Inflatable penile prosthesis and salvage protocol for mechanical failure: is it really necessary?

Efficacy and safety of malleable penile prosthesis compared to inflatable penile prosthesis in erectile dysfunction patients

INTRODUCTION

Erectile dysfunction can cause self-withdrawal and decreased quality of life. Patients who do not respond to pharmacological therapy and other conservative treatments are urged to undergo penile prosthesis implantation. Malleable penile prosthesis was the first prosthesis developed, but then inflatable penile prosthesis was developed to give a more natural erection. There is no meta-analysis comparing inflatable and malleable penile prostheses in terms of safety and efficacy. This study is conducted to evaluate patient and partner satisfaction, ease of use, mechanical failure, and infection rate in patients who underwent penile prosthesis implantation.

METHOD

This meta-analysis followed Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) protocols. Five eligible studies were included from Pubmed, Scopus, ScienceDirect, and SemanticScholar databases.

RESULT

In this study, patient and partner satisfaction are significantly better (OR 3.39, 95% CI 1.66-6.93, p = 0.0008) (OR 2.32, 95% CI 1.75-3.08, p < 0.00001). Mechanical failure is also significantly higher in inflatable penile prostheses (OR 5.60, 95% CI 2.02-15.53, p = 0.0009). There is no significant difference in terms of ease of use and infection rate in inflatable or malleable penile prostheses.

CONCLUSIONS

This study concluded that inflatable penile prosthesis is better in terms of patient and partner satisfaction, but mechanical failures occur more frequently in this type of prosthesis.

Intraoperative and postoperative complications of penile implant surgery. Diagnosis and treatment

We describe the most frequent complications associated with penile implant surgery, paying special attention to their practical management. We have analyzed preoperative complications and postoperative complications separately. The intraoperative include perforation of the corpora cavernosa during dilation, cylinder cross-over or cross-placement and urethral injury during implantation. The most frequent postoperative complications are mechanical failure, cylinder erosion and prosthesis infection. We emphasize on rescue surgery and reimplantation techniques in cavernous tissue fibrosis.

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.

Retropubic Dilation With a Foley Catheter Balloon: A Novel Technique for Penile Prosthesis Reservoir Placement

Background: The 3-piece inflatable penile prosthesis was introduced in 1973 as a treatment for men with erectile dysfunction. Consisting of 2 corporal cylinders, 1 pump, and a fluid-filled reservoir, the prosthesis is placed by blunt dissection into the retropubic space. The dissection for the reservoir is performed blindly into a space juxtaposed with nerves, vessels, and the bladder.

Objective: To propose a novel approach for inflatable penile prosthesis reservoir placement involving gentle dilation of the retropubic space using a Foley catheter balloon.

Methods: Patient medical records from 1 surgeon were reviewed. Patients did not have a history of pelvic surgery or prostatectomy. Each implant was approached using a penoscrotal incision, and the retropubic space was dilated with a 30-mL Foley catheter balloon filled to 100-mL capacity before reservoir placement. The postoperative visits were examined for complications, including reservoir infection and herniation. A literature search of penile prosthesis reservoir placement technique and complications (eg, herniation, infection) of reservoir placement was also performed.

Results: Fifteen patient records were examined. The reservoir herniation rate was 0% and the infection rate was 7%. The average reservoir herniation rate is reported to be 1% to 3%, and the average infection rate is reported to be 1% to 5%.

Conclusion: The use of a Foley catheter balloon is a safe, atraumatic, cost-effective, and easily performed method of dilating the retropubic space for subsequent inflatable penile prosthesis reservoir placement.

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.

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.

National trends in the treatment of penile prosthesis infections by explantation alone vs. immediate salvage and reimplantation

INTRODUCTION

A penile prosthesis infection (PPI) is either treated with explantation of the prosthesis with a possible delayed reimplantation or a salvage procedure with an immediate reimplantation of the prosthesis.

AIM

We used a large, all-payer national database to investigate the use of the salvage procedure in the setting of PPI.

METHODS

The study used years 2000-2009 of the Nationwide Inpatient Sample to identify PPIs treated with immediate salvage or explantation alone. Admissions were then stratified by various parameters to compare differences in the salvage rates.

MAIN OUTCOME MEASURES

Salvage Rate of Penile Prosthesis infection.

RESULTS

A total of 1,557 patients were treated with an explantation only (82.7%) or salvage (17.3%) for PPI, a proportion that remained stable over the study period. The patients treated with salvage were younger (60.4 vs. 65.1 years), more likely to be discharged home (87.3% vs. 61.9%), and were less likely to have a severe presentation (7.2% vs. 31.6%) than those who were explanted only (P < 0.001). These factors were confirmed on multivariate regression analysis. The regression also revealed that treatment at rural hospitals had lower odds of salvage than treatment at urban teaching hospitals. Race, comorbid diabetes, and insurance status did not independently affect the salvage rate. There was no significant difference in total hospital charges between groups.

CONCLUSIONS

Salvage rates have remained low over the past decade. Our study elucidated several factors decreasing the chances of salvage after PPI including age, severity of presentation, and hospital setting.