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.

Best practices for infection prevention in penile prosthesis surgery.

PURPOSE OF REVIEW: In this review, we synthesize the most current data on strategies for the prevention and reduction of infections in men undergoing penile prosthesis surgery. We highlight important strategies for preventing infections along every step from patient selection, to the preoperative, intraoperative and postoperative states. RECENT FINDINGS: Over the last decade, significant advances have been made to help minimize penile implant infections, with the most impactful likely being the introduction of antibiotic coated penile implants. Although this has led to infection rates lower than 0.5% being reported in some series, it appears that more virulent organisms are causing a larger share of infections. SUMMARY: The change in the microbiology and persistent occurrence of penile implant infections challenges us to develop strategies to target these organisms by using novel antibiotic mixes for irrigation, dips and implant coatings. Equally important is the continual search to identify patient risk factors for the development of infections and the further optimization of the use of oral and intravenous antibiotics. It is likely we will find inspiration by looking at nonurological surgical specialties where implantation of permanent devices is routine.

Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses.

BACKGROUND: Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature. AIM: To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections. METHODS: This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review. OUTCOMES: 26 patients (12%) with fungal infections were identified. RESULTS: 23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m2 (range 23.7-45 kg/m2; median 28.4 kg/m2), and that for diabetic patients was 30.8 kg/m2 (range 24.1-45 kg/m2, median 29.7 kg/m2). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation. CLINICAL IMPLICATIONS: More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients. STRENGTHS & LIMITATIONS: This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small. CONCLUSION: Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

A Surgeon's Guide to the Various Antibiotic Dips Available During Penile Prosthesis Implantation.

PURPOSE OF REVIEW: Inflatable penile prosthesis (IPP) is a treatment for erectile dysfunction. IPPs have undergone improvements; however, post-surgical infections still occur. Furthermore, the type of pathogens infecting the implants has changed recently from Gram-positive to Gram-negative bacteria and fungi due to advances in antibiotic dips targeting the skin flora. To protect against infection, the AMS 700 is pre-coated with InhibiZone (mixture of Rifampin/Minocycline) and the Coloplast Titan, with several antibiotic dip options of differing efficacies. This review discusses strategies to decrease the infection rates in implant surgery, focusing on antibiotic dips. RECENT FINDINGS: Current research endorses the use of rifampin/gentamicin as the most studied combination; however, some studies have utilized different dips for additional coverage including the InhibiZone on the AMS 700. With the increasing prevalence of diabetes and Gram-negative organisms, there is a need to develop strategies for increased coverage against infections. Controlled studies with different antibiotic combinations are needed to identify the ideal cocktail to decrease infection.

Infection Prevention Strategies Prior to Penile Implant Surgery.

CONTEXT: Over the last 4 decades, penile implant surgery has advanced significantly. Penile implant infection prevention continues to be an active area of research due to the significant patient morbidity associated with infection. OBJECTIVE: To summarize current approaches and supporting data for infection prevention. EVIDENCE SYNTHESIS: Common approaches to infection prevention include careful patient selection and preoperative evaluation, broad-spectrum antimicrobial prophylaxis, and modifications to surgical technique that minimize skin contact and postoperative hematoma formation. CONCLUSION: Many of these measures have proven efficacious, but our knowledge regarding the pathophysiology of penile prosthesis infection continues to evolve and demands continued efforts towards infection prevention.

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.

Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery?

INTRODUCTION: A preoperative negative urine culture is generally advised before implantation of urologic prosthetics to prevent device infection. However, a review of the medical literature indicates sparse evidence to support this practice. AIM: To describe outcomes for patients undergoing prosthetic implantation without preoperative urine cultures. METHODS: The cases of men undergoing artificial urinary sphincter (AUS) and/or inflatable penile prosthesis (IPP) placement at a tertiary care center from 2007 through 2015 were reviewed. Of 713 devices implanted in 681 patients (337 AUSs in 314 patients, 376 IPPs in 367), 259 cases without preoperative urine cultures were analyzed (41%). Patients received standard perioperative antibiotics. MAIN OUTCOME MEASURES: Device infection was diagnosed clinically. Average follow-up was 15 months. RESULTS: Device infection occurred in 4 of 259 patients (1.5%) with no difference noted in infection rate between device groups (AUS = 3 of 174 [2%]; IPP = 1 of 85 [1%]; P = .99); this rate appears to be consistent with the infection rate of numerous other published prosthetic series. Common skin organisms were implicated as the infectious agents in half the infected devices. Only one patient (0.4%) developed an Escherichia coli infection. CONCLUSION: This study suggests that prosthetic urologic surgery can be safely performed without preoperative urine cultures. Kavoussi NL, Viers BR, Pagilara TL, et al. Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery? Sex Med Rev 2018;6:157-161.

Colonización bacteriana de las prótesis de pene tras su retirada por fallo mecánico / Bacterial colonization of penile prosthesis after its withdrawal due to mechanical failure

Introducción: La cirugía protésica para el tratamiento de la disfunción eréctil tiene un riesgo de infección de hasta un 3%, pero este riesgo puede aumentar hasta un 18% cuando se trata de una cirugía de recambio. Este aumento del riesgo de infección se atribuye a la colonización bacteriana de las prótesis durante la primera cirugía. Objetivo: Analizar la presencia de gérmenes en las prótesis que se retiran por fallo mecánico (no infección), así como los resultados quirúrgicos y su evolución. Materiales y método: Estudio retrospectivo de todos los recambios realizados entre el año 2013 y el 2016 en un solo centro. Se analizan datos demográficos, tipo de prótesis previa, procedimiento quirúrgico, estudio microbiológico y evolución. Resultados: De 12 procedimientos de recambio se realizó un estudio microbiológico de la prótesis extraída en un total de 10 casos. De los 10 recambios, los cultivos resultaron positivos en 5 casos (50%). Staphylococcus epidermidis fue el germen mayoritario. Todos los pacientes se sometieron a un procedimiento de lavado y se implantó una prótesis recubierta de antibiótico. No registramos infecciones del nuevo dispositivo implantado tras un seguimiento medio de 27,33 meses (DE 4,13; IC 95% 18,22-36,43). Conclusión: En nuestra población a estudio objetivamos un alto índice de colonización bacteriana de las prótesis que se recambian por fallo mecánico. Tras realizar un procedimiento de lavado en el momento del recambio no objetivamos un mayor número de infecciones que lo descrito en casos vírgenes

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

Bacterial colonization of penile prosthesis after its withdrawal due to mechanical failure. / Colonización bacteriana de las prótesis de pene tras su retirada por fallo mecánico.

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.

Biofilm and Infectious Agents Present at the Time of Penile Prosthesis Revision Surgery: Times Are a Changing.

INTRODUCTION: Although infection rates have decreased with the use of antibiotic-coated implants and other enhancements, the risk of infection is still considered a serious concern in penile implant revision surgeries. AIM: To review the literature for advances made in inflatable penile prosthesis (IPP) revision surgery and organisms found at the time of revision, the significance of biofilm in prosthetic infection, and the bacteriology of infection. METHODS: PubMed was reviewed for articles spanning the past three decades that discussed micro-organisms and biofilm in relation to penile implant revision surgery. MAIN OUTCOME MEASURES: All articles were reviewed for evidence of bacteria found at revision IPP surgeries and any improvements made in surgical techniques and prosthesis enhancements. RESULTS: During the period examined, several improvements have lowered the rate of infection in penile implant surgery: notably, antibiotic-coated IPPs, revision washout, and alcohol-based skin preparations. The biofilm composition on clinically uninfected and infected IPPs appears to have changed over time. The abundance of staphylococcal species-particularly coagulase-negative organisms-in positive cultures has decreased in infected implants, and clinically uninfected implants also have shown a decrease in the proportion of staphylococcal species. Conversely, other isolates such as fungi, Escherichia coli, and Enterococcus species have increased in clinically uninfected and infected implants, and there has been an overall increase in unique isolates that form the biofilm. CONCLUSION: A multitude of enhancements has decreased the presence of micro-organisms and the subsequent formation of biofilm. Nevertheless, the formation of biofilm on penile implants has been noted more frequently in the past decade, and the microbial composition of biofilms seems to be changing. Dawn LE, Henry GD, Tan GK, Wilson SK. Biofilm and Infectious Agents Present at the Time of Penile Prosthesis Revision Surgery: Times Are a Changing. Sex Med Rev 2017;5:236-243.

Non-infected penile prosthesis cultures during revision surgery; comparison between antibiotic coated and non - coated devices

ABSTRACT 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.

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.

Active Polysubstance Abuse Concurrent With Surgery as a Possible Newly Identified Infection Risk Factor in Inflatable Penile Prosthesis Placement Based on a Retrospective Analysis of Health and Socioeconomic Factors.

INTRODUCTION: Since the introduction of inflatable penile prostheses (IPPs), risk of infection has decreased. However, concurrent substance abuse has not been investigated in prosthetic urology. AIMS: To determine whether substance abuse would stand out as a relevant risk factor for infection in patients undergoing IPP implantation. METHODS: This retrospective study was conducted on charts from the past 12 years at our institution, where a single surgeon completed 602 primary IPP surgeries, with only 12 cases (2%) resulting in postoperative infection. Five of these patients (42%) were actively misusing at least one substance at the time of operation (ie, alcohol, marijuana, cocaine, heroin, other illicit substances, and prescription narcotics). Substance abuse was identified in the medical chart by International Classification of Diseases, Ninth Revision code or by clear documentation by a provider. Multivariate logistic regression analysis was used to estimate the probability of infection as a function of demographic, physical, and treatment variables. MAIN OUTCOME MEASURES: Logistic regression analysis was used to determine statistically significant correlations between risk factors and IPP infection. RESULTS: Polysubstance abuse, poorly controlled blood sugar, and homelessness at the time of procedure positively correlated with postoperative infection. Use of the mummy wrap correlated with decreased infection. CONCLUSION: Active polysubstance abuse, poor glycemic control, and homelessness increase infection risk at IPP implantation. We encourage other implanters to discuss active polysubstance abuse with their patients and to tread cautiously because of the increased risk of infection.

The Mulcahy Salvage: Past and Present Innovations.

INTRODUCTION: Inflatable penile implants are a mainstay for the surgical correction of erectile dysfunction. For the last 40 years they have provided reliable outcomes with durable patient satisfaction. Infection of the implant continues to remain the primary surgical concern, despite the advent of antibiotic-coated devices and improved skin preparation solutions. METHODS: In this article, we review and evaluate the published literature for important contributions surrounding the various salvage techniques and washout strategies. In addition, the role of biofilm in prosthetic infection will be discussed. RESULTS: First described by Mulcahy for instances of device infection, the salvage or rescue procedure was established to avoid complete removal and staged replacement. This approach, with its avoidance of difficult revision surgery, penile shortening and patient discomfort, has produced success as high as 84%. CONCLUSION: Mulcahy's innovative approach at salvage or rescue reimplantation has proven to be a highly successful approach to this difficult surgical problem. Without question, the report of the long-term results of his salvage patients has directly influenced a generation of prosthetic surgeons.

Intravesical penile implant reservoir: case report, literature review, and strategies for prevention.

To present a case of intravesical erosion of an infected multiple-component inflatable penile prosthesis (IPP) reservoir. We retrospectively reviewed a case of complete intravesical erosion of an infected IPP reservoir. We also reviewed the prior urologic literature concerning bladder-related reservoir complications, and formulated potential strategies to prevent these complications in the future. This patient was successfully managed with complete explantation of the cylinders and pump, along with cystotomy, intravesical reservoir removal and cystorraphy. Several months later, he was successfully reimplanted with a multiple-component IPP, and, with 7 months follow-up, has had no further complications. Management of intravesical placement or erosion of an IPP reservoir should be tailored to the clinical scenario. In cases with peri-prosthetic infection and subsequent intravesical reservoir erosion, complete explantation and delayed subsequent reimplantation has been successful. Inadvertent intravesical reservoir placement has been successfully managed via immediate cystotomy, reservoir repositioning and cystorraphy. Reservoir insertion via a counter-incision, an infrapubic approach and under direct vision can avoid this complication. Bladder laceration during reservoir reinflation has been successfully managed with cystorraphy and reservoir repositioning.

Dilemmas of inflatable penile prosthesis revision surgery: what practices achieve the best outcomes and the lowest infection rates? (CME).

INTRODUCTION: When a clinically uninfected penile prosthesis has malfunctioned, removal of the broken prosthesis and simultaneous replacement with a new prosthesis is generally accepted as the treatment of choice. During prosthesis replacement, questions inevitably arise as to whether or not a washout of the implant spaces with saline or antiseptic solution should be undertaken. Since removal of the reservoir from the retropubic space is often challenging, the operating surgeon must decide whether to remove all the components or leave the reservoir in situ. AIM: To present strategies for optimal outcomes in inflatable penile prosthesis revision surgery. METHODS: We review the current literature to find evidence regarding indications and support for washout procedures, strategies to achieve the lowest infection rates, and the need for total vs. single prosthesis component removal at the time of revision surgery. For illustration, we present the case of a clinically uninfected, malfunctioning penile prosthesis that requires replacement. MAIN OUTCOME MEASURES: Survival from revision surgery for infection and medical complication based on published literature in peer-reviewed journals. RESULTS: Recent peer-reviewed publications were summarized for guidance in addressing the dilemmas of revision surgery. CONCLUSIONS: Penile prosthesis revision in a clinically uninfected patient has a higher infection rate than a first-time implantation. The combination of infection-retardant coated components, vigorous washout, proper preparation of skin incision site, use of perioperative antibiotics, and avoiding contact between the patient's skin and the implant will lower infection rates. Compared with single-component exchange, complete component removal appears to confer advantages related to future infection and malfunction. More work is needed to establish optimal strategies for handling reservoirs since clinical experience shows minimal risk of future infection in retained reservoirs.

Penile prosthesis infection: approaches to prevention and treatment.

Epidemiologic studies have estimated that more than 50% of men ages 40 to 70 have some form of erectile dysfunction. Penile prosthesis implantation remains a mainstay for treatment of erectile dysfunction unresponsive to other less-invasive methods. Improvements in penile prosthesis design have extended the long-term survival of implants. As the improved design of prostheses has led to their increased mechanical survival, other complications, such as infection, have emerged as the leading causes of implant failure. This article focuses on approaches to prevention and treatment of penile prosthesis infection.

Contemporary revision penile prosthesis surgery is not associated with a high risk of implant colonization or infection: a single-surgeon series.

INTRODUCTION: Revision penile prosthesis surgery has traditionally been associated with a greater risk of postoperative infection than primary implant placement. This has been attributed to the high prevalence of asymptomatic bacteria found surrounding the implant at the time of revision surgery. AIM: To validate whether contemporary revision surgery remains associated with a high risk of asymptomatic colonization and postoperative infection. METHODS: A comprehensive, prospective database consisting of consecutive patients undergoing primary and revision penile prosthesis surgery at our center was analyzed. MAIN OUTCOME MEASURES: The infection risk in primary and revision implant surgery was compared. The prevalence of asymptomatic implant colonization during revision surgery, and whether this was associated with clinical infection was evaluated. The spectrum of bacterial species causing infection in this contemporary single-surgeon series was described. RESULTS: One hundred seventeen primary and 72 revision implant recipients were studied. Infection developed in four (3.4%) patients undergoing primary implants, two (4.3%) patients undergoing removal and replacement for mechanical malfunction, and three (12%) patients undergoing rerouting for extrusion (P = 0.26). Intraoperative cultures were positive in 5 (9.8%) of 51 revision patients, none of whom developed infections. Organisms causing infection included Staphylococcus aureus and Enterobacter aerogenes. Unexpectedly, an adjuvant, alcohol-based skin prep in our last 83 patients reduced the infection risk to 1.2%. CONCLUSIONS: In our series, the infection risk associated with revision of malfunctioning devices was no greater than primary implant placement. Rerouting was associated with a higher infection risk, likely due to technical factors, and not implant colonization. Less than 10% of our revision implants were colonized, and this had no bearing on the development of a postoperative infection. S. epidermidis was not the most common organism implicated in device infections. Finally, our experience with an adjuvant, alcohol-based skin prep warrants further randomized prospective evaluation.

Isolated infection of a decommissioned penile prosthesis reservoir with Actinomyces neuii.

INTRODUCTION: Inflatable penile prostheses (IPPs) are a well-established and reliable treatment for medication refractory erectile dysfunction. The most serious complication with IPPs is infection, with the reported incidence after primary placement 1% to 3% and after revision surgery 8% to 18%. AIM: The aim of this report is to describe an infected decommissioned IPP reservoir with Actinomyces neuii with successful preservation of a functioning implant. METHODS: After 9 years of successful use with an IPP (AMS 700 CX) for Peyronie's disease and organic erectile dysfunction, a 79-year-old man underwent replacement with an AMS 700 LGX. The decommissioned reservoir was kept in the right prevesical space, and the new reservoir was placed in the left prevesical space. Three months later, he presented with right inguinal pain and swelling. RESULTS: He was found to have an infected right reservoir with A. neuii, sparing his new IPP. After removal of the right reservoir, he had an uneventful recovery and has shown no evidence of infection in the new device. CONCLUSION: Revision surgery for IPPs carries a higher risk for implant infection. This is the first report of a genitourinary implant infection with A. neuii. Aggressive surgical and medical treatment may allow preservation of the functioning implant, despite gross infection of the decommissioned reservoir.