Local Treatment of Penile Prosthesis Infection as Alternative to Immediate Salvage Surgery
Saturnino Luján, MD, PhD; Ramón Rogel, MD; Enrique Broseta, MD, PhD; Francisco Boronat, MD, PhD
ONLINE: July 2016 (Article in Press) – Sexual Medicine
DOI: http://dx.doi.org/10.1016/j.esxm.2016.06.002
Introduction and Goal
While most implantations of inflatable penile prostheses (IPP) go smoothly, a percentage of cases develop infections. Some men, such as those with immune- compromising conditions, may be more prone to infection.
Typically, such cases are treated in one of two ways. First, the prosthesis can be removed and a new device implanted in three to six months. However, fibrotic tissue can make reimplantation difficult, and satisfactory outcomes may be diminished. The second method is salvage surgery, which involves removing the infected device, cleaning the wound, and implanting a new prosthesis. While this technique is able to salvage the majority of cases in appropriately selected individuals, patients are still at a higher risk for infection compared to those who undergo primary surgery.
Prior studies have also shown that biofilm or positive bacterial cultures from the implant are present in up to 70% of men who undergo revision IPP surgery and do not have infected devices. It’s possible that tissues can heal over the infected devices, which could allow for treatment without IPP removal.
This study investigated such an alternative and described two cases of local scrotal infection after IPP implantation.
Method
The procedure included the following steps:
1. Patients were given general anesthesia.
2. Thirty minutes before incision, they received an intravenous combination of Tobramycin, amoxicillin, and clavulanate potassium.
3. Patients were scrubbed and prepared for surgery.
4. A circular incision was made around the open part of the primary infected incision.
5. All devitalized tissue around the pump was removed.
6. A high pressure pulsated lavage was used to irrigate the area with a combination of vancomycin, half-strength hydrogen peroxide, and half-strength povidone iodine.
7. A multilayered surgical closure was performed with an aspiration drainage tube in place for 24 hours.
8. Intravenous antibiotics were administered.
9. Patients were discharged 24 hours after the procedure and continued taking amoxicillin and clavulanate for the next ten days.
Results
The following table describes some characteristics of each patient:
| Patient A | Patient B | |
|---|---|---|
| Age | 44 | 51 |
|
Time between IPP implantation and infection |
3 weeks | 8 weeks |
| Type of IPP | AMS 700 IPP with InhibiZone | Coloplast TITAN IPP |
| Diabetes status | Type 1 | Type 1 |
| Bacteria found | Staphylococcus aureus | Staphylococcus epidermidis |
| Total resolution of symptoms | In 20 months | In 36 months |
Both patients had a clear discharge with about 25% of the device exposed. Neither patient had pain or tenderness in the scrotum, and neither had systemic or septic symptoms. Each patient took antibiotics for two weeks after presentation of symptoms. When the medications did not bring improvement, they decided to move forward with surgery.
Discussion
The authors explained that IPP infection presents in two ways. The first is local, as was the case with these patients. Other patients may have a fever along with a swollen scrotum draining purulent material. The latter patients would not be a candidate for this type of treatment and would be managed differently.
They also pointed out the cost effectiveness of the alternative approach. They estimated that the cost of treating an infected IPP in one of the traditional ways could be more than 6 times the cost of the original implant. With the alternative method, the cost of a new device is avoided.
Still, more research is needed. “We present this alternative as an emerging possibility that needs to be confirmed with larger series that try to keep the prosthesis in place,” the authors wrote. They added that only a few studies have reported on cases of “conservative treatment” instead of complete removal or salvage procedures.
The approach could be viable for men with local IPP infections and nonpurulent symptoms, they said, but not for men with systemic infections. If this approach was not successful in certain cases, total removal or salvage surgery would still be options.