Antibiotic patterns with inflatable penile prosthesis insertion

Timing and causative organisms associated with modern inflatable penile prosthesis infection: an institutional retrospective

BACKGROUND

The advent of antibiotic-coated devices has reduced the rate of inflatable penile prosthesis (IPP) infections; however, this may have altered microbial profiles when infections do occur.

AIM

To describe the timing and causative organisms behind infection of infection retardant-coated IPPs in the context of our institution's perioperative antimicrobial protocols.

METHODS

We retrospectively reviewed all patients undergoing IPP placement at our institution from January 2014 to January 2022. In all patients, perioperative antibiotic administration was congruent with American Urological Association guidelines. Boston Scientific devices are impregnated with InhibiZone (rifampin and minocycline), and all Coloplast devices were soaked in rifampin and gentamicin. Intraoperative irrigation was performed with betadine 5% irrigation prior to November 2016 and with vancomycin-gentamicin solution afterward. Cases involving prosthesis infection were identified, and variables were extracted from the medical record. Descriptive and comparative statistics were tabulated to identify clinical characteristics, including patient comorbidities, prophylaxis regimen, symptom onset, and intraoperative culture result. We previously reported an increased infection risk with Betadine irrigation and stratified results accordingly.

OUTCOMES

The primary outcome was time to infectious symptoms, while the secondary outcome was description of device cultures at the time of explantation.

RESULTS

A total of 1071 patients underwent IPP placement over 8 years with an overall infection rate of 2.6% (28/1071). After discontinuation of Betadine, the overall infection rate was significantly lower at 0.9% (8/919) with a relative risk of 16.9 with Betadine (P < .0001). Primary procedures represented 46.4% (13/28). Of 28 patients with infection, only 1 had no identified risk factors; the remainder included Betadine at 71% (20/28), revision/salvage procedure at 53.6% (15/28), and diabetes at 50% (14/28). Median time to symptoms was 36 days (IQR, 26-52); almost 30% of patients had systemic symptoms. Organisms with high virulence, or ability to cause disease, were found in 90.5% (19/21) of positive cultures.

CLINICAL IMPLICATIONS

Our study revealed a median time to symptoms of just over 1 month. Risk factors for infection were Betadine 5% irrigation, diabetes, and revision/salvage cases. Over 90% causative organisms were virulent, demonstrating a microbial profile trend since antibiotic coating development.

STRENGTHS AND LIMITATIONS

The large prospectively maintained database is a strength along with the ability to follow specific changes in perioperative protocols. The retrospective nature of the study is a limitation as well as the low infection rate, which limits certain subanalyses from being performed.

CONCLUSION

IPP infections present in a delayed manner despite the rising virulence of infecting organisms. These findings highlight areas for improvement in perioperative protocols in the contemporary prosthetics era.

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.

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.

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.

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.

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.

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.

Prevention, identification, and management of post-operative penile implant complications of infection, hematoma, and device malfunction

Penile prosthesis implant surgery is an effective management approach for a number of urological conditions, including medication refractory erectile dysfunction (ED). Complications encountered post-operatively include infection, bleeding/hematoma, and device malfunction. Since the 1970s, modifications to these devices have reduced complication rates through improvement in antisepsis and design using antibiotic coatings, kink-resistant tubing, lock-out valves to prevent autoinflation, and modified reservoir shapes. Device survival and complication rates have been investigated predominately by retrospective database-derived studies. This review article focuses on the identification and management of post-operative complications following penile prosthetic and implant surgery. Etiology for ED, surgical technique, and prosthesis type are variable among studies. The most common post-operative complications of infection, bleeding, and device malfunction may be minimized by adherence to consistent technique and standard protocol. Novel antibiotic coatings and standard antibiotic regimen may reduce infection rates. Meticulous hemostasis and intraoperative testing of devices may further reduce need for revision surgery. Additional prospective studies with consistent reporting of outcomes and comparison of surgical approach and prosthesis type in patients with variable ED etiology would be beneficial.

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.

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.