A systematic review of penile prosthesis infection and meta-analysis of diabetes mellitus role

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.

A multicenter investigation examining timing of penile prosthesis infection management and responsible organisms

The purpose of this investigation was to examine the timing of penile prosthesis infection management by different responsible organisms. A retrospective cohort study was performed of patients who underwent penile prosthesis salvage or explant procedures due to a suspected infection between 2001 and 2018. The cohort consisted of 216 patients from 33 different facilities and six countries. The most common primary organisms responsible for device infections included, Gram-positives (31.5%), no growth cultures (30.6%), Gram-negatives (22.2%), fungal (11.6%), and anaerobic organisms (4.2%). Overall, median time to infection was 1.8 (interquartile range [IQR]: 1.0-3.0) months for all patients. Median time to infection management was similar between responsible organisms: 1.0 (IQR: 1.0-2.3) months for Gram-negatives and 2 months for Gram-positives (IQR: 1.0-1.4), fungal (IQR: 1.0-5.0), anaerobes (IQR: 1.0-2.5), and no growth cultures (IQR: 1.0-3.0, p = 0.56). Median time to infection management was significantly shorter among patients who received aminoglycoside/vancomycin prophylaxis (1.5 months, IQR: 1.0-2.5, p < 0.01) compared to other antibiotic groups. Median time to infection management was significantly longer for patients managed with a three-piece inflatable implant salvage procedure (2.8 months, IQR: 1.0-5.0, p = 0.02) compared to other salvage procedures. Conventional wisdom surrounding early versus late penile prosthesis infections should largely be abandoned. More than half of penile prosthesis infections are surgically managed within 2 months of initial device placement.

A propensity score-matched analysis of intra- and postoperative penile prosthetic complications in the solid organ transplant population

INTRODUCTION

Solid organ transplant (SOT) has an anticipated higher risk of penile prosthesis (PP) complications related to immunosuppression and surgical approach post-SOT. It is still not determined if PP surgery in the SOT population incurs these same higher risks.

OBJECTIVES

To observe differences in intra- and postoperative PP complications between SOT and non-SOT cases from the TriNetX US Collaborative Network, a large real-world database of deidentified patient data from 56 health care organizations within the United States.

METHODS

We used the TriNetX database to perform a propensity score-matched cohort study comparing 10-year outcomes between patients with and without a SOT (kidney, heart, lung, liver, pancreas, and intestine) who underwent a PP procedure. Cohorts were matched on age, race/ethnicity, history of pelvic and abdominal surgery, overweight and obesity status, type 2 diabetes mellitus, atherosclerosis, substance use disorders, socioeconomic difficulties, anticoagulant/antiplatelet medications, and spinal cord injury. Outcomes included intra- and perioperative complications as well as prosthetic complications (mechanical malfunction, fibrosis, displacement, hemorrhage, pain, stenosis, removal with or without replacement, and complex [all postoperative complications]).

RESULTS

There were 233 patients in each group after matching (SOT and non-SOT). The mean ± SD age at the prosthesis procedure was 59.7 ± 9.89 years, and 44% of patients were White (P > .05). There was no significant difference for incidence of intra- and perioperative complications (2.62% vs 2.19%, P = .76). The SOT group did not have a higher 10-year incidence of complex complications (30.58% vs 27.51%, P = .11) or mechanical malfunction (10.35% vs 11.62%, P = .25) when compared with the non-SOT group. No difference was found for other prosthetic-related complications (P > .05).

CONCLUSION

In our analysis, patients with a SOT were not more likely to experience long-term complications related to PP. Surgeons performing PP surgery in the SOT population may consider this procedure a potentially safe and viable option for restoring erectile function.

Successful Conservative Therapy for Infected Penile Implants: A Case Series

BACKGROUND Traditionally, penile implant infections have been treated by removal followed by immediate or delayed replacement. The use of antibiotics in conservative therapy has recently attracted attention. CASE REPORT We report our experience with 4 cases of infected penile implants managed conservatively. Case 1 was a 41-year-old with sickle cell anemia who presented with low-grade fever and purulent discharge that started 1 month postoperatively and lasted for 3 weeks. He had left graft after fibrotic tissue excision with 14-mm collection in the left corpus cavernosum. He was managed with IV pipracillin/tazobactam and vancomycin for 13 days. Follow-up after 23 weeks showed complete wound healing. Case 2 was a 62-year-old with diabetes who had purulent discharge that started 41 days postoperatively and lasted for 1 week. He received 5 days of IV vancomycin and gentamycin. Follow-up after 4 weeks showed marked improvement of the wound. Case 3 was a 61-year-old with diabetes and ischemic heart disease. He presented 30 days postoperatively with fever, purulent discharge for 5 days. He received a total of 10 days of IV vancomycin and gentamycin. Follow-up 3 weeks after discharge showed complete wound healing. Case 4 was a 61-year-old with diabetes and ischemic heart disease. He presented 1 month postoperatively with fever and pus discharge for 1 week. He completed 10 days of IV vancomycin and gentamycin. Follow-up after 1 week showed marked wound healing. CONCLUSIONS Choosing patients with early superficial infected penile prosthesis for conservative management should be tailored to selected patients who does not have leukocytosis, signs of sepsis, high-grade fever, or an exposed device.

Penile prosthesis in the medically complex patient: a narrative review

Background and Objective

Penile prosthesis surgery is considered a safe and effective treatment for patients with erectile dysfunction. Implantation in the medically complex patient can be a challenge. The benefits of treatment must outweigh the possible risks or complications. A description of possible problems and how to cope with them is given in this narrative review.

Methods

Literature search was performed in January 2023 using different search prompts in PubMed. These articles, excluding non-English and non-full text articles, were listed by the two authors and afterwards, the most relevant ones were included.

Key Content and Findings

This article is divided into five important topics. We evaluated different comorbidities such as spinal cord injury, diabetes mellitus and cardiovascular disease, in which preoperative work-up and counseling is of significant importance. A detailed description of these comorbidities and how to handle these can be found in each section. In addition to the preoperative aspect in organ transplant patients, problems during surgery can arise, e.g., with the reservoir placement. Similarly, in patients with previous pelvic surgery, an ectopic reservoir placement can prevent possible complications.

Conclusions

Preoperative diagnostics are crucial and prosthetic surgery should be done by an experienced high-volume surgeon with a diverse range of surgical techniques at his disposal.

Crohn's-related enterocutaneous fistula: a unique cause of penile prosthesis infection

Genitourinary manifestations are rare in patients with Crohn's disease, and a small percentage of patients will experience enterocutaneous fistulas. Infection is one of the most common complications associated with inflatable penile prosthesis placement, which can be associated with fistula formation. In this report, we present a patient with Crohn's disease who developed an inflatable penile prosthesis infection secondary to an undiagnosed enterocutaneous fistula.

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.

Penile prostheses harbor biofilms driven by individual variability and manufacturer even in the absence of clinical infection

BACKGROUND

Culture-based studies have shown that penile prostheses harbor biofilms in the presence and absence of infection, but these findings have not been adequately validated using contemporary microbiome analytic techniques.

AIM

The study sought to characterize microbial biofilms of indwelling penile prosthesis devices according to patient factors, device components, manufacturer, and infection status.

METHODS

Upon penile prostheses surgical explantation, device biofilms were extracted, sonicated, and characterized using shotgun metagenomics and culture-based approaches. Device components were also analyzed using scanning electron microscopy.

OUTCOMES

Outcomes included the presence or absence of biofilms, alpha and beta diversity, specific microbes identified and the presence of biofilm, and antibiotic resistance genes on each prosthesis component.

RESULTS

The average age of participants from whom devices were explanted was 61 ± 11 years, and 9 (45%) of 20 had a diagnosis of diabetes mellitus. Seventeen devices were noninfected, and 3 were associated with clinical infection. Mean device indwelling time prior to explant was 5.1 ± 5.1 years. All analyzed components from 20 devices had detectable microbial biofilms, both in the presence and absence of infection. Scanning electron microscopy corroborated the presence of biofilms across device components. Significant differences between viruses, prokaryotes, and metabolic pathways were identified between individual patients, device manufacturers, and infection status. Mobiluncus curtisii was enriched in manufacturer A device biofilms relative to manufacturer B device biofilms. Bordetella bronchialis, Methylomicrobium alcaliphilum, Pseudoxanthomonas suwonensis, and Porphyrobacter sp. were enriched in manufacturer B devices relative to manufacturer A devices. The most abundant bacterial phyla were the Proteobacteria, Actinobacteria, and Firmicutes. Glycogenesis, the process of glycogen synthesis, was among the predominant metabolic pathways detected across device components. Beta diversity of bacteria, viruses, protozoa, and pathways did not differ among device components.

CLINICAL IMPLICATIONS

All components of all penile prostheses removed from infected and noninfected patients have biofilms. The significance of biofilms on noninfected devices remains unknown and merits further investigation.

STRENGTHS AND LIMITATIONS

Strengths include the multipronged approach to characterize biofilms and being the first study to include all components of penile prostheses in tandem. Limitations include the relatively few number of infected devices in the series, a relatively small subset of devices included in shotgun metagenomics analysis, and the lack of anaerobic and other expanded conditions for culture.

CONCLUSION

Penile prosthesis biofilms are apparent in the presence and absence of infection, and the composition of biofilms was driven primarily by device manufacturer, individual variability, and infection, while being less impacted by device component.

Technological advances in penile implants: past, present, future

Attempts to "cure" erectile dysfunction (ED) are as old as recorded history. The history of penile prosthetic devices dates back over 500 years, when a French military surgeon designed the first known wooden prosthesis to support micturition. There have since been a great many technological advancements in penile prosthetics. Penile implants for the improvement of sexual function date to the twentieth century. Like all human endeavors, penile prosthesis innovations have progressed via trial and error. This review aims to provide an overview of penile prostheses for the treatment of ED since their introduction in 1936. More specifically, we aim to highlight important advances in penile prosthesis development and discuss dead ends that were abandoned. Highlights include two-piece inflatables, three-piece inflatables, and malleable/semirigid, along with modifications and updates to each basic design that improved both insertion and usability. Dead ends include innovative ideas that were lost to history due to a variety of factors. We also look to the future and discuss expected advances, including remotely activated devices and prostheses designed for special populations, including transgender men.

Corpus cavernosum abscess after Al-Ghorab shunt with Snake Maneuver for ischemic priapism treatment: Clinical and surgical treatments

Corpus cavernosum abscess is a rare condition that can lead to permanent and debilitating consequences. This case reports a 58-year-old man who developed erectile dysfunction with no response to oral and intracavernous medications after the surgical treatment of a penile abscess.

Management of urologic prosthetic reservoirs at the time of inguinal or pelvic surgery

INTRODUCTION

The artificial urinary sphincter and 3-piece inflatable penile prosthesis each require a fluid storage component and thus have components in the inguinal and pelvic regions. Because of this, patients with urologic prosthetics sometimes present challenges during future nonprosthetic operations. Presently, there is no established guideline for device management with ensuing inguinal or pelvic surgery.

AIMS

This article outlines concerns during pelvic and inguinal surgery for patients with an artificial urinary sphincter and/or inflatable penile prosthesis and proposes an algorithm for preoperative surgical planning and decision making.

METHODS

We conducted a narrative review of the literature on operative management of these prosthetic devices. Publications were identified by searching electronic databases. Only peer-reviewed publications available in English were considered for this review.

RESULTS

We review the important considerations as well as available options for operative management of these prosthetic devices during subsequent nonprosthetic surgery and highlight the advantages and disadvantages of each. Finally, we suggest a framework for helping surgeons determine which management strategy is most appropriate for their individual patients.

CONCLUSION

The best management strategy will differ depending on patient values, the planned surgery, and patient-specific factors. Surgeons should understand and counsel patients on all available options and encourage informed, shared decision making to determine the best individualized approach.

Salvage Case of Corpus Cavernosum Necrosis and Urethral Perforation associated with Infection after Penile Prosthesis Insertion

Penile prosthesis implantation can be considered in patients with unsuccessful treatment with phosphodiesterase type 5 inhibitors for erectile dysfunction. Its associated postoperative complications include infection and urethral injury. Nevertheless, only a few studies have reported the successful management of severe cases. Herein, we report a case of corpus cavernosum necrosis and distal urethral perforation caused by infection after penile prosthesis insertion, which had favorable outcomes. A 60-year-old man with multiple atherosclerotic risks underwent penile prosthesis implantation for erectile dysfunction at another hospital. Postoperatively, he developed infectious necrosis and underwent prosthesis removal. However, he presented at our department because of technical difficulties in the treatment at other hospitals. The initial examination revealed extensive necrosis of the corpus cavernosum and perforation of the peripheral urethra. A thin urethral catheter was inserted, and the necrotic corpus cavernosum was debrided to preserve the artery and urethra. Then, the perforated urethra was sutured. Subsequent negative pressure wound therapy resulted in sufficient granulation and closure of the perforated urethra. One month after the surgery, the scar was resected and sutured following the circumcision line. Despite experiencing this severe postoperative complication, good functional and cosmetic outcomes were achieved after minimal surgery with a blood-flow-conserving method.

The management of erectile dysfunction in men with diabetes mellitus unresponsive to phosphodiesterase type 5 inhibitors

INTRODUCTION

Erectile dysfunction is associated with diabetes mellitus with an estimated prevalence of 52.5% in the diabetic population. The first-line therapy for erectile dysfunction is phosphodiesterase type 5 inhibitors, but data suggest that diabetic men may be less responsive than non-diabetic men. Thus, other treatments, including intracavernosal injections, intraurethral prostaglandin, vacuum erection devices and penile prosthetic surgery, should be considered in management of diabetic men with erectile dysfunction refractory to phosphodiesterase type 5 inhibitors. Furthermore, combination therapy of phosphodiesterase type 5 inhibitors and other oral treatments such as arginine or l-carnitine may have synergistic effects resulting in better outcomes. In addition, there are novel therapies such as low-intensity shockwave therapy and stem-cell therapy, which may also be effective in targeted treatment modalities. Furthermore, studies suggest that erectile dysfunction can be improved by targeting concurrent comorbidities or metabolic diseases such as depression, hypertension, hypogonadism, and dyslipidaemia. We present an evidence-based narrative review focusing on the management of erectile dysfunction in diabetic men who have not responded to phosphodiesterase type 5 inhibitors.

CONCLUSIONS

Both clinicians and patients should be aware of the different management options in diabetic patients who have not responded to phosphodiesterase type 5 inhibitors.

Prosthetics in urology: Current status and future directions

The field of genitourinary prosthetics has evolved rapidly to become the standard of care for conditions such as incontinence and refractory erectile dysfunction. Its scope has expanded to encompass newer indications such as Peyronie's disease and gender-affirming surgeries. This review, based on the Urological Society of India's Best Essay Award 2022, aims to elaborate on the advances in the field of urological prosthetics in the past 20 years as well as to provide an insight into ongoing research and what one can expect to see in the next decade, particularly in the area of penile and testicular prosthetics as well as treatment of incontinence. A PubMed and patent search was performed to achieve these objectives. Future considerations include improving acceptance, reliability, making them more accessible for developing countries and improving training and education to improve outcomes.

Outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus: A subgroup analysis

OBJECTIVES

To estimate the surgical and quality-of-life outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus (DM). Subanalyses were performed using the same population as that in our previous multicenter, prospective, observational study.

METHODS

A total of 135 male patients who underwent primary artificial urinary sphincter implantation were divided into two groups: those with and without DM. The revision-free rates, that is, the percentage of patients who did not require revision surgery, were compared between patients with and without DM. The number of urinary pads required per day, International Consultation on Incontinence Questionnaire-Short Form, and King's Health Questionnaire were used to compare the continence status and quality of life (QOL) between the two groups preoperatively and at 1, 3, and 12 months after surgery.

RESULTS

Revision-free rates were significantly lower in the DM group (83.9%, 77.4%, and 67.8% at 1, 2, and 3 years after implantation, respectively) than in the non-DM group (95.5%, 92.5%, and 85.5% at 1, 2, and 3 years after implantation, respectively). Both continence status and QOL, assessed by questionnaires, markedly improved after surgery in patients with and without DM.

CONCLUSIONS

Despite differences in the durability of the artificial urinary sphincters, patients with DM can obtain as much benefit from artificial urinary sphincter implantation regarding continence and quality-of-life improvement as patients without DM. Therefore, DM was not considered a comorbidity that contraindicated artificial urinary sphincter implantation. Additional large-scale studies are required to verify our findings.

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 surgery-managing complications

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

Practical Considerations in Inflatable Penile Implant Surgery

BACKGROUND

Penile prosthesis implantation remains an effective solution for men with medical-refractory erectile dysfunction (ED) following radical pelvic surgery. Despite the distortion of pelvic anatomy, a penile implant can be performed with excellent clinical outcomes provided strict patient selection, proper preoperative workup and safe surgical principles are adhered to.

AIM

To provide practical recommendations on inflatable penile prosthesis (IPP) implantation in patients with medical-refractory ED, with an emphasis on patient selection and counselling, preoperative workup as well as surgical considerations to minimize intraoperative complications.

METHODS

A Medline search on relevant English-only articles on penile prostheses and pelvic surgery was undertaken and the following terms were included in the search for articles of interest: "bladder cancer", "prostate cancer", "rectal cancer", "pelvic surgery" and "inflatable penile implant".

OUTCOMES

Clinical key recommendations on patient selection, preoperative workup and surgical principles.

RESULTS

Patients should be made aware of the mechanics of IPP and the informed consent process should outline the benefits and disadvantages of IPP surgery, alternative treatment options, cost, potential prosthetic complications and patient's expectations on clinical outcomes. Specialised diagnostic test for workup for ED is often not necessary although preoperative workup should include screening for active infection and optimising pre-existing medical comorbidities. Precautionary measures should be carried out to minimise infective complication. Corporal dilation and reservoir placement can be challenging in this group, and surgeons may require knowledge of advanced reconstructive surgical techniques when dealing with specific cases such as coexisting Peyronie's disease and continence issue.

CLINICAL TRANSLATION

Strict patient selection and counselling process coupled with safe surgical principles are important to achieve excellent linical outcomes and patient satisfaction rates.

STRENGTHS AND LIMITATIONS

This masterclass paper provides an overview of the practical considerations for men who are undergoing IPP surgery following radical pelvic surgery. Limitations include the lack of highquality data and detailed surgical description on each surgical troubleshooting steps for various prosthetic-related complications.

CONCLUSION

The IPP implantation can be performed efficiently and safely in patients following radical pelvic surgery. Chung E, Mulhall J. Practical Considerations in Inflatable Penile Implant Surgery. J Sex Med 2021;18:1320-1327.