Salmonella Infection of a Penile Prosthesis

Is it safe to implant a penile prosthesis in a solid organ transplant recipient? A systematic review

Solid organ transplant recipients exhibit an elevated incidence of erectile dysfunction, attributed to comorbidities and specific factors associated with organ failure. While treatment mirrors the general population's, response rates are lower, and there is a heightened concern about implanting a penile prosthesis in immunocompromised patients due to the potential occurrence of severe complications. The aim of this study was to assess the safety of penile prostheses in this population. Among fourteen included studies, ten were case reports or series of cases, and four were non randomized case-control studies with non-transplanted patients as controls. Complications affected 34 patients (11.15%), with mechanical device failures in 18 cases (5.9%) and infections in 13 cases (4.26%). Most infections required hospitalization, antibiotic treatment, and prosthesis removal, with two cases of life-threatening Fournier's gangrene. Case-control studies revealed no differences in overall reoperation rates between transplant recipients and controls. However, pelvic organ transplant recipients undergoing three-piece prosthesis implantation showed higher complications rates related to reservoir issues. Despite limited evidence, case-control studies demonstrated a generally low/moderate risk of bias within each specific domain, although overall bias was moderate/severe. As a result, clinicians may mitigate concerns regarding penile prosthesis implantation in solid organ transplant recipients.

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.

Two Fungal Infections of Inflatable Penile Prostheses in Diabetics

Introduction

Penile prosthesis infections have decreased since the introduction of antibiotic‐coated implants. Infections that do occur can be from more rare and virulent organisms than the traditional skin flora historically implicated.

Aim

In this report, we present two cases of inflatable penile prosthesis (IPP) infection from Candida organisms in insulin‐dependent diabetic patients.

Methods

Case report with literature review.

Main Outcome Measures

Resolution of the two cases.

Results

Both patients were found to have insulin‐dependent diabetes. Both patients also presented with infection of the device with Candida species, with the implant pump adherent to their scrotal skin.

Conclusions

This report supports the emerging literature that the flora of IPP infections is changing. We suggest considering adding antifungal agents to antibiotic coatings, dips, or washout solutions at the time of penile prosthesis surgery in diabetic patients. Cotta BH, Butcher M, Welliver C, McVary K, and Köhler T. Two fungal infections of inflatable penile prostheses in diabetics. Sex Med 2015;3:339–342.

Three-piece Inflatable Penile Prosthesis: Surgical Techniques and Pitfalls

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

Long-term revision rate due to infection in hydrophilic-coated inflatable penile prostheses: 11-year follow-up

INTRODUCTION

Penile implant surgery continues to be an important option for men with erectile dysfunction. Advancements in technology of implants have contributed to improved survival from mechanical breakdown. Prosthesis infection remains a serious adverse event. For the last 8 years, the Titan implant (Coloplast Corporation, Minneapolis, MN, USA) has been available with an infection-retardant polyvinylpyrrolidone coating.

AIM

To compare the infection rates between coated three-piece inflatable penile prostheses (IPPs) with the previous non-coated model.

MAIN OUTCOME MEASURES

Infection-related revisions reported in the physician-generated, manufacturer-tabulated patient information forms (PIFs).

METHODS

PIFs reported into the voluntary, post-market registry of Coloplast Corporation from July 14, 2000 to September 30, 2011 were retrospectively reviewed. Infection-related revisions entered into the product evaluation database for coated and non-coated IPPs were compared. Data were analyzed using Pearson's chi-squared test.

RESULTS

The database included 36,391 PIFs related to primary IPP implantation. At 11 years of follow-up, 4.6% (7,031) of non-coated IPPs were removed or replaced due to infections, whereas 1.4% (29,360) of hydrophilic-coated implants reported replacements due to device infections. The hydrophilic coating of the IPP components makes the device slippery and prevents bacterial attachment. The hydrophilic coating allows rapid absorption of antibiotics in an aqueous solution and allows these water-soluble antibiotics to elute off the device into the implant spaces. Unfortunately, information pertaining to what agents were used in the studies patients was not tabulated. The rate of revision due to device infection was reduced 69.56% in patients with hydrophilic-coated IPPs (P<0.001).

CONCLUSION

To the best of our knowledge, this is the longest post-marketing registry report related to IPP infections. At 8 years of follow-up, the hydrophilic-coated IPPs demonstrated a significant reduction in revision rates due to infection when compared with the 11-year follow-up of non-coated implants. Since there was no information or uniformity of antibiotics used in the soaking solution, it is uncertain which antibiotic selection provided the best results. In vitro testing against known infectious agents may further benefit IPP patients by reducing the prosthesis infection rate.

Anti-infection dip suggestions for the Coloplast Titan Inflatable Penile Prosthesis in the era of the infection retardant coated implant

INTRODUCTION

Infection is the worst complication seen with inflatable penile prosthesis (IPP). Both the American Medical Systems (AMS) and Coloplast IPP have infection retardant coatings. AMS is coated at the factory with rifampicin and minocycline (InhibiZone). The Coloplast IPP has a hydrophilic coating covalently bonded to its components that will absorb any aqueous solution before implantation and provides increased surface lubricity to decrease bacterial adherence.

AIM

We tested several antibiotic dips comparing zones of inhibition (ZOI) against five commonly infecting bacteria with coated Coloplast implants. Results were compared with those ZOI created with strips of an AMS IPP precoated with InhibiZone.

METHODS

  Pieces of sterile Coloplast Titan IPP were dipped in (i) trimethoprim/polymixin B ophthalmic solution; (ii) trimethoprim/sulfamethoxazole infusion solution; (iii) bacitracin; (iv) rifampicin/minocycline; and (v) rifampin/trimehtoprim/sulfamethoxazole. ZOI for the Titan strips and for AMS InhibiZone coated strips were tested against Staphylococcus epidermidis, Staphylococcus lugdunensis, Staphylococcus aureus, Pseudomonas, and Enterococcus.

MAIN OUTCOME MEASURE

ZOIs of the Coloplast Titan for each of the medicated solutions were compared with ZOI created by undipped strips of a sterile InhibiZone coated IPP placed on plates of the identical bacteria.

RESULTS

All dips except bacitracin showed ZOI≥InhibiZone (P≥0.005) for most organisms. Because of broad-spectrum effectiveness, ease of handling, and cost, infusion vial of trimehtoprim/sulfamethoxazole seemed optimal at this time. If trimehtoprim/sulfamethoxazole is unavailable; the ZOI with Polytrim ophthalmic solution zones were almost as good.

CONCLUSIONS

The Coloplast strips when dipped in several solutions showed equal or significantly larger ZOI against commonly infecting organisms than the InhibiZone coated strips. At the present time using off the shelf trimethoprim sulfamethoxazole infusion solution seems optimum. The flexibility of choosing the drug eluting from the Coloplast device seems promising in the changing bacterial environment.

Antibiotic patterns with inflatable penile prosthesis insertion

INTRODUCTION

A clear set of guidelines has not been defined in the use of antibiotics in penile prosthesis implantation. Aim.  We surveyed urologists throughout the United States to determine current practice patterns regarding antibiotic use in primary and revision penile prosthesis surgery.

METHODS

Fifty-two Sexual Medicine Society of North America (SMS) member urologist and 164 non-SMS member urologist responses were obtained.

MAIN OUTCOME MEASURES

The survey contained 10 questions regarding antibiotic selection for primary and revision inflatable penile prosthesis (IPP) implantation.

RESULTS

One hundred percent of responders in both groups utilize intraoperative antibiotics, most commonly vancomycin and gentamicin in both groups. Of SMS members, 94% prescribed postoperative home oral antibiotics in contrast to 88% of non-SMS members (P = 0.3). Among SMS members, the most common antibiotic prescribed postoperatively was levofloxacin 500 mg daily while among non-SMS members, the most common antibiotic postoperatively was cephalexin 500 mg 2-4 times daily. Of SMS members, antibiotic irrigation intraoperatively occurred with 100% and with 92% of non-SMS members (P = 0.04). Thirty-seven percent SMS physicians and 15% non-SMS physicians made modifications of intraoperative and postoperative antibiotics for high-risk patients (P = 0.001). In the circumstance of revision of a clinically noninfected IPP, 23% SMS and 16% non-SMS member physicians utilized additional antibiotics/treatment (P = 0.3). Sixteen of those surveyed admitted that they had been approached by their institution about their antibiotic use and asked to change. In the past 5 years, 29% surveyed have changed their practice patterns in antibiotic use.

CONCLUSIONS

There is significant difference between practice patterns of SMS and non-SMS urologists in terms of antibiotic irrigation usage, modifications for high-risk patients, and consensus about the importance of antibiotic use with Coloplast Titan implant (Coloplast, Minneapolis, MN, USA). A significant lack of uniformity exists among urologists performing prosthetic surgery with regard to antibiotic protocols. A standard set of guidelines may prove useful to implanters.

What is new for inflatable penile prostheses?

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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