Penile prosthesis cultures during revision surgery: a multicenter study

A systematic review comparing different approaches for inflatable penile prosthesis revision: partial-component exchange, complete-component exchange, or reservoir "drain and retain"

INTRODUCTION

In cases of a noninfected malfunctioning inflatable penile prosthesis (IPP) device, surgeons often opt to exchange all of the device rather than the defective component for fear of an increased infection rate and future mechanical dysfunction.

OBJECTIVES

To assess whether partial-component exchange of an IPP device has comparable outcomes to complete explant and replacement of an IPP device with or without a retained reservoir.

METHODS

A systematic review was conducted following the PRISMA 2020 and AMSTAR guidelines. Searches were performed on MEDLINE (Ovid), PubMed, and the Cochrane Library from inception to June 2023, identifying studies reporting outcomes and complications of revision surgery for noninfected malfunctioning IPP devices. Three groups were compared: those undergoing single- or 2-component exchange, those with complete explantation and replacement, and those with replacement of all components while retaining the primary reservoir.

RESULTS

Analysis included 11 articles comprising 12 202 patients with complete device replacement, 234 with partial device exchange, and 151 with retained reservoirs following revision. Mean ages ranged from 62 to 68 years, with median follow-up times between 3 and 84 months. Partial-component exchange showed a higher infection rate (6.3%) as compared with complete replacement (2.7%) and reservoir retention (3.9%). Similarly, partial exchange had a higher complication rate (23.9%) when compared with complete replacement (11.3%) and reservoir retention (19.6%). Mechanical failure rates for partial exchange were similar across the 3 groups (10%, 2.8%, and 5.8%, respectively).

CONCLUSION

Partial-component exchange during IPP revision is associated with higher infection and perioperative complication rates but comparable rates of mechanical failure as compared with complete-component replacement, with or without retaining the original reservoir.

Practical Guidance for Clinical Microbiology Laboratories: Microbiologic diagnosis of implant-associated infections

SUMMARYImplant-associated infections (IAIs) pose serious threats to patients and can be associated with significant morbidity and mortality. These infections may be difficult to diagnose due, in part, to biofilm formation on device surfaces, and because even when microbes are found, their clinical significance may be unclear. Despite recent advances in laboratory testing, IAIs remain a diagnostic challenge. From a therapeutic standpoint, many IAIs currently require device removal and prolonged courses of antimicrobial therapy to effect a cure. Therefore, making an accurate diagnosis, defining both the presence of infection and the involved microorganisms, is paramount. The sensitivity of standard microbial culture for IAI diagnosis varies depending on the type of IAI, the specimen analyzed, and the culture technique(s) used. Although IAI-specific culture-based diagnostics have been described, the challenge of culture-negative IAIs remains. Given this, molecular assays, including both nucleic acid amplification tests and next-generation sequencing-based assays, have been used. In this review, an overview of these challenging infections is presented, as well as an approach to their diagnosis from a microbiologic perspective.

Infection rates following urologic prosthetic revision without replacement of any device components compared to partial or complete device exchange: a single-center retrospective cohort study

Urologic implant revision carries a higher infection risk than virgin implantation. Historically, exchanging device components at the time of revision was performed to reduce infection risk. We hypothesize that revision without replacement of any parts of the device may not be associated with increased infection risk. A single-center, retrospective cohort study was performed on patients undergoing urologic implant revision from 2000 to 2021. Revisions involving exchange of any/all device components (+CE) were compared to revisions without exchange of any components (-CE). The primary outcome was infection or erosion within 12 weeks of revision. Infection rates were compared using Fischer exact test. Infection-free survival (IFS) was compared with Kaplan-Meier (KM) log-rank test and Cox proportional hazards (CPH) model. 551 revisions were included, including 497 revisions with CE and 54 without CE. Among those with at least 12 weeks follow-up, no difference was seen in infection rates within 12 weeks of revision [-CE 3/39 (7.7%) vs. +CE 10/383 (2.6%)], p = 0.109). In addition, IFS was comparable between groups (log-rank test p = 0.22, HR for -CE 1.65 (0.65-4.21). Revision surgery for IPP or AUS without CE may not present an elevated risk of infection in the properly selected patient.

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.

Penile implant infection part 3: the changing spectrum of treatment

Penile prosthesis infection remains a rare but devastating complication of implantation. Historically, management of device infection was always extirpation. While certainly effective, device removal leaves an unhappy patient with a shortened penis. In this last part of a three-part series on the topic of penile prosthesis infection, we seek to highlight new and emerging ideas of infection management which have allowed surgeons the option of preserving the implanted status in select patients.

Effect of 0.05% chlorhexidine gluconate in water on the hydrophilic inflatable penile prosthesis: biocompatibility, adherence, and dip time

BACKGROUND

Rates of infection after inflatable penile prosthesis range from 1% to 3%; however, a new surgical irrigation solution is Food and Drug Administration cleared as antimicrobial wound lavage and appears to be safe for patients and noncaustic during hydrophilic inflatable penile prosthesis (hIPP) dipping and irrigation.

AIM

To evaluate if 0.05% chlorhexidine (CHG) lavage is caustic to the hIPP coating and if dip adherence is dependent on time.

METHODS

Preconnected hIPP devices were tested at a Coloplast research and development laboratory. The devices were soaked in the 0.05% CHG lavage solution or normal saline for 1, 15, 30, and 60 minutes. Subsequently, all parts were dried for 15 minutes in a 35 °C oven. A Congo red dye test was performed following a Coloplast-validated and Food and Drug Administration-cleared test method to ensure product reliability. Implants were then visually inspected for deleterious effects as well as dip coverage. In addition, we evaluated 0.05% CHG lavage solution vs previously published hIPP dipping solutions.

OUTCOMES

0.05% CHG lavage does not appear to damage the hIPP coating, and adherence of this solution is not dependent on dip time.

RESULTS

All components of the preconnected hydrophilic IPPs were tested for coating adherence and defects. All tested IPPs achieved a "satisfactory" coating, meaning a uniform coat without flaking or clumping. Furthermore, there were no noticeable caustic effects or differences in coating adherence between the normal saline-soaked control and 0.05% CHG-coated arms with increasing dip time. A review of the literature for 0.05% CHG lavage solutions vs previously published hIPP dipping solutions revealed that it may have some advantages over previously reported antibiotic solutions.

CLINICAL IMPLICATIONS

This study serves as a foundation to introduce 0.05% CHG lavage to the urologic literature as a potentially new "magic bullet" irrigation.

STRENGTHS AND LIMITATIONS

Major strengths of the study are that it is the first study of its kind to address the question of what dip duration should be used and whether it is scientifically reproducible. A limitation is the in vitro model, thus needing validation in a clinical setting.

CONCLUSION

0.05% CHG does not appear to negatively affect the hIPP coating or differ in adherence with increasing dip time; however, long-term device performance has not been verified.

Environmental, Microbiological, and Immunological Features of Bacterial Biofilms Associated with Implanted Medical Devices

The spread of biofilms on medical implants represents one of the principal triggers of persistent and chronic infections in clinical settings, and it has been the subject of many studies in the past few years, with most of them focused on prosthetic joint infections. We review here recent works on biofilm formation and microbial colonization on a large variety of indwelling devices, ranging from heart valves and pacemakers to urological and breast implants and from biliary stents and endoscopic tubes to contact lenses and neurosurgical implants. We focus on bacterial abundance and distribution across different devices and body sites and on the role of environmental features, such as the presence of fluid flow and properties of the implant surface, as well as on the interplay between bacterial colonization and the response of the human immune system.

Microorganism Profiles of Penile Prosthesis Removed for Infection, Erosion, and Mechanical Malfunction Based on Next-Generation Sequencing

BACKGROUND

Next-generation sequencing (NGS) is an emerging technology that may allow for more sensitive and sophisticated microbial testing of the microbiota of penile prostheses (PP).

AIM

To describe the microorganism profiles of PP explanted for infection, erosion, and mechanical malfunction using NGS.

METHODS

All patients who underwent PP removal by two physicians at two institutions were identified. Differences in alpha diversity (ie, number of species detected, species diversity across samples) and microbiome compositional profiles (Bray-Curtis community dissimilarities) across samples were assessed using ANOVA and PERMANOVA, respectively.

OUTCOMES

Number of species detected, species diversity across samples, and microbiome compositional profiles.

RESULTS

A total of 83 patients who underwent device removal for infection (n = 8, 10%), erosion (n = 5, 6%), and mechanical malfunction (n = 70, 84%) were included. When considering all devices, 56% (n = 48) of NGS and 29% (n = 24) of standard cultures resulted positive for presence of microorganisms. Culture only detected the most abundant NGS species in 62.5% (n = 5) of infected devices. Species richness and microbiome compositional profiles varied by surgical indication, but not by age, race, diabetes status, or implant duration. Most frequent organisms by surgical indication were Pseudomonas aeruginosa (infection), Staphylococcus epidermidis (erosion), and Escherichia coli (mechanical malfunction). The highest relative abundance organisms were P aeruginosa (infection), Corynebacterium jeikeium (erosion), and E coli (mechanical malfunction).

CLINICAL IMPLICATIONS

Identifying microbiome profiles of PP removed for infection, erosion, and mechanical malfunction may guide the selection of peri-operative antibiotics and PP antibiotic coatings or hydrophilic dip solutions for each individual scenario.

STRENGTHS AND LIMITATIONS

While this is the first study to utilize next-generation sequencing to evaluate penile prosthesis biofilm, the clinical significance of these findings has yet to be determined. A prospective, randomized trial aimed at evaluating the clinical significance of NGS in patients with PP infection is currently underway.

CONCLUSION

NGS testing identified distinct microbiome profiles of PP removed for infection, erosion, and mechanical malfunction. Chung PH, Leong JY, Phillips CD, Henry GD. Microorganism Profiles of Penile Prosthesis Removed for Infection, Erosion, and Mechanical Malfunction Based on Next-Generation Sequencing. J Sex Med 2022;19:356-363.

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.

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.

Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation

Introduction

Impending cylinder erosion and floppy glans secondary to an undersized penile prosthesis are rare complications that can cause cosmetic deformity and patient discomfort.

Aim

To demonstrate a technique for the management of impending cylinder erosion and floppy glans secondary to cylinder under-sizing.

Methods

We retrospectively reviewed 6 patients who required the proximal extracapsular tunneling technique during penile prosthesis revision surgery.

Main Outcome Measure

Main outcome was successful placement of a penile prosthesis with proper cylinder placement.

Results

Mean patient age for these 6 patients was 71.2 years (64–86 y). After a mean follow-up of 6.6 months, all 6 patients who underwent this procedure had a functional penile prosthesis without evidence of recurrence.

Conclusion

The proximal extracapsular tunneling technique is a simple approach performed through a single incision that can be used for proper cylinder replacement during penile prosthesis revision surgeries. It may be utilized for the management of impending cylinder erosion and other cases with coporal dilation-related complications in which the surgical pseudo-capsule has already formed around the implant. This technique can be safely performed without the need of a distal counter-incision on the penis. Clavell-Hernández J. Proximal Extracapsular Tunneling: A Simple Technique for the Management of Impending Cylinder Erosion and Complications Related to Corporal Dilation. Sex Med 2021;9:100379.

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.

Long-term outcomes after penile prosthesis placement for the Management of Erectile Dysfunction: a single-Centre experience

Background

Penile prothesis (PP) is the gold-standard treatment of drug-refractory erectile dysfunction (ED). While postoperative outcomes have been widely described in the literature, there are few data about patient satisfaction and intraoperative events. We aimed to assess long-term patient satisfaction and perioperative outcomes after PP implantation in a single-centre cohort of unselected patients using validated scales.

Results

A total of 130 patients received a PP (median age: 62.5 years [IQR: 58–69]; median International Index of Erectile Function (IEEF-5) score: 6 [IQR: 5–7]). Median follow-up was 6.3 years [IQR: 4–9.4]. Thirty-two (24.6%) patients underwent surgical revision, of which 20 were PP removals (15.4%). Global PP survival rate was 84.6% and previous PP placement was a risk factor for PP removal (p = 0.02). There were six (4.6%) non-life-threatening intraoperative events including two which resulted in non-placement of a PP (1.5%). EAUiaic grade was 0 for 124 procedures (95.4%), 1 for four procedures (3.1%) and 2 for two procedures (1.5%). Of patients who still had their PP at the end of the study, 91 (80.5%) expressed satisfaction.

Conclusions

PP implantation is a last-resort treatment for ED with a satisfactory outcome. PPs are well accepted by patients.

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.

Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery?

The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.

Comparison of Penile Prosthesis Cultures Within Individual Patients After Removal/Replacement and Subsequent Salvage

Introduction

Infection rates for virgin inflatable penile prostheses (IPPs) range from 1 to 3%; however, this can increase to 7–18% after IPP revision or removal/replacement (RR) for mechanical malfunction. Although studies have reported various RR and salvage cultures, limited data are available that directly compare microorganisms after each of these procedures within the same patient. Comparison of these cultures may determine if the infection is due to a persistent microorganism or new inoculation.

Aim

Our aim is to characterize prosthesis cultures within individual patients who develop infection after RR.

Methods

We retrospectively reviewed patients undergoing various IPP procedures at our institution from September 2002 to August 2018. RR procedures were determined by current procedural terminology codes 54,410 or 54,416. Infection, defined as salvage or explantation without replacement for infectious reasons, was described by current procedural terminology codes 54406, 54411, 54415, or 54417. Inclusion criteria consisted of IPP infection after RR and the presence of both RR and salvage cultures within the same patient. Owing to the small cohort size, only descriptive statistics were used.

Main Outcome Measures

Characterization of removal/replacement and salvage cultures is the main outcome measure of this study.

Results

A total of 202 non-infected RR procedures were performed with 9 cases (4%) of IPP infection after RR identified. Four (44%) of the RR cultures were positive and contained gram-positive (44%) and gram-negative (11%) organisms. In comparison, salvage cultures grew gram-positive bacteria (66%), gram-negative bacteria (33%), and/or fungal elements (33%). A direct comparison of the RR and salvage cultures indicated that only 2 patients (22%) grew similar organisms.

Conclusions

The risk of IPP infection after RR and modified washout is low. In this small series, gram-positive bacteria were most common at the time of RR and salvage. The increased incidence of fungal infections may indicate a need to modify RR protocols. Larger multi-institutional studies are needed to further investigate this relationship.

Chandrapal J, Harper S, Davis LG, et al. Comparison of Penile Prosthesis Cultures Within Individual Patients After Removal/Replacement and Subsequent Salvage. Sex Med 2020;8:783–787.

Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study

Introduction

Infection remains a persistent complication of penile prosthesis (PP) surgery. Despite popularity of Mulcahy’s PP washout protocol, Betadine has known tissue toxicity.

Aim

We evaluated PP infection rate based on the type of intraoperative irrigation used, ½ strength Betadine vs vancomycin/gentamicin.

Methods

We reviewed a prospective database of men undergoing primary, revision, and salvage PPs. No other changes to operative or perioperative techniques occurred after the change in irrigation solution. Univariate and logistic regression analyses were used to evaluate differences in infection rate with use of Betadine vs vancomycin/gentamicin irrigation. Potential confounders were reviewed.

Main Outcome Measure

The primary outcome was rate of PP infection before and after change of intraoperative irrigation.

Results

From 2014 to 2018, 217 patients underwent PP placement at our institution by a single surgeon; of whom, 21 (9.7%) experienced an infection (primary = 10 [7.1%], revision = 11 [17.19%], salvage = 0 [0%]). Overall, 152 (70%) received irrigation with Betadine and 65 (30%) with Vancomycin/Gentamicin. Univariate analysis demonstrated significantly increased infection rates with Betadine irrigation (odds ratio [OR]: 4.64, P = .006) and with revision surgery (OR: 2.68, P = .02). Significance of increased infection rate with Betadine was maintained (OR: 9.3; P = .025) after controlling for age, body mass index, Charlson comorbidity index, smoking, diabetes, primary vs revision/salvage, prior penile surgery, use of ectopic reservoir, and adjunctive glanulopexy.

Conclusions

Changing from intraoperative Betadine to vancomycin/gentamicin solution dramatically reduced infection rates among men undergoing PP placement in both primary and revision cases. We hypothesize that differences in infection rate may relate to the relative toxicity or non-sterile nature of Betadine.

Manka MG, Yang D, Andrews J, et al. Intraoperative Use of Betadine Irrigation is Associated With a 9-Fold Increased Likelihood of Penile Prosthesis Infection: Results From a Retrospective Case-Control Study. Sex Med 2020;8:422–427.

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.

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.

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.

Infection Prevention Considerations for Complex Penile Prosthesis Recipients

PURPOSE OF REVIEW

The purpose of this review is to critically analyze and summarize recent studies in the area of penile prosthesis surgery outcomes with a focus on infection prevention in high-risk patients.

RECENT FINDINGS

Reduction of surgical time in complex prosthesis surgery may reduce infection risk. Concomitant implant surgery is not associated with increased infection risk. Certain immunocompromised patients may be more likely to have penile implant infections, but these may not include patients with well-controlled HIV, well-controlled diabetes, or transplant recipients. Substance abuse is correlated with increased risk of infection after penile implant surgery. Careful patient selection and preoperative optimization can reduce infection risk in spinal cord injury patients. In the last 5 years, there have been several important studies investigating the risk of penile prosthesis infection in complex patients, clarifying which patient categories are at increased risk and how that risk can be mitigated.

Infection Retardant Coatings Impact on Bacterial Presence in Penile Prosthesis Surgery: A Multicenter Study

OBJECTIVE

To investigate patients for positive culture rates with or without infection retardant coatings (IRC) penile prostheses (PPs) and to examine changes in culture positive isolates found in patients presenting overt clinical infection.

METHODS

Cultures were obtained from PPs immediately upon surgical exposure of the pump. 236 patients were broken down into 2 groups, with each further divided into 2 groups. The noninfected group included 208 patients: 133 with uncoated PPs and 75 with IRC implants. The infected group included 28 patients: 16 with uncoated PP and 12 with IRC inflatable penile prostheses (IPP). Additionally, sensitivity to the combination of tetracycline and rifampin were evaluated on all cultures.

RESULTS

In the noninfected group, culture positive isolates were found in 85 patients with uncoated PP's and in 32 patients with IRC implants [P value = 0.0003]. Cultures positive for Staphylococcus genus were found in 75 uncoated PP patients, while 20 patients with IRC implants had an isolate of this genus. In the infected group, culture positive isolates were found in 7 patients with uncoated PP and 6 patients with IRC IPPs [P value = 1.000]. Positive cultures for Staphylococcus genus were found in 6 patients with uncoated PP, while 3 patients with IRC IPP had an isolate of this genus. All bacterial isolates were sensitive to the combination of tetracycline and rifampin.

CONCLUSION

Positive bacterial cultures have been shown to be present on clinically uninfected IPPs at time of revision surgery. Culture isolates grown from patients with IRC IPPs reveal a nontraditional bacterial profile: fewer cultured isolates of Staphylococcus genus.

Infection risk of undergoing multiple penile prostheses: an analysis of referred patient surgical histories

Inflatable penile prosthesis (IPP) is the gold standard for medically refractory erectile dysfunction. Infectious complications remain a significant concern in IPP revision surgery. We sought to evaluate the impact of number of IPP surgeries on subsequent infection rates. A retrospective analysis was performed on all new patients (self or outside provider referred) presenting for consideration of IPP revision or salvage surgery between 2013 and 2015. Histories were reviewed including number of prior IPPs, reason for evaluation, and rate, number, and timing of prior IPP infections. No patients were operated on by the primary investigator prior to data acquisition. We identified 44 patients with at least one prior IPP presenting for consultation regarding IPP revision/salvage. There were 88 IPPs placed by 28 different surgeons. In patients with two or more devices, 55% had at least two different surgeons. The most common reason for presentation was malfunction (52%). The risk of specific device infection was strongly correlated and increased based on number of prior IPPs: 1st (6.8%; 3/44), 2nd (18.2%; 4/22), 3rd (33.3%; 4/12), 4th (50%; 4/8), and 5th (100%; 2/2) (R² = 0.90, p = 0.01). Similarly, overall rates of infection positively correlated with number of prior IPP-related surgeries performed (R² = 0.97, p < 0.01). The median time to development of infection after most recent IPP surgery was 2 months (IQR 1-3.3 months). Infection rates of revision/salvage IPP surgery increase with each subsequent IPP placement or following IPP-related surgeries. The majority of patients referred for penile implant surgery can expect to have experienced at least one infection by their 4th device. These data represent a change in paradigm on revision prosthetic surgery.

Outcome of penile prosthesis implantation: are malleable prostheses an appropriate treatment option in patients with erectile dysfunction caused by prior radical surgery?

The aim of our study was to evaluate the outcome of penile prosthesis implantation in patients with various comorbidities as a cause of erectile dysfunction (ED). The data of 181 patients who underwent surgery between 1998 and 2012 in two centers were evaluated. The mean age of the patients was 52.2 years (range: 31-71 years). The study group contained 162 patients (89.5%) with malleable prostheses and 19 (10.5%) with inflatable implants. All patients were re-evaluated 1 month later to assess prosthesis function and complications, and further re-examinations were performed if needed. Satisfaction was defined as having satisfactory intercourse and happiness with the device in general. The follow-up period was at least 12 months for each patient. The postoperative complication rate was 32% (n = 58). The number of complications with inflatable and malleable prostheses was 7 (3.9%) and 51 (28.1%), respectively. Overall, 21 prostheses (11.6%) had to be removed because of various complications and patient dissatisfaction. Patients with prior radical surgery had higher extraction rates (ƛ = 14.606, P < 0.05, Chi-square test). The main reasons for removal were erosion (n = 11; 6.1%) and infection (n = 3; 2.1%). With respect to satisfaction during intercourse, we found that 104 (57.5%) patients described themselves as very satisfied with the prosthesis, while 21 (11.6%) were unsatisfied. The high explantation rate in patients with prior surgery was remarkable in our study. Our results revealed that a malleable prosthesis should not be the preferred type of implant for patients with prior surgery.

Bacterial colonization of penile prosthesis after its withdrawal due to mechanical failure

INTRODUCTION

Prosthetic surgery to treat erectile dysfunction has a risk of infection of up to 3%, but this risk can increase to 18% when the surgery involves replacement. This increased risk of infection is attributed to the bacterial colonization of the prosthesis during the initial surgery.

OBJECTIVE

To analyse the presence of germs in the prosthesis that is withdrawn due to mechanical failure (not infection), as well as the surgical results and its progression.

MATERIALS AND METHOD

A retrospective study was conducted of all replacements performed between 2013 and 2016 at a single centre. We analysed demographic data, prior type of prosthesis, surgical procedure, microbiological study and follow-up.

RESULTS

Of the 12 replacement procedures, a microbiological study of the extracted prosthesis was performed in a total of 10 cases. Of the 10 replacements, the cultures were positive in 5 cases (50%). Staphylococcus epidermidis was the most prevalent germ. All patients underwent a flushing procedure, and an antibiotic-coated prosthesis was implanted. We recorded no infections with the new implanted device after a mean follow-up of 27.33 months (SD 4.13; 95% CI 18.22-36.43).

CONCLUSION

In our study population, we observed a high rate of bacterial colonization of the prostheses that were replaced due to mechanical failure. When a flushing procedure was performed during the replacement surgery, there were no more infections than those reported in treatment-naive cases.

Medical pre-operative considerations for patients undergoing penile implantation

Penile prosthesis surgery has become the standard treatment for patients with erectile dysfunction refractory to medical management. Refinements in the both the surgical technique and device manufacturing have made this a safe and reliable treatment with excellent patient satisfaction. In this review, we will overview the basic medical and pre-operative considerations for patients undergoing penile prosthesis implantation. We intend to provide a simple and practical checklist for the implanter to reference when considering implantation of a penile prosthesis.

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.

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.

Minimising the risk of device infection in penile prosthetic surgery: a UK perspective

We have reviewed articles published on penile prosthetic infection in Medline and EMBASE databases from 2000 to 2012 with the intention of signposting ‘best evidence’ for the UK prosthetic implanter. Using the Oxford Centre for Evidence-based Medicine Levels of Evidence (LE), no paper exceeded an LE of 2b and the majority were LE 4 (case series) and LE 5 (expert opinion). This is not surprising from a UK perspective since HES data for 2009 to 2010 reported 263 penile prosthetic surgeries performed in 35 hospitals, with only five hospitals performing 15 or more. Our literature review suggests that the use of antibiotic-coated IPPs and measures aimed at reducing inoculating bacteria into the surgical wound with alcohol skin preparation, a no-touch technique and peri-operative antibiotic use are most important in minimising the risk of device infection. The use of post-operative antibiotics is contentious (LE 5). It remains unproven whether diabetics have a higher rate of prosthetic infection compared to nondiabetics. In cases of re-implantation for mechanical failure, it remains debatable whether a washout technique should be used and indeed uncertainty remains regarding the pathological role of biofilm in the causation of device infection in this scenario. A washout technique during salvage penile prosthetic surgery for device infection is advocated. Further research on biofilm may offer the best chance of reducing the incidence of device infections overall.

Conservative Therapy is an Effective Option in Patients With Localized Infection After Penile Implant Surgery

INTRODUCTION

Traditionally, penile implant (PI) infections have been managed by removal with immediate or delayed replacement. Recently, interest has been focused on conservative therapy (CT) using antibiotic therapy.

AIM

To investigate the success rate and predictive factors affecting the outcome of CT in PI infection patients.

METHODS

Patients diagnosed with early, localized PI infection were considered candidates for CT. Exclusion criteria included temperature >37.5°C, WBC >13,000/μL, and appearance of any sign of sepsis. In patients with purulent drainage, culture swabs were taken and an antibiotic was chosen based on sensitivity results. Oral antibiotics were used until the local infection was completely resolved. Patients were evaluated weekly during this process.

RESULTS

Thirty-seven patients were retrospectively reviewed and constituted the study population. Mean age was 58.1 (range 37-85; SD 9.9) years. All were diabetic. Mean BMI was 31.8 (range 24-47; SD 5.0). PI was malleable in 33 cases and inflatable in 4 cases. Culture results (n = 19) included Staphylococcus epidermidis (42 %), pseudomonas (21%), Escherichia coli (21%), and S aureus (16%). Four of 37 patients needed the PI removed due to CT failure and onset of systemic symptoms, at a mean time-point of 75 ± 1.8 days after CT commencement. In men who were cured, mean time to complete healing was 49 (range 29-97; SD 15.8) days. Two of 37 patients (5%) had PI removal because of persistent penile pain despite complete wound healing, at a mean time point of 128 ± 2.5 days after CT commencement. All men managed conservatively resumed sexual intercourse.

CONCLUSION

CT of localized PI infection appears to be a viable option for such patients, with the majority of patients retaining their implant and resuming sexual activity.

A practical overview of considerations for penile prosthesis placement

Penile prostheses have remained the gold-standard therapy for medically refractory erectile dysfunction (ED) since their popularization. Advances in device design and surgical techniques have yielded improved rates of infection, satisfaction, and mechanical survival of devices. Operative techniques in penile prosthesis surgery include the use of adjunctive procedures (such as ventral phalloplasty and release of the suspensory ligament), management of penile fibrosis, and manoeuvres to correct Peyronie's-disease-related curvature. Complications include urethral and corporal perforation, crossover, infection, impending erosion, and/or supersonic transporter deformity. Long-term data regarding mechanical, overall, and infection-free survival demonstrate excellent results, and, given the consistently high satisfaction rates and limited alternatives for medically refractory ED, penile prostheses are likely to remain a relevant and important treatment strategy for the foreseeable future.

History, Contemporary Outcomes, and Future of Penile Prostheses: A Review of the Literature

INTRODUCTION

Since their introduction, penile prostheses have consistently remained a superior treatment option for men with erectile dysfunction (ED) refractory to conservative measures. Ongoing enhancements to prosthetic design, materials, and surgical techniques have resulted in improved outcomes.

AIM

To review available literature on notable historical advancements and improvements of the penile prosthesis, summarize contemporary outcomes of recent devices, and discuss possible future directions of the penile prosthesis.

METHODS

A PubMed search was performed of all articles published from 1960 to present relating to penile prosthesis. Priority was given to series with 12 months of follow-up or greater, larger series, and studies reporting on outcomes of more recent prosthetic models.

MAIN OUTCOME MEASURES

Main outcomes included historical review of improvements leading to, and contemporary series reporting on rates of mechanical failures, infections, and satisfaction with penile prostheses.

RESULTS

Penile prostheses have undergone numerous enhancements since initial reports of synthetic materials utilized in the 1950s. Among others, recent notable device enhancements include Parylene coating, Bioflex® material, Inhibizone^TM antibacterial impregnation, hydrophilic coating, lockout valves, and easy release pump mechanisms, all of which have improved mechanical reliability, reduced infection rates, and/or improved patient satisfaction with penile prostheses. Contemporary series of 3-piece penile prostheses report mechanical survival of 81-94%, 68-89%, and 57-76% at 5, 10, and 15 years, respectively. Infection rates of current devices are 1-2% in first-time, low-risk populations, and 2-3% for higher risk groups, with patient and partner satisfaction at 92-100% and 91-95%, respectively. Two-piece and malleable devices are associated with slightly higher mechanical reliability and decreased patient satisfaction. Minimal data currently exist on the outcomes of selected patient populations, including Peyronie's disease and corporal fibrosis.

CONCLUSIONS

Penile prostheses are associated with excellent, long-term outcomes and remain the gold-standard treatment for men with refractory ED. Additional research with prospective studies utilizing objective measures and standardized questionnaires is required. Trost L and Hellstrom WJG. History, contemporary outcomes, and future of penile prostheses: A review of the literature. Sex Med Rev 2013;1:150-163.

Significance of biofilm for the prosthetic surgeon

Biofilm formation on implanted medical devices is becoming more recognized as both a common finding and a potential problem. Although seen frequently in nature, these sequestered bacterial communities are proving to be an assiduous enemy as medical device technologies advance. The penile prosthesis has gone through many improvements, now with a more reliable mechanical function and a reduced infection rate. However, there remains a notable increase in infectious risk in revisions compared to novel cases, with many implants found to harbor a subclinical bacterial presence isolated in biofilms. This article focuses on recent updates in implant technology and surgical technique to combat infection, and reviews current research on biofilm prevention and treatment.

Intentionally retained pressure-regulating balloon in artificial urinary sphincter revision

INTRODUCTION

The traditional surgical approach for revision of a malfunctioning artificial urinary sphincter (AUS) includes removal and replacement of all device components, identical to that employed in the setting of an infected or eroded AUS.

AIMS

  To describe outcomes of our technique in which we intentionally leave behind the original pressure-regulating balloon (PRB) at time of AUS revision in a clinically non-infected setting.

METHODS

We retrospectively reviewed our combined institutional series of 35 patients who underwent 36 AUS revisions in which the original pressure-regulating balloon was left undisturbed. We removed and replaced the defective cuff and pump through a single peno-scrotal incision for most patients requiring revision of a non-infected AUS. The new PRB was then placed on the opposite side through this single incision.

MAIN OUTCOME MEASURES

Assessment of outcomes, complication, and infection rate of this surgical series.

RESULTS

All of the patients had the original pressure-regulating balloon placed through an inguinal counter-incision. Mean follow-up time was 14 months (2-33 months). Overall complication rate for the revision series was 11%. No infections or complications occurred secondary to the retained PRB.

CONCLUSION

Follow-up of our series provides evidence that retention of the original PRB at the time of non-infected AUS revision is safe. Potential advantages include elimination of a counter incision and technically challenging exploration. By eliminating these aspects, the potentially resultant decreased operative time may help counter the theoretical yet unproven risk of infection from leaving the old PRB in place.

Long-term infection outcomes of 3-piece antibiotic impregnated penile prostheses used in replacement implant surgery

PURPOSE

Patients who undergo device revision surgery are at higher risk for infection than virgin implant recipients. The revision rate due to virgin implant infection is statistically significantly lower for minocycline/rifampin impregnated than for nonimpregnated inflatable penile prostheses. We determined whether the frequency of infection revision events after device replacement surgery would also be lower for minocycline/rifampin impregnated inflatable penile prostheses.

MATERIALS AND METHODS

Patient information forms voluntarily submitted to AMS® after replacement inflatable penile prosthesis implantation between 2001 and 2007 were retrospectively reviewed to compare secondary infection related revision events for antibiotic impregnated vs nonimpregnated implants. Only men who received an inflatable penile prosthesis at a first recorded operation to replace a previously implanted penile prosthesis were included in the study. Life table survival analysis was done between the groups to compare infection related events resulting in a second surgical revision after replacement implantation. Survival function extrapolation was based on parametric analysis using the Weibull distribution model.

RESULTS

On life table survival analysis secondary revision due to infection was significantly less common in the minocycline/rifampin impregnated group than in the nonimpregnated group (log rank p = 0.0252). At up to 6.6 years of followup 2.5% of 9,300 men with vs 3.7% of 1,764 without an impregnated device underwent secondary revision due to infection.

CONCLUSIONS

This long-term device survival analysis provides clinical evidence of a significant decrease in infection related secondary revisions using minocycline/rifampin impregnated prostheses vs nonimpregnated inflatable penile prostheses at replacement implant surgery.

A review of surgical techniques for impending distal erosion and intraoperative penile implant complications: part 2 of a three-part review series on penile prosthetic surgery

INTRODUCTION

More than half of intraoperative complications occur during dilatation of the corpora cavernosa, a critical step in the placement of any type of penile prosthesis, which can be especially difficult in a patient with corporal fibrosis. A late manifestation of cylinder placement can be impending erosion with lateral extrusion or medial deviation (into the urethra) of the distal tips. There are many different approaches to try and fix these surgical issues.

AIM

The review article evaluates the many different surgical techniques prosthetic surgeons use in the management of intraoperative complications and lateral extrusion.

METHODS

A review of the literature was preformed with published results being evaluated to try to help guide the management of intraoperative complications and impending distal erosion. There is a special focus on dilation of the corpora cavernosa.

MAIN OUTCOMES MEASURES

The article reviews and evaluates the outcomes of the landmark papers in the management of intraoperative complications and impending distal erosion.

RESULTS

Intraoperative complications of penile implant placement can be distressing for the prosthetic surgeon, but with proper recognition, most of these complications can be navigated with excellent postoperative results.

CONCLUSIONS

This review article summarizes many of the techniques, outcomes, and new developments in the complicated field of penile prosthetic surgery to help guide the implanting surgeon.