported in the general population. However, the results were produced from dated and low/moderate quality studies that may not fully reflect the outcomes of modern PPIs and implantation protocols. There is an urgent need to gather more information on this topic through studies relevant to contemporary practice.

A multi-institutional update on surgical outcomes after penile silicone sleeve implantation

Background

The increasing popularity of the silicone sleeve penile implant has been accompanied by concerns over potential risks and adverse events.

Objectives

To provide multi-institutional data on safety outcomes in patients undergoing silicone sleeve penile implant surgery across high-volume implant surgeons. In addition, we discuss preventative techniques to minimize postoperative complications and the management of these events.

Design and methods

We performed a retrospective analysis of men undergoing penile silicone sleeve implants between November 2020 and November 2022 with four surgeons, each from a separate institution. Perioperative and postoperative adverse events, including unsatisfactory cosmetic outcomes requiring revision, were determined by physician follow-up. Flaccid penile length and girth were measured preoperatively and postoperatively.

Results

A total of 299 male patients underwent silicone sleeve implant surgery, with an average age of 42.5 ± 10.5 years and an average body mass index of 28.5 ± 4.0. The patient cohort exhibited minimal comorbidities, with 5% having hyperlipidemia, 2% being smokers, 2% having cardiovascular disease, and 1% having diabetes. Patients experienced an average increase of 4.1 ± 1.5 cm in their flaccid penile length (a 50% increase) and an average increase of 3.4 ± 1.5 cm in their flaccid girth (a 37% increase) (p < 0.01). Complication rates included new-onset postoperative erectile dysfunction (0%), infection (1.3%), seroma (2.0%), and erosion (5.0%). The average follow-up time was 11.6 months. Notably, our rates of infection and seroma were lower than those reported in a previous single-center review, while erosion rates were higher.

Conclusion

This is the largest study to characterize the safety of the penile silicone sleeve implant across multiple institutions. In men who desire cosmetic size augmentation, silicone sleeve implant surgery is associated with significantly increased flaccid penile length and girth. Complications are mainly cosmetic and may be corrected; however, patients should be appropriately counseled on the risk of erosion, which appears to be higher than previously reported.

Delayed closed-suction drain removal following inflatable penile prosthesis placement: a multi-institutional experience

BACKGROUND

There are little published data regarding longer percutaneous drain durations following inflatable penile prosthesis placement; despite this, drain proponents suggest reduced scrotal hematoma formation, while detractors cite the risk of retrograde device seeding.

AIM

Here, we quantify the outcomes of a multi-institutional cohort with drain durations of 48 hours or greater.

METHODS

Data were collected retrospectively for patients undergoing primary 3-piece inflatable penile prosthesis (IPP) placement who had a postoperative drain placed. Cases were performed by 3 surgeons at 3 high-volume centers between January 1, 2020, and March 31, 2022. It was the routine practice of these surgeons to leave percutaneous drains for an interval of 48 hours or greater. R software was used to perform statistical analysis and data visualization.

OUTCOMES

Primary outcomes included rates of infection and hematoma formation. Secondary outcomes included device explantation.

RESULTS

During the study period, there were 224 patients meeting initial inclusion criteria. Of these, 15 patients had their drains removed before 48 hours, leaving 209 patients for the analysis. Mean drain duration was 67 ± 24.7 hours. The mean follow-up interval was 170 days. Diabetes mellitus was present in 84 (40%) patients with a mean hemoglobin A1c of 7.2%. Penoscrotal and infrapubic approaches were employed (n = 114 [54.5%] vs n = 95 [45.5%]). Reservoir location was split between space of Retzius and high submuscular, with space of Retzius being more common (n = 164 [78.5%] vs n = 45 [21.5%]). Discrete hematomas were observed in 7 patients, with subsequent operative intervention on 2. Notably, both of these were infection cases. There were 3 (1.4%) total device infections. Revision for noninfection causes was required in 9 (4.3%) patients. Fisher's exact testing demonstrated significant association between hematoma formation and anticoagulation and/or antiplatelet therapy (P = .017). On multivariable logistic regression, only anticoagulation and/or antiplatelet therapy remained significant (P = .035).

CLINICAL IMPLICATIONS

Maintaining percutaneous closed-suction bulb drains for >48 hours following IPP placement is safe.

STRENGTHS AND LIMITATIONS

This multi-institutional study fills a hole in IPP perioperative literature, as there have been no previously published data regarding drain durations >48 hours. The primary limitations are the retrospective nature and lack of a control population.

CONCLUSION

Maintaining closed-suction bulb drains for >48 hours following IPP implantation is safe and associated with infection rates comparable to other modern cohorts and a very low rate of hematoma formation.

Microbe-metabolite interaction networks, antibiotic resistance, and in vitro reconstitution of the penile prosthesis biofilm support a paradigm shift from infection to colonization

To understand differences between asymptomatic colonized and infected states of indwelling medical devices, we sought to determine penile prosthesis biofilm composition, microbe-metabolite interaction networks, and association with clinical factors. Patients scheduled for penile prosthesis removal/revision were included. Samples from swabbed devices and controls underwent next-generation sequencing, metabolomics, and culture-based assessments. Biofilm formation from device isolates was reconstituted in a continuous-flow stir tank bioreactor. 93% of 27 analyzed devices harbored demonstrable biofilm. Seven genera including Faecalibaculum and Jeotgalicoccus were more abundant in infected than uninfected device biofilms (p < 0.001). Smokers and those with diabetes mellitus or cardiac disease had lower total normalized microbial counts than those without the conditions (p < 0.001). We identified microbe-metabolite interaction networks enriched in devices explanted for infection and pain. Biofilm formation was recapitulated on medical device materials including silicone, PTFE, polyurethane, and titanium in vitro to facilitate further mechanistic studies. Nearly all penile prosthesis devices harbor biofilms. Staphylococcus and Escherichia, the most common causative organisms of prosthesis infection, had similar abundance irrespective of infection status. A series of other uncommon genera and metabolites were differentially abundant, suggesting a complex microbe-metabolite pattern-rather than a single organism-is responsible for the transition from asymptomatic to infected or painful states.

Rigicon disposable Furlow insertion tool has the potential to decrease infection rates after inflatable penile prosthesis implantation

Furlow insertion tool is frequently used during the insertion of the inflatable penile prosthesis cylinders inside the corporal bodies. Although these devices are completely disassembled and separately sterilized after each operation, the residual blood clots and tissues after inadequate cleaning may become the primary sources of penile prosthesis infection. In order to minimize the risk of infection, Rigicon, Inc. (NY, USA) has developed the first disposable Furlow insertion tool. Head-to-head comparison studies with conventional and disposable Furlow insertion tools are necessary to confirm if there is a significant difference in post-implant infection rates.

The outcomes of penile prosthesis in neurologic patients: a multicentric retrospective series

Introduction

Neurological disease is a known entity for causing erectile dysfunction (ED). Pharmacological therapies are not always effective these patients - penile prosthesis implant (PPI) is an established surgical treatment option. For a variety of reasons, neurological patients may experience differing outcomes of PPI compared to those whose ED arises from other causes. We investigated outcomes of PPI in neurological patients using the Italian multi-institutional national registry of penile prostheses [Italian Nationwide Systematic Inventarization of Surgical Treatment for ED (INSIST-ED)].

Methods

Patients undergoing PPI were investigated via the INSIST-ED registry, from 2014 to 2021. Data were prospectively recorded by 45 surgeons on a dedicated website (www.registro.andrologiaitaliana.it) and reviewed by a data manager. We subselected patients with neurological disease undergoing PPI for ED, and these patients were reviewed at 3, 6, and 12 months, and annually thereafter. Postoperative complications and functional outcomes were evaluated through validated questionnaires [International Index of Erectile Function-5 (IIEF-5), Sexual Encounter Profile 2-3, and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS)]. A nonvalidated questionnaire was administered to assess patient satisfaction.

Results

A total of 33 patients were included with a median age of 49 [interquartile range (IQR) 41-55]. Median follow-up was 83 months (IQR 67-99.5). A penoscrotal approach for PPI was performed in most cases (90.9%), while infrapubic was used in three cases (9.1%). Inflatable and malleable devices were implanted in 30 (90.9%) and 3 cases (9.1%), respectively. Intraoperative complications occurred in one case (3%). Early postoperative complications (<90 days) were observed in three cases (9.1%): two wound dehiscence (Clavien-Dindo G1 and G3a respectively) and one device infection requiring prosthesis explant (Clavien-Dindo G3a). Mechanical failures of inflatable devices were not observed during the follow-up period. Median IIEF-5 before surgery was 8 (IQR 7-9). At the latest follow-up, IIEF-5 was 22 (IQR 19-23.5), and median EDITS was 79 (IQR 64-88). A total of 28 patients (84.8%) self-reported to be fully satisfied with the PPI.

Conclusion

Although PPI in the neurological population has been historically considered to be at increased risk, in our study, PPI complications and infections rates in this cohort did not differ from general population.

Outcomes of a Single Center's Initial Experience With the Penuma® Penile Implant

OBJECTIVE

To provide new data, techniques, and safety and efficacy outcomes in patients undergoing Penuma penile implant surgery at a large tertiary care center.

METHODS

We performed a retrospective analysis of men undergoing Penuma implants between November 2020 and January 2022 with a single surgeon at a tertiary hospital. Measurements of penile length were made both pre- and postoperatively. Adverse events including infection and unsatisfactory cosmetic outcomes requiring revision were recorded. We also provide detailed technique descriptions of Penuma implantation and revision. Outcomes include measurements of incidents of peri and post-operative adverse events and penile length and girth pre- and post-operatively.

RESULTS

49 male patients underwent Penuma implant surgery. Mean age was 40.2 ± 8.9 years. Mean BMI was 28.2 ± 4.5. All but 2 patients were nonsmokers and only 2 had comorbidities (diabetes). Preoperative mean flaccid length was 8.1 ± 1.9 cm. Postoperative mean length was 12.3 ± 1.9 cm. Patients added an average of 4.9 ± 2.9 cm to their penile length, a 52% increase (P < .01). Average follow up time was 6 months. Among the complications were 1 case of infection and 2 cases of erosion. There were 4 cases of persistent flaring of the Penuma; 3 required revision surgery, all with a good cosmetic outcome.

CONCLUSION

The Penuma implant can be used to safely enhance flaccid penile length and girth in patients with retractile penis or other cosmetic deformities. Should complications occur, they are mainly cosmetic and can be easily corrected with low risk.

The International Penile Prosthesis Implant Consensus Forum: clinical recommendations and surgical principles on the inflatable 3-piece penile prosthesis implant

Despite significant scientific advances in the modern three-piece inflatable penile prosthesis implant surgery, it is not without surgical risks and can carry additional cosmetic and psychosocial consequences in poorly selected and consented individuals. To address this problem, an international group of key opinion leaders and high-volume prosthetic surgeons reviewed the current guidelines and clinical evidence, discussed their experiences, and formed a consensus regarding inflatable penile prosthesis surgery. The findings of this consensus panel were presented at the 17th biennial Asia Pacific Society of Sexual Medicine scientific meeting. The experts concluded that proper patient selection, informed consent and strict adherence to safe surgical principles are important to optimize clinical outcomes. Furthermore, most intraoperative complications, if recognized, can be addressed intraoperatively to enable placement of the device at the time of initial surgery. Men with significant corporal fibrosis due to Peyronie's disease, prior prosthesis explantation and priapism, and men who have undergone construction of a neophallus, as well as men who receive concurrent continence surgery, are complex cases requiring additional care and advanced techniques to obtain optimal surgical outcomes. Variability in patient care - in terms of postoperative antibiotic use, pain management, scrotal care, and cycling of the penile prosthesis implant - must be reduced to enable optimization and assessment of outcomes across patient groups.

Surgical Applications of Materials Engineered with Antimicrobial Properties

The infection of surgically placed implants is a problem that is both large in magnitude and that broadly affects nearly all surgical specialties. Implant-associated infections deleteriously affect patient quality-of-life and can lead to greater morbidity, mortality, and cost to the health care system. The impact of this problem has prompted extensive pre-clinical and clinical investigation into decreasing implant infection rates. More recently, antimicrobial approaches that modify or treat the implant directly have been of great interest. These approaches include antibacterial implant coatings (antifouling materials, antibiotics, metal ions, and antimicrobial peptides), antibacterial nanostructured implant surfaces, and antibiotic-releasing implants. This review provides a compendium of these approaches and the clinical applications and outcomes. In general, implant-specific modalities for reducing infections have been effective; however, most applications remain in the preclinical or early clinical stages.

Penile prosthesis salvage: a historical look at the Mulcahy technique and a review of the latest literature

Historically, management of inflatable penile prosthesis infection was explantation of the device with delayed reimplantation at a later date. In 1991, this paradigm was challenged when early attempts at washout and immediate salvage proved successful. The clinical experiences and data generated over the past 30 years have allowed implanters to refine their salvage procedures to improve patient outcomes. In this article, we review the original Mulcahy technique for salvage and discuss updates to this protocol based on recent data.

Penile implant infection factors: a contemporary narrative review of literature

Objective

We aim to review and summarize published literature that features implanted penile devices and details infection of these devices as a complication. In particular, we will detail the factors that influence infection of penile implants.

Background

Types of penile prostheses (PP) include inflatable implants and semirigid implants; these are utilized for treatment of erectile dysfunction. Likely the most feared complication of penile implants is infection. There are a handful of factors that are implicated in device infection.

Methods

Searches were performed using MEDLINE and PubMed databases using keywords and phrases ‘penile implant AND infection’; ‘penile prosthesis AND infection’; ‘penile implant infection’. We have presented results from our literature search. We divided these into ‘Surgical Elements’ and ‘Patient Selection and Factors.’ Each topic is discussed in its own section.

Conclusions

Strides have been made since the initial penile prosthesis (IPP) surgeries to improve infection rates including diabetes control, antibiotic coating of devices, and antibiotic implementation. Going forward, more studies, especially randomized control trials, need to focus on defining levels of diabetic control (sugar control and A1C control), determining the role of metabolic syndrome in infection promotion and determining laboratory values which could be predictive of infection. We present a discussion of important factors to consider in the realm of PP infections. In addition, we include studies which discuss topics for future directions in decreasing the number of infections seen with PP.

The Augmenta Implant: A Cadaver Model of a Novel Anatomic Subdermal Implant for Cosmetic Penile Enhancement

INTRODUCTION

There are limited options for cosmetic penile enhancement and the correction of structural penile deformities.

AIM

We present the Augmenta, an innovative, technologically advanced subcutaneous elastomer-silicone cosmetic penile implant (CPI), as evaluated by objective structural changes in a cadaveric model.

METHODS

Five fresh male cadaver pelves were utilized in this preclinical setting. Placement of a subcutaneous elastomer-silicone CPI was performed via a penoscrotal approach. Penile circumference was measured at the base and distal shaft before and after implant placement. Penile length was measured from the pubic bone to the tip of the glans penis before and after implantation of Augmenta.

MAIN OUTCOME MEASURE

Objective outcomes included changes in penile circumference and shaft length in both the flaccid and erect state, both before and after CPI placement.

RESULTS

In 5 cadaver models, implantation of the Augmenta CPI increased flaccid penile shaft base circumference from an average of 8.7 cm to 12.0 cm after implantation (39.1% increase, P < .001). Flaccid distal circumference increased from 7.3 cm to 10.3 cm (41.8% increase, P = .020). During the erect state, penile base circumference increased from an average of 12.5 cm to 13.7 cm (6.3% increase, P = .273), while distal erect circumference changed from an average of 11.3 cm to 12.4 cm (9.7% increase, P = .298). Nonstretched flaccid shaft length increased from an average of 12.1 cm to 14 cm (15.2% increase, P = .073).

CLINICAL IMPLICATIONS

The Augmenta CPI could serve as alternative option for men seeking cosmetic penile enhancement.

STRENGTHS AND LIMITATIONS

Limitations include a small number of cadavers which do not completely reproduce living physiologic function and the use of a single technical approach. However, a consistent and standardized surgical approach reduces operator-dependent outcomes. Another strength is the use of fresh human cadavers that most closely represent live models.

CONCLUSION

In a cadaveric model, the Augmenta CPI demonstrates enhancements in penile girth in both the flaccid and erect state. The unique honeycomb technology, the embedded polyester mesh, and the antimicrobial hydrophilic coating of the Augmenta CPI may provide an advantage to currently available CPIs. Clinical trials will be needed to demonstrate both the safety and feasibility. Clavell-Hernández J, Tatem AJ, Lipshultz LI, et al. The Augmenta Implant: A Cadaver Model of a Novel Anatomic Subdermal Implant for Cosmetic Penile Enhancement. Sex Med 2021;XX:XXXXXX.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

Tips and tricks in the management of inflatable penile prosthesis infection: A review

Objective:

To review the management of inflatable penile prosthesis (IPP) infection.

Methods: The ‘gold-standard’ treatment for medication-refractory erectile dysfunction is the IPP, wherein the most dreaded complication is infection. To prevent and manage an infected IPP requires a strict protocol during the pre-, intra-, and postoperative course. A variety of techniques and antibiotics are used in conjunction with IPP implantation to prevent contamination. This modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review of the literature examines the current practices by leading urologists in the management of IPP infection, as well as provides insights for improved patient outcomes.

Results

: Patient selection is important to reduce IPP infections, and those with risk factors need to be optimised prior to surgery. Proper antibiotic prophylaxis includes pre-, intra-, and postoperative administration. As most infections derive from normal skin flora, every measure must be taken to sterilise the skin and avoid direct device skin contact. Up to 3% of virgin IPPs develop infections and this number increases to 18% in revision cases. Antibiotic coverage depends on the presenting microbe, which can vary significantly between patients.

Conclusions

: A greater success in IPP implantation can be attributed to appropriate prophylaxis, field sterilisation, and surgical technique. For those implants that do become infected, often erectile function can be preserved by immediate antibiotic coverage combined with salvage procedures.

The Association Between Hemoglobin A1c Levels and Inflatable Penile Prosthesis Infection: Analysis of US Insurance Claims Data

BACKGROUND

The association between elevated hemoglobin A1c (HbA1c) levels and the risk of postoperative infection after penile prosthesis surgery remains controversial.

AIM

To examine the association between HbA1c levels and penile implant infections in men undergoing inflatable penile prosthesis (IPP) surgery for erectile dysfunction using a large insurance claims database.

METHODS

This was a retrospective review using Optum's de-identified Clinformatics Data Mart Database. Male subjects 18 years and older with available laboratory data undergoing IPP insertion between 2003 and 2018 were included. Administrative diagnosis and procedural codes were used to assess subsequent penile implant revision surgery status for either infectious or noninfectious causes. Associated conditions were controlled for such as smoking status, hyperlipidemia, hypertension, obesity status, and Peyronie's disease.

OUTCOMES

The main outcomes were risk of revision for infection and time to revision.

RESULTS

A total of 2,363 individuals underwent initial IPP insertion and had available HbA1c data with a mean HbA1c of 6.9%. The overall IPP infection revision rate was 3.9% and the highest rate of 12.1% was seen in the highest HbA1c group (>10%). After adjusting for demographic and health factors, a higher HbA1c level was associated with a higher risk of revision for infection, with every 1 point increase in HbA1c conferring an increased risk of infection requiring revision by 29% (95% CI 17-42%). When infections did occur, they happened sooner in men with HbA1c > 10.0% with an average of 1.3 months vs 3.5 months in the HbA1c < 6.0% group.

CLINICAL IMPLICATIONS

These findings provide insight into the potential relationship between HbA1c levels and postoperative risk of infection after penile prosthesis surgery and may aid in clinical decision-making.

STRENGTHS AND LIMITATIONS

Strengths include the large sample size, length of data coverage, and real-world analysis of surgeries done across the United States. Limitations include the reliance on insurance claims data, the retrospective study design, and lack of additional relevant clinical variables that may impact infection rates.

CONCLUSIONS

While the overall risk of penile prosthesis infection remains modest, the current report notes an increased risk of infection for diabetic men with poor glycemic control. Chen T, Li S, Eisenberg ML. The Association Between Hemoglobin A1c Levels and Inflatable Penile Prosthesis Infection: Analysis of US Insurance Claims Data. J Sex Med 2021;18:1104-1109.

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.

Biofilm and penile prosthesis infections in the era of coated implants: 2021 update

William Costerton, the pioneer of bacterial biofilm research and Wilson published a review of this subject in 2012. Recent events and false claims have prompted an update for urologists regarding the science of penile implant biofilm. The recent biofilm literature has been investigated and new conclusions regarding penile implant biofilm physiology are clarified in this review. The timeline of biofilm formation is as follows. The wound is contaminated upon incision, and the inoculum of bacteria ceases with incision closure. Almost immediately planktonic bacteria attach to the implant and secrete biofilm which alters the host's ability to eradicate the bacteria. Infection retardant coatings impair clinical infection by common skin organisms including coagulase negative staphylococci, the most frequent offenders. In the modern era of availability of infection retardant coated implants, the increasingly rare penile implant infections are now usually caused by more virulent bugs. Antibiotic elution from the surface of the implant is a tiny dose and only truly helpful in the first 24 h. AMS and Coloplast infection retardant coatings reduce infection equally and contemporary primary implant infections are far lower in experienced implant surgeons' practices.

Infected penile prosthesis: literature review highlighting the status quo of prevention and management

INTRODUCTION

Erectile dysfunction affects over 50% of men 70 years and above, and penile prosthesis (PP) is its third-line treatment. Complications of PPs include infection, however, no formal guidelines exist for its management.

METHODS

We performed a literature search and reviewed 53 recent published literatures of experiences with management of PP infections, prevention, and treatment.

RESULTS

Acute infection can present early with pain and discharge and detection of early signs is of utmost importance. MRI studies are more sensitive than CT studies to diagnose and plan surgical intervention. Introduction of antibiotic impregnated devices attributed to the reduction of infection rates with superiority proven for certain types; the no-touch technique had further reduced this rate. The Mulcahy salvage remains the most widely used surgical approach for treatment despite modifications and novel techniques described; conservative management of PP infections is recently reported with promising results.

CONCLUSIONS

Despite absence of strict guidelines for the management of infected PPs, we reviewed and discussed numerous panel opinions and suggestions throughout literature. More research into the pathology, prevention, conservative management and advances in surgical treatment of this condition are called for to produce guidelines that unite the efforts to tackle these infections.

Updates in penile prosthesis infections

Inflatable penile prostheses are an important tool in the treatment of medically refractory erectile dysfunction. One of the major complications associated with these prostheses is infections, which ultimately require device explanation and placement of a new device. Over the past several decades, significant work has been done to reduce infection rates and optimize treatment strategies to reduce patient morbidity. This article reviews the current state of knowledge surrounding penile prosthesis infections, with attention to the evidence for methods to prevent infection and best practices for device reimplantation.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

Penile prosthesis implant in the special populations: diabetics, neurogenic conditions, fibrotic cases, concurrent urinary continence surgery, and salvage implants

Penile prosthesis implant (PPI) remains an effective and safe treatment option for men with erectile dysfunction (ED). However, PPI surgery can be associated with a higher risk of complications in certain populations. This article provides a critical review of relevant publications pertaining to PPI in men with diabetes, significant corporal fibrosis, spinal cord injury, concurrent continence surgery, and complex salvage cases. The discussion of each category of special populations includes a brief review of the surgical challenges and a practical action-based set of recommendations. While specific patient populations posed considerable challenges in PPI surgery, strict pre- and postoperative management coupled with safe surgical practice is a prerequisite to achieving excellent clinical outcomes and high patient satisfaction rate.

Intraoperative use of vancomycin paste during penile prosthesis placement: initial outcomes

Penile prosthesis implantation is a safe and effective treatment option in the management of erectile dysfunction, associated with high satisfaction and low complication rates. Infection is a rare complication (0.5-3%), but devastating for the patient and surgeon when it occurs. Adapting from other surgical disciplines, we have utilized vancomycin paste to provide prolonged focal antibiotic exposure around the penile prosthesis pump, a site prone to infection. The aim of this study is to determine the safety and efficacy of intraoperative vancomycin paste with regards to infection prevention during penile prosthesis placement. This is a multi-institutional nonrandomized retrospective IRB-approved study comparing patients who underwent placement of a primary inflatable penile prosthesis with intraoperative vancomycin paste to those without. Primary outcomes included pump fibrosis, infection, erosion, hematoma, and complete device malfunction. From April 2019 to October 2019, two surgeons utilized vancomycin paste intraoperatively during virginal penile prosthesis surgery on 90 patients, whose mean age was 60 years. These patients were compared to an historical control group that included 166 patients, also with a mean age of 60 years, who underwent the same penile prosthesis surgery between 2014 and 2017 without the paste. Among the intervention group, the overall complication rate was 1.1%, due to a scrotal hematoma. Ultimately, there was no statistically significant difference in infection rate (0% in both groups) or overall complication rate (1.1% in the intervention group compared to 1.2% in the control group). The use of vancomycin paste appears to be safe, however future prospective studies are needed to determine its efficacy in infection prevention.

Sustained Glycemic Control Observed in Diabetic Men Who Improve Hemoglobin A1c Values to Allow for Elective Penile Prosthesis Placement

OBJECTIVES

We hypothesize that men with diabetes mellitus whose inflatable penile prosthesis (IPP) implantation is delayed for unacceptably high hemoglobin A1c (HbA1c) will have durable improvements in their glycemic control after achieving acceptable HbA1c levels for surgery.

METHODS

Per institutional protocol, an A1c <9% must be documented prior to IPP placement. After IRB approval, a single surgeon IPP database was retrospectively queried for data specific to diabetes mellitus management. Men without HbA1c values at ≥1-year follow-up were excluded. Univariate and multivariate statistical analyses were performed to assess associations with sustained HbA1c control.

RESULTS

From January 2011 to March 2019, 138 diabetics undergoing IPP were identified. Thirty-seven were excluding for insufficient follow-up. Nineteen of the 101 analyzed men (18.8%) were delayed a median 4 months (range 2-17) for elevated HbA1c values (median 10.1, range 9.1-12.3). Following improvements, median preoperative HbA1c remained higher (8.2% vs 7.0%) in delayed men (P < .001). Among delayed recipients, 11 (58%) improved without medication changes while insulin was newly initiated (5) or dosage was increased (5) in 42%. At 32 months follow-up, a HbA1c <9% was similarly maintained in delayed and nondelayed men (74% vs 87%, P = .17). Delayed men more commonly required insulin therapy at follow-up (89.5% vs 54.9%, P = .008), but had a similar median change in BMI (+0.1 vs +0.1, P = .65). Device infection occurred in 1 nondelayed patient (0.7%).

CONCLUSION

Men who improve HbA1c for IPP surgery are likely to demonstrate persistent improvement. IPP implantation appears to be safe in diabetic men with HbA1c <9%.

Comparing Risk Factors for Adverse Outcomes in Virgin Inflatable Penile Prosthesis Implantations and Revisions: A Retrospective Cohort Study

INTRODUCTION

Recent studies place the risk of infection following inflatable penile prosthesis (IPP) implantation at 1-2%. This risk may be underestimated due to the exclusion of high-risk patients, such as patients undergoing multiple revisions or revision following IPP infection, from data.

AIM

To calculate the rate of postoperative complications for all patients undergoing IPP implantation and revision, and to determine the risk factors predictive of complications following virgin implantation and revision independently.

METHODS

The charts of 280 patients undergoing 331 IPP implantations performed over the last 20 years at a large academic medical center were reviewed for postoperative complications and suspected preoperative and operative risk factors.

MAIN OUTCOME MEASURE

This included the prevalence of adverse operative outcomes including postoperative infection and device malfunction.

RESULTS

63 (20.7%) surgeries resulted in postoperative complications: 38 (12.5%) resulting in device malfunction and 25 (8.20%) resulting in infection. Smoking (odds ratio [OR] = 4.14, P = .00) was associated with overall postoperative complications. Within subgroups, concomitant procedures (OR = 4.77, P = .03) were associated with infection for those undergoing virgin implantation, but not those undergoing revision procedures. Alternatively, diabetes mellitus (DM) (OR = 28.3, P = .02) was associated with postoperative infection for those undergoing revision procedures, but not those undergoing virgin implantation.

CONCLUSION

The rate of postoperative infection for all patients undergoing IPP was found to be 8.20%, a higher estimate than historically recorded. To varying degrees, smoking, concomitant procedures, and DM were associated with adverse operative outcomes. Subset analyses revealed significant associations between postoperative infections and either concomitant procedures or DM in those undergoing virgin implantations or revision surgeries, respectively. Miller JA, Bennett NE. Comparing Risk Factors for Adverse Outcomes in Virgin Inflatable Penile Prosthesis Implantations and Revisions: A Retrospective Cohort Study. J Sex Med 2020;8:388-395.

Treatment of Penile Prosthesis Implant's Infection

INTRODUCTION

Penile prosthesis implant is a safe and effective option in erectile dysfunction patients, being implant procedures safe with a low risk of infection. However, when infection occurs, it represents a concrete problem for both surgeon and patient.

METHODS

This is a comprehensive review of all issues relating to prosthesis infection, including causes and risk factors, methods of prevention, and management. We analyzed all preoperative and perioperative factors, which can play a role in infection of the device.

RESULTS

Infection of penile prosthesis implant is hard to manage and correct. While the incidence of infection following first implant is up to 3%, in cases of re-implant surgery, the rate can reach as high as 18%. Many articles were found addressing prevention and treatment of penile prosthesis infection, and many analyzed all relevant pre- and perioperative factors associated with penile prosthesis implant. Although such factors have been well studied, there is no clear consensus worldwide on certain topics.

CONCLUSIONS

Penile prosthesis implant is a safe and effective option. Despite infection is a rare event, surgeons should follow strictly pre-, intra- and postoperative recommendations in order to reduce the risk of device's infection. An appropriate antibiotic therapy should be tailored on patient's characteristics and pathogens isolated.

Prostatic irradiation-induced sexual dysfunction: A review and multidisciplinary guide to management in the radical radiotherapy era (Part II on Urological Management)

Prostate cancer is the most common malignancy in men and the second leading cause of cancer-related death in men. Radiotherapy is a curative option that is administered via external beam radiation, brachytherapy, or in combination. Sexual dysfunction is a common toxicity following radiotherapy, similar to men undergoing radical prostatectomy, but the etiology is different. The pathophysiology of radiation-induced sexual dysfunction is multi-factorial, and the toxicity is a major cause of impaired quality of life among long-term prostate cancer survivors. Management of a patient's sexual function during and after radiotherapy requires multidisciplinary coordination of care between radiation oncology, urology, psychiatry, pharmacy, and dermatology. This review provides a framework for clinicians to better understand prostatic radiotherapy-induced sexual dysfunction diagnosis, evaluation, and a patient-centered approach to toxicity preventive strategies and management.

Prospective analysis of cultures from the Furlow insertion tool: a possible etiology for penile prosthesis infections

The most dreaded complication of penile prosthesis (PP) implantation is device infection. We sought to assess whether inadequate cleaning and sterilization of the reusable Furlow inserter may represent one of the last etiologies of infection in PP patients. We performed a prospective analysis of cultures of the Furlow inserter used for PP surgeries from seven centers between May 1st and June 30th, 2019. Once the Furlow was received for surgery, the surgical team inspected the device for assembly status (disassembled or not) and the presence of visible stains, pieces of tissue or discoloration on either the interior of the barrel or the plunger. Swab aerobic and anaerobic bacterial and fungal cultures were then obtained from the internal component, after removal from the external component if assembled, and after introduction and immediate removal from the external component if disassembled. A total of 83 Furlow devices were cultured. Median age of surgical instrument was 4 years (2-10 years). Methods of sterilization included autoclave, wet autoclave, steam, and Sterad. Median time from sterilization was 3 days (1-22). On initial presentation, 79 devices were disassembled (95.1%) and 4 devices were still assembled (4.9%). Three external components were discolored (3.6%), while internal components demonstrated two stains (2.4%) indicative of improper cleaning which were thought to be residual blood products. Overall, 2/83 (2.4%) devices revealed positive swab cultures for Staphylococcus epidermidis. Swab cultures were negative for fungi and anaerobic bacteria. This patient cohort will continue to be followed to see if device infection occurs but it is unlikely to be meaningful since contaminated Furlows were discarded. Improper cleaning and/or sterilization of the Furlow Insertion Instrument may represent a source of infection for patients undergoing PP implantation.

The future of penile prostheses for the treatment of erectile dysfunction

Penile prostheses (both inflatable and malleable) are standard care in the management of erectile dysfunction (ED). Introduced over 45 years ago, modern penile implants have evolved greatly during that period of time and now represent the cutting edge in materials science and function. Despite the introduction of highly effective oral pharmacotherapy for ED, these devices have remained relevant and will almost certainly remain so for the foreseeable future. Despite their high degree of efficacy, there is always potential for further improvements in both implants themselves and the surgical techniques and processes used for their placement. In this manuscript we speculate on the future of penile implants, based in large part on the historical perspective and recent developments in the implant surgery space. We include recommendations on future technical innovations, post-operative management, and novel implant designs that may revolutionize the future management of ED.

Multicenter investigation on the influence of climate in penile prosthesis infection

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of <0.001. Humidity results were similar, and fungal infections correlate with daily humidity. Infected implants performed in the fall and summer were over 3 and 2.3 times, respectively, more likely to grow Gram-positive bacteria compared to implants performed in spring (p = 0.004; p = 0.039). This was consistent across geographic location, including in the Southern hemisphere. We found trends between climate factors and IPP infection like those seen and proven in other surgical literature. To our knowledge these data represent the first exploration of the relationship between temperature and infection in prosthetic urology.

Penile Prosthesis Infection: Myths and Realities

Penile prosthesis infection is the most significant complication following prosthesis implant surgery leading to postoperative morbidity, increased health care costs, and psychological stress for the patient. We aimed to identify risk factors associated with increased postoperative penile prosthesis infection. A review of the literature was performed via PubMed using search terms including inflatable penile prosthesis, penile implant, and infection. Articles were given a level of evidence score using the 2011 Oxford Centre for Evidence-Based Medicine Guidelines. Multiple factors were associated with increased risk of post-prosthesis placement infection (Level of Evidence Rating) including smoking tobacco (Level 1), CD4 T-cell count <300 (Level 4), Staphylococcus aureus nasal carriage (Level 2), revision surgery (Level 2), prior spinal cord injury (Level 3), and hemoglobin A1c level >8.5 (Level 2). Factors with no effect on infection rate include: preoperative cleansing with antiseptic (Level 4), history of prior radiation (Level 3), history of urinary diversion (Level 4), obesity (Level 3), concomitant circumcision (Level 3), immunosuppression (Level 4), age >75 (Level 4), type of hand cleansing (Level 1), post-surgical drain placement (Level 3), and surgical approach (Level 4). Factors associated with decreased rates of infection included: surgeon experience (Level 2), "No Touch" technique (Level 3), preoperative parenteral antibiotics (Level 2), antibiotic coated devices (Level 2), and operative field hair removal with clippers (Level 1). Optimization of pre-surgical and intraoperative risk factors is imperative to reduce the rate of postoperative penile prosthesis infection. Additional research is needed to elucidate risk factors and maximize benefit.

Innovating Incrementally: Development of the Modern Inflatable Penile Prosthesis

PURPOSE OF REVIEW

The inflatable penile prosthesis (IPP) was introduced in 1973. Since that time, the fundamental design of the IPP has not changed, but numerous improvements to the device, surgery, and peri-operative management have resulted in a modern IPP with excellent reliability, infection control, safety profile, and user experience.

RECENT FINDINGS

We describe important modifications to the IPP and review available data assessing the impact of these changes. We also discuss possible changes to the IPP that would result in continued improvement. Since its introduction in 1973, changes to the penile prosthesis have resulted in significant improvements in reliability, infection control, safety, and user experience. Design changes are anticipated to continue, resulting in a better and more versatile penile prosthesis.

Recent advancements in penile prosthetics

Since the original inflatable penile prosthesis in the 1970s, several enhancements to penile prosthesis implant design, implant surgical technique, and post-operative care have been developed to increase overall patient (and partner) satisfaction rates. We, in this communication, seek to discuss these advancements and the overall impact in combating erectile dysfunction. As we continue to pursue avenues of effective and definitive treatment modalities for erectile dysfunction refractory to medical therapy, rates of infection and mechanical failure will hopefully continue to decline in the perioperative setting.

Damage Control Considerations During IPP Surgery

PURPOSE OF REVIEW

This review summarizes the latest reports in inflatable penile prosthesis (IPP) complication management.

RECENT FINDINGS

IPP complications are rare, and reports are limited to retrospective studies. However, recent multi-institutional studies and use of national databases have provided further insight into risk factors for complications. Guidance on complication management is largely limited to techniques recommended by experts within the field. American Urological Association guidelines place IPP implantation as a first line erectile dysfunction treatment. However, the majority of cases are performed by low-volume (≤ 4 cases/year) surgeons. Herein, we summarize the IPP literature and our personal experience to provide guidance on managing IPP complications.

A Surgeon's Guide to the Various Antibiotic Dips Available During Penile Prosthesis Implantation

PURPOSE OF REVIEW

Inflatable penile prosthesis (IPP) is a treatment for erectile dysfunction. IPPs have undergone improvements; however, post-surgical infections still occur. Furthermore, the type of pathogens infecting the implants has changed recently from Gram-positive to Gram-negative bacteria and fungi due to advances in antibiotic dips targeting the skin flora. To protect against infection, the AMS 700 is pre-coated with InhibiZone (mixture of Rifampin/Minocycline) and the Coloplast Titan, with several antibiotic dip options of differing efficacies. This review discusses strategies to decrease the infection rates in implant surgery, focusing on antibiotic dips.

RECENT FINDINGS

Current research endorses the use of rifampin/gentamicin as the most studied combination; however, some studies have utilized different dips for additional coverage including the InhibiZone on the AMS 700. With the increasing prevalence of diabetes and Gram-negative organisms, there is a need to develop strategies for increased coverage against infections. Controlled studies with different antibiotic combinations are needed to identify the ideal cocktail to decrease infection.

Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database

INTRODUCTION

Although diabetes mellitus (DM) is often discussed as a risk factor for inflatable penile prosthesis (IPP) infection, the link between DM diagnosis and IPP infection remains controversial. High-quality population-based data linking DM to an increased risk of IPP infection have not been published.

AIM

To evaluate the association of DM with IPP infection in a large public New York state database.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for men who underwent initial IPP insertion from 1995-2014. Diabetic patients were identified using ICD-9-CM codes. Patients presenting for first operation with diagnosis or Current Procedural Terminology codes suggestive of prior IPP surgery were excluded. Chi-squared analyses were performed to compare infection rates in diabetics and non-diabetics within the pre- and postantibiotic impregnated eras. Multivariate Cox proportional hazards models were constructed to evaluate whether or not DM was independently associated with IPP infection in the time periods before (1995-2003) and after (2004-2014) the widespread availability of antibiotic impregnated penile prostheses.

MAIN OUTCOME MEASURE

Time to prosthesis infection was measured.

RESULTS

14,969 patients underwent initial IPP insertion during the study period. The overall infection rate was 343/14,969 (2.3%). Infections occurred at a median 3.9 months after implant (interquartile ratio: 1.0-25.0 months). Infectious complications were experienced by 3% (133/4,478) of diabetic patients and 2% (210/10,491) of non-diabetic patients (P < .001). Diabetes was associated with a significantly increased IPP infection risk on multivariable analysis controlling for age, race, comorbidities, insurance status, annual surgeon volume, and era of implantation (Hazard Ratio: 1.32, 95% CI: 1.05-1.66, P = .016).

CONCLUSION

Our analysis supports the notion that DM is a risk factor for IPP infection. This has important implications for patient selection and counseling, and raises the question of whether this increased risk can be mitigated by optimization of glycemic control before surgery. Lipsky MJ, Onyeji I, Golan R, et al. Diabetes Is a Risk Factor for Inflatable Penile Prosthesis Infection: Analysis of a Large Statewide Database. Sex Med 2019;7:35-40.

Inflatable Penile Prostheses Implantation: Does Antibiotic Exposure Matter?

Background

Inflatable penile prosthetic (IPP) infections are unusual but carry high patient morbidity and healthcare costs.

Aim

To increase the bactericidal effect of IPP tubing material to prevent future bacterial infections and to determine whether this effect is time-dependent.

Methods

A modified disk diffusion assay was developed to measure the zones of inhibition against Escherichia coli, Proteus mirabilis, Staphylococcus aureus, and Staphylococcus epidermidis when tubing was immersed in gentamycin, ampicillin, tetracycline, kanamycin, erythromycin, or ciprofloxacin. To further assess the efficacy of this approach, IPP tubing was exposed to ampicillin or ciprofloxacin for 30 seconds, 2 minutes, 10 minutes, or 60 minutes.

Outcomes

Bacterial zones of inhibition against IPP tubing material exposed to various treatments.

Results

IPP tubing was more effective against Gram-positive bacteria (S aureus and S epidermidis) then Gram-negative bacteria (E coli and P mirabilis). Immersing IPP tubing material in ampicillin or ciprofloxacin increased bactericidal effect of tubing material against Gram-positive and Gram-negative bacteria, respectively. The observed inhibitory effect was time dependent.

Clinical Translation

Exposing IPP to a specific antimicrobial directly before implantation increases the bactericidal properties of the material, potentially decreasing the likelihood of infection.

Strengths & Limitations

This study is limited in that it is in vitro experimentation observing the effect of a single strain of each bacterium. Although the strains used were clinically relevant, further analysis is required to determine whether these results were strain specific.

Conclusion

Immersing IPP material into an antibiotic solution, such as ampicillin or ciprofloxacin, increases the bactericidal properties and may aid in the prevention of infection.

Chanyi RM, Alzubaidi R, Leung EJY, Wilcox HB, Brock GB, Burton JP. Inflatable Penile Prostheses Implantation: Does Antibiotic Exposure Matter? Sex Med 2018;6;248–254.

The Impact of Immediate Salvage Surgery on Corporeal Length Preservation in Patients Presenting with Penile Implant Infections

PURPOSE

Removal of an infected penile implant often results in corporeal fibrosis, irreversible penile shortening and dissatisfaction with future implant surgery. Salvage surgery may avoid these problems but to our knowledge no study to date has evaluated these specific end points. We evaluated patients who presented to our center with an infected implant to determine the impact of salvage surgery on penile length.

MATERIALS AND METHODS

We evaluated consecutive patients undergoing removal of an infected penile prosthesis with immediate salvage or delayed reimplantation using a comprehensive, prospective database. Total corporeal length prior to and following immediate salvage or delayed reimplantation were compared. The impact of patient age, comorbidities, bacterial species, initial penile length and time to reimplantation on subsequent total corporeal length was evaluated.

RESULTS

The cohort consisted of 40 patients. Overall 81% of salvaged cases were successful, resulting in a mean 0.6 cm (95% CI 0.20 to 1.1) reduction in total corporeal length. Delayed reimplantation resulted in a mean 3.7 cm (95% CI 2.9-4.5) total corporeal length loss. In patients who underwent delayed reimplantation the total corporeal length reduction was directly proportionate to the initial penis size of the patient. No statistically significant impact on penile length was attributable to patient age, diabetes, bacterial species or time to reimplantation.

CONCLUSIONS

When possible, salvage surgery should be offered to patients with an infected penile implant. Our data confirmed that successful salvage surgery preserves penile length. When a device is explanted and replaced at a later date, patients can expect to lose 15% to 30% of penile length irrespective of age, diabetes, type of infecting organism and time to reimplantation.

Is Hba1c level of diabetic patients associated with penile prosthesis implantation infections?

BACKGROUND AND OBJECTIVES

Diabetes mellitus is an important risk factor for erectile dysfunction (ED). Penile prosthesis implantation surgery is the final solution for diabetic patients with ED, but infections thereof are still a serious risk factor. While some studies suggest that most infections associated with penile prosthesis implantation are associated to high glycated hemoglobin (HbA1c) levels, other research did support such relationship.

MATERIALS AND METHODS

The current study assessed retrospectively, the association between HbA1c level and penile prosthesis surgery infection. We retrieved and reviewed the records of 300 diabetic patients who had penile prosthesis surgery at our Institution (January 2012-November 2016). Patients' mean age was 55.26 ± 10.9 years (31% patients were <50 years of age), and mean HbA1c was 7.60 ± 1.90%.

RESULTS

Infection rate among diabetics was 0.67%. Prevalence of prosthesis infection among patients with HbA1c ≤ 9% was 0.9%, compared with 0% among patients with HbA1c > 9%. Prosthesis infection risk did not significantly increase with higher HbA1c levels, with no meaningful difference in the median or mean level of HbA1c in the infected and non-infected diabetic patients.

CONCLUSION

Findings do not support the use of HbA1c values among diabetic patients who are candidates for penile prosthesis implantation surgery in order to identify and exclude those who might be prone to increased risk of prosthesis infections. Future studies would benefit from larger sample sizes in order to support or refute our findings.

Defining a glycated haemoglobin (HbA1c) level that predicts increased risk of penile implant infection

OBJECTIVES

To re-evaluate the role of diabetes mellitus (DM) as a risk factor for penile implant infection by exploring the association between glycated haemoglobin (HbA1c) levels and penile implant infection rates and to define a threshold value that predicts implant infection.

PATIENTS AND METHODS

We conducted a multicentre prospective study including all patients undergoing penile implant surgery between 2009 and 2015. Preoperative, perioperative and postoperative management were identical for the entire cohort. Univariate analysis was performed to define predictors of implant infection. The HbA1c levels were analysed as continuous variables and sequential analysis was conducted using 0.5% increments to define a threshold level predicting implant infection. Multivariable analysis was performed with the following factors entered in the model: DM, HbA1C level, patient age, implant type, number of vascular risk factors (VRFs), presence of Peyronie's disease (PD), body mass index (BMI), and surgeon volume. A receiver operating characteristic (ROC) curve was generated to define the optimal HbA1C threshold for infection prediction.

RESULTS

In all, 902 implant procedures were performed over the study period. The mean patient age was 56.6 years. The mean HbA1c level was 8.0%, with 81% of men having a HbA1c level of >6%. In all, 685 (76%) implants were malleable and 217 (24%) were inflatable devices; 302 (33.5%) patients also had a diagnosis of PD. The overall infection rate was 8.9% (80/902). Patients who had implant infection had significantly higher mean HbA1c levels, 9.5% vs 7.8% (P < 0.001). Grouping the cases by HbA1c level, we found infection rates were: 1.3% with HbA1c level of <6.5%, 1.5% for 6.5-7.5%, 6.5% for 7.6-8.5%, 14.7% for 8.6-9.5%, 22.4% for >9.5% (P < 0.001). Patient age, implant type, and number of VRFs were not predictive. Predictors defined on multivariable analysis were: PD, high BMI, and high HbA1c level, whilst a high-volume surgeon had a protective effect and was associated with a reduced infection risk. Using ROC analysis, we determined that a HbA1c threshold level of 8.5% predicted infection with a sensitivity of 80% and a specificity of 65%.

CONCLUSION

Uncontrolled DM is associated with increased risk of infection after penile implant surgery. The risk is directly related to the HbA1c level. A threshold HbA1c level of 8.5% is suggested for clinical use to identify patients at increased infection risk.

Preoperative counseling and expectation management for inflatable penile prosthesis implantation

The inflatable penile prosthesis (IPP) is the gold standard surgical treatment for medical refractory erectile dysfunction (ED). While the modern IPP has enjoyed high satisfaction rates as a product of its continued innovation, reliability, and performance, patient dissatisfaction can still occur. IPP implantation restores physiologic function with cosmetic and psychological consequences, both of which place inherent emphasis on preoperative counseling and expectation management. This review aims to highlight the complex nature of such counseling and provide practitioners with a roadmap to navigate the landscape. Preoperative counseling begins with appropriate patient selection and identification of those patients who are at risk for dissatisfaction as a result of personality characteristics. The informed consent provides a natural framework to discuss the host of complications and risks that are associated with surgery, including infection, device malfunction, damage to nearby structures, and device erosion. Device selection is a nuanced process that merges patient preference with clinical factors and consideration. We address device selection through a description of cylinder construction, pump design, and reservoir placement in the context of preoperative counseling. Lastly, we draw attention to expectation management with a specific focus on possible post-operative changes to penile length and sensation as well as partner involvement. The modern IPP provides excellent results with high patient and partner satisfaction. Ultimately, satisfaction is dependent on multiple factors, but providing accurate, realistic counseling and expectation management prepares patients for the best possible outcomes.

Evaluating the Role of Postoperative Oral Antibiotic Administration in Artificial Urinary Sphincter and Inflatable Penile Prosthesis Explantation: A Nationwide Analysis

OBJECTIVE

To determine whether postoperative oral antibiotics are associated with decreased risk of explantation following artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) placement. Although frequently prescribed, the role of postoperative oral antibiotics in preventing AUS or IPP explantation is unknown.

MATERIALS AND METHODS

We queried the MarketScan database to identify male patients undergoing AUS or IPP placement between 2003 and 2014. The primary end point was device explantation within 3 months of placement. Multivariate regression analysis controlling for clinical risk factors assessed the impact of postoperative oral antibiotic administration on explant rates.

RESULTS

We identified 10,847 and 3594 men who underwent IPP and AUS placement, respectively, between 2003 and 2014. Postoperative oral antibiotics were prescribed to 60.6% of patients following IPP placement and 61.1% of patients following AUS placement. The most frequently prescribed antibiotics were fluoroquinolones (35.6%), cephalexin (17.7%), trimethoprim/sulfamethoxazole (7.0%), and amoxicillin-clavulanate (3.2%). Explant rates did not differ based upon receipt of oral antibiotics (antibiotics vs no antibiotics: IPP: 2.2% vs 1.9%, P = .18, AUS: 3.9% vs 4.0%, P = .94). On multivariate analysis, no individual class of antibiotic was associated with decreased odds of device explantation.

CONCLUSION

Postoperative oral antibiotics are prescribed to nearly two-thirds of patients but are not associated with reduced odds of explant following IPP or AUS placement. Given the risks to individuals associated with use of antibiotics and increasing bacterial resistance, the role of oral antibiotics after prosthetic placement should be reconsidered and further studied in a prospective fashion.

Non-infected penile prosthesis cultures during revision surgery; comparison between antibiotic coated and non - coated devices

Introduction:

Aim of this study is to investigate bacterial growth on non-infected devices and compare antibiotic-coated and non-coated implants.

Materials and methods:

The charts of 71 patients who underwent revision surgeries for penile prosthesis between 1995 and 2013 were reviewed. Of those, 31 devices were antibiotic-coated prostheses, while 40 of the implants were non-coated. Swab cultures were routinely obtained from corporal, pump or reservoir site during the operation. If a bacterial biofilm was determined on the prosthesis, it was also cultured.

Results:

A total of 5 different organisms were cultured from 18 patients. Of them, 4 devices were antibiotic-coated and the other 14 were non-coated devices. Staphylococcus epidermidis was the most common organism, while Staphylococcus hominis, beta hemolitic streptococcus, Escherichia coli and Proteus mirabilis were also cultured. All patients who had positive cultures were treated with appropriate antibiotics for four weeks postoperatively. Median follow-up time was 41 months, ranging between 8 and 82 months. One prosthesis (non-coated) became clinically infected in the follow-up period with a totally different organism. Culture positivity rates of antibiotic-coated and non-coated devices were 13% and 35% respectively and the result was significant (p=0.00254).

Conclusions:

Positive bacterial cultures are present on non-infected penile prostheses at revision surgeries in some of the patients. Antibiotic coated prostheses have much less positive cultures than non-coated devices.