1. Penile prosthesis implantation can effectively treat both penile deformity and erectile dysfunction from Peyronie's disease, with high success and satisfaction rates. However, prosthesis infections remain a concern. 2. Risk of infection can be reduced through proper patient selection and preparation, use of antibiotic-coated devices, adherence to surgical protocols like restricted OR traffic and appropriate skin preparation and draping, and post-operative wound care measures. Perioperative antibiotics are also recommended. 3. While no method can completely prevent infection, these evidence-based practices aim to lower the risk to less than 1%, avoiding severe consequences of prosthesis removal and re-implantation that can result from device infections

1. ERECTILE RESTORATION: SURGICAL
Peri-operative management and guidelines
Esther García Rojo
Madrid, Spain
@rojo_esther

2. INTRODUCTION
• It can correct both the penile deformity and erectile
dysfunction.
• This procedure has demonstrated an excellent success rate
and low morbidity; and, high rates of patient satisfaction
have been achieved.
Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction. CC Carson. International
Journal of Impotence Research(2000)12,Suppl4,S122±S126
• Peyronie ´s disease (PD): increased incidence of penile veno-occlusive abnormalities
accompanied by erectile dyfunction (ED).
• Straightening procedures may not restore erectile function.
• Penile prosthesis (PP) is an established treatment option for men with PD and ED.

3. Safe, but….

5. With a standardization of surgical technique and
improvement in device construction complications
have been reported in fewer than 5% of cases!
Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of
efficacy, satisfaction profile and complications. G Antonini et all. International Journal of Impotence
Researchvolume 28, pages4–8 (2016

6. considered hematogenous infection less common
and believed bacterial biofilm may allow infection
to be quiescent for many years before clinical
demonstration. The experience of Fishman et al6
demonstrated that 56% of prosthesis infection
occurred within 7 months of implantation, 36%
between 7 and 12 months, and only 2.6% after 5 y.
fungal and myc
infections in pro
case of bilateral
Candida albican
remote fungal
Candida albican
of infections; Ne
cases of penile
Neisseria gonorr
Risk factors f
Risk factors that
incidence includ
Prolonged hospi
Table 1 Reported incidence of penile prosthesis infection3
Decade Studies Patients % Infection
1970 4 484 2.1
1980 24 6264 2.4
1990 11 3371 3.7
Multicenter study 372 3.2
CCCarson
S140
• Virgin Cases 1-3%  0-1%
• Revision Cases 7-18%  3-4%
• Best published results:
• Henry, AUA 2014 - Propper Study: 0/466
• Eid, Urology 2012 - 0.46%
Schwartz B et al J Urol 1996; 156: 991 – 994.

7. The best chance for success is first IPP…
• Each subsequent surgery has higher risk of infection and
complication.
Percentage of patients developing an infection based on the IPP device number (Pearson
Correlation Coefficient R²=0.90, p=0.01).

8. •Good selection of patient. Realistic expectations!
•Proper selection of the prosthesis
•Planning the surgery
•Surgeon preferences

9. PATIENT`S SELECTION
• Explain the risks and rewards. Not every conceivable complication has to
be outlined but you should discuss the risk of infection (less than 1%) and
the risk of mechanical breakage (less than 30% in 15 years)
• Identify patients with preexisting psychosocial variables that can
negatively affect operative success and long-term satisfaction.
• Important good glycemic control in diabetic patients (Glycosilated
hemoglobine)
• Good indication: Patients with PD and ED.
The patient should either be contraindicated from trying oral
tretaments, have tried and not responded or have concerns
about the side effects.

12. PREOPERATIVE MEASURES
• Document steril urin. If not: treat it.
• No skin infection near the surgical site.
• Avoid multiple surgical procedures at the time of implantation
• Inspect patients for and express any scrotal sebaceous collections well before
they have a chance to contaminate
Delayed postoperative or intraoperative antibiotics are less
effective than those given in the 2 hours before the surgery
PJ Muench. Infections versus penile implants: the war on bugs. J. Urol;2013:189:1631-1637
• Have patients shower/wash the genital area in the morning of surgery

14. OPERATING ROOM CONSIDERATIONS
• Traffic in and out the OR schould be restricted to decrease the chances of settled
contaminants becoming airborne
• Laminar flow rooms
• Shaving schould be done on the OR table immediately before the procedure
• Recognize the distal urethra flora as a sorce of possible wound contamination.
Squirting 2 ml or less povidone-iodine solution into the urethra
• Irrigate copiously (2-3 L) during the procedure
Mulcahy JJ et al JSM 2004;1:98
2. Darouiche RO et al. N Engl J Med 2010; 362:18

15. Oxford Level of Evidence for IPP Infection
• There is no demonstrated benefit of pre-operative chlorhexidine scrub or detergent scrub for several days leading
up to surgery
• HIV Status does not increase risk of infection.
• No difference in infection using surgical site hair removal vs. no hair removal.
• Per SMSNA, either clippers or razors are acceptable at the surgeon’s discretion.
Level 1: Factors associated with decreased surgical site infections
• It is worth noting that most evidence below comes from non-urologic, non IPP surgical literature
• Smoking Cessation at least 4 weeks prior to surgery
• Operative Site Scrub: Chlorhexidine-alcohol based prep is superior to povidone-iodine preparation of soap &/or painted
solution
Level 1: Factors associated with no change in surgical site infections

16. • 10-minute traditional hand scrubbing vs. 90 second application of Chlorhexidine scrub or
alcohol based waterless solution (e.g. Avagard® or Sterilium®).
Level 2: Factors associated with no change in surgical site infections
Oxford Level of Evidence for IPP Infection

17. Choose the best skin prep.
Dorouiche et al. (2010) reproted that cleaning the
skin before surgery with chlorhexidine-alcohol rather
that the standart povidone-iodine resulted in 40%
fewer SSI
2.Darouiche RO et al. N Engl J Med 2010; 362:18
TOPICAL SCRUB OF THE GENITAL AREA

20. ...to drain or not to drain -that is the question!
425 patients underwent primary
implantation with a inflatable
penile prosthesis (Mentor alpha 1
or AMS 700)
three medical centers in
New Jersey,
Arkansas, and Ohio
all patients received a 10
French closed-suction drain
Round Blake or Jackson Pratt
The mean follow-up was
18 months with a range
of 12–36 months
Overall, there were 14 (3.3%)
infections and 3 (0.7%)
hematoma
during follow-up period
closed-suction drainage of the scrotum for 12–24h following
penile prosthesis surgery does not result in increased infection
rate and is associated with a very low incidence of postoperative
hematoma formation, swelling, and ecchymosis

21. • Diabetes. Conflicting data whether HGB A1C level or fasting blood sugar predictive.
• Spinal cord injury.
Level 3: Factors associated with no change in surgical site infections
• Radiation.
• Obesity.
• Concomitant circumcision.
• Immunosuppression. There is conflicting published evidence but one can summarize that chronic use of
immunosuppression for disease control may have increased risk of device infection but transient use of these drugs
for transplant coverage does not.
• Post-operative drain placement.
Oxford Level of Evidence for IPP Infection
Level 3: Factors associated with increased surgical site infections

22. The Henry „Mummy Wrap“
• A mummy wrap is applied to decrease swelling and promote healing
• Scrotum is elevated in a “broccoli stalk” fashion, making sure both testicles and the pump are pulled up
• Typically, the dressing is removed the next day

23. Level 2: Factors associated with decreased surgical site infections
• Treatment of Staph aureus in nares with mupirocin combined with chlorhexidine scrub for 5 days prior
to surgery.
• Infection retardant coated implants
• IPP coated with specific antibiotics (minocycline/rifampin, rifampin/gentamicin &
Trimethoprim/sulfamethoxazole) is superior to use of vancomycin/gentamicin, and other antiseptic
coatings.
• Peri-operative Antibiotics – The AUA Guidelines recommend the use of antibiotic prophylaxis including
aminoglycoside with either vancomycin or a 1st/2nd generation cephalosporin for 24 h.
Oxford Level of Evidence for IPP Infection

24. Hydrophilic Coating
Fig. 1 Titan Touch implant
should be placed into the
standard antibiotic solution
(for less than 1 minute)
Fig. 2 allows surgeon to
maintain current device
preparation and soak the
device in the solution of
choice
Tailor the dip to the clinical
situation. Hydrophilic coating allows
an absorbtion of the physician´s
choice of antibiotic agents
Coated Titan zone of inhibition
exceeded Inhibi ZoneTM by 56% for
S. Epidermidis & 33% for E. coli
(Dhabuwala, CB. J Sex Med 2/2011)
Current recomended dips:
Rifampin/Gentamicin
Infusion TMP-SMX
All components including RTE and
connectors elute drug
Authority D. Osmonov

25. Perioperative antibiotics
Cephalosporins and flouroquinolones have been shown to be effective in most perioperative settings
Perioperative antibiotics are effective only in the immediate preoperative time
Antibiotic agents must be administered 1–2h prior to surgery since those agents begun
intraoperatively or postoperatively are less likely to be effective in preventing wound infection
Elimination of preoperative antibiotics and a shortened interval between perioperative antibiotic
administration and surgical procedures has the added advantage of decreasing the emergence of
multiple drug-resistant bacteria Schwartz B et al J Urol 1996; 156: 991 – 994.
Classen DC et al. N Engl J Med 1992; 326: 281 – 286.

26. Level 2: Factors associated with decreased surgical site infections
• Treatment of Staph aureus in nares with mupirocin combined with chlorhexidine scrub for 5 days prior
to surgery
• Infection retardant coated implants
• IPP coated with specific antibiotics (minocycline/rifampin, rifampin/gentamicin &
Trimethoprim/sulfamethoxazole) is superior to use of vancomycin/gentamicin, and other antiseptic
coatings
• Peri-operative Antibiotics – The AUA Guidelines recommend the use of antibiotic prophylaxis including
aminoglycoside with either vancomycin or a 1st/2nd generation cephalosporin for 24 h
Oxford Level of Evidence for IPP Infection

27. Prosthesis-associated infections often result
in:
• removal of the device
• severe disability
• loss of function
• loss of tissue
• difficulty with subsequent implantation
• It has been estimated that the cost of treating infected penile
prostheses exceeds the cost of the original prosthetic implant by more
than six-fold
Montague DK, Angermeier KW, Lakin MM. Penile prosthesis infection. Int J Impot Res 2001; 13: 326 – 328)

28. Antibiotic choices and Salvage approaches
• Antibiotic selection
• Retrospective multi-institution study, 25 centers
• 227 cultures obtained at salvage or explant
• 153 cultures positive
Gross MS et al. J Sex Med 2017.
Cultured Organisms
Number of
Cultures Total %
Positive cultures 153/227 67%
Gram positives 111/153 73%
Gram negatives 60/153 39%
Candida 17/153 11.1%
Anaerobes 16/153 10.5%
MRSA 14/153 9.2%
Negative cultures 74/227 33%
• FINDINGS:
– Candida and anaerobes total 22% of positive
cultures at salvage and explant
– Current recommended regimens do not cover
candida and anaerobes or MRSA adequately

29. Mulcahy Salvage
• Revolutionized infection management
• A technique born out of necessity and
chance
• 82% infection-free rate
• Minimizes loss of penile size and
fibrosis
• Decreases sexual inactivity
• Avoids difficult reimplantation
Mulcahy JJ. J Urol 2000.
Mulcahy JJ. Curr Urol Rep 2010.

30. IPP Salvage
• Uncommon use in practice
• Estimated 17.3% salvage rate in USA1
• More common in academic centers, younger
patients
• Suggests an easier, safer alternative is needed
• Very few studies since original paper 1. Zargaroff, S et al. J Sex Med 2014.
2. Gross MS et al. J Urol 2015.
Malleable Implant Salvage Technique
• Improved infection-free rate with malleable vs. Mulcahy salvage2 (93%
vs. 82%)
• Feasible to convert malleable to IPP (31%)
• Many patients elect to keep malleable
Mulcahy Salvage Technique

31. Salvage Wilson
Mini Washout
(Hydrogen peroxide-betadine)
Salvage operation
Steps as Performed
by Dr. Wilson
1. Remove infected prosthesis
2. Irrigate 2 corporal spaces, reservoir space and pump space with the
following solutions – one full bulb syringe in each space – i.e. 4 syringes
of each solution – one in each of the four spaces – total 28 syringes of
fluid.
a. Diluted hydrogen peroxide (1 bottle H2O2 in 500 cc of saline)
b. Diluted Betadine (1 bottle Betadine in 500 cc of saline)
c. Physician’s regular antibiotic solution – 500 cc
d. Mixture of 1G Vancomycin, 80 mg Gentamicin in 500 cc saline
e. Repeat a.
f. Repeat b.
g. Mix “c” and “d” solutions and irrigate 4 spaces until all gone
3. Change gloves, drapes, and instruments

32. closed-suction drainage of the scrotum for 12–24h is associated with
a very low incidence of postoperative hematoma
delayed postoperative or intraoperative antibiotics are less effective
than those given in the 2 hours before the surgery
Shaving the SS schould be done on the OR table immediately before the
procedure
IPP infection remains a problem and requires further study
Provider discussion with patients about salvage options and prolonged
antibiotics in certain cases is imperative
Consider standardizing processes and adjusting antibiotics (anti-
fungals etc.) based on new literature

33. Thank you!