The Association Between Hemoglobin A1c Levels and Inflatable Penile Prosthesis Infection: Analysis of US Insurance Claims Data

Chlorhexidine gluconate application, diabetes, revision surgery, and extended operative time increase risk for penile implant infection

BACKGROUND

Chlorhexidine gluconate (CHG) (0.05%) has recently been suggested as a dip and irrigation solution at time of inflatable penile prosthesis (IPP) surgery.

AIM

This study evaluated infection rates before and after implementing CHG protocol while investigating concurrent risk factors contributing to post operative infections.

METHODS

A retrospective, consecutive cohort study was performed that included patients who underwent insertion of a Coloplast Titan IPP including both virgin and revision cases between 2021 and 2024. Cases performed from January 2021 to August 2022 utilized rifampin/gentamicin for dip and vancomycin/gentamicin for irrigation (ABX), whereas those from October 2022 to May 2024 utilized CHG for both dip and irrigation. Perioperative risk factors including dip and irrigation solution used at time of surgery were compared between groups.

OUTCOMES

We defined the incidence of postoperative infection and risk factors associated with infection in each group.

RESULTS

The incidence of infection was significantly higher in the 0.05% CHG group (13/377) compared to the ABX group (0/320) (P < .001). When analyzed separately by subgroup, virgin cases treated with CHG for dip and irrigation demonstrated a significantly higher infection rate (7/315) compared to those in the ABX group (0/280) (P = .012). Similarly, in revision cases, the CHG group also exhibited a significantly higher infection rate (0/40) than the ABX group (6/62) (P = .043).Univariable analysis of the CHG cohort identified three significant risk factors for infection: diabetes mellitus (DM), extended operative time (OP), and revision surgery (P = .003, .001, and < .001, respectively). Multivariable regression analysis revealed that patients with DM had a 5.7-fold increased risk of infection (OR: 5.70, P = .004), while those undergoing revision surgery faced a 5.3-fold higher risk (OR: 5.26, P = .004). Additionally, each minute increase in OP was associated with a 1% higher infection risk (OR: 1.01 per minute, P = .007). These associations remained significant after adjusting for all variables in the model.

CLINICAL IMPLICATIONS

Prosthetic surgeons should be cautious about adopting 0.05% CHG for both dip and irrigation in the absence of strong clinical evidence demonstrating its non-inferiority to antibiotic solutions.

STRENGTHS AND LIMITATIONS

This is the first clinical study reporting infection rates after IPP surgery using 0.05% CHG for both dip and irrigation. While retrospective and non-randomized, we present a relatively large sample size of patients.

CONCLUSIONS

Our findings identify four risk factors for penile prosthesis infection: usage of the 0.05% CHG solution for dip and irrigation solution of Coloplast hydrophilic-coated devices, DM, revision surgery, and extended OP.

Therapeutic management of erectile dysfunction: The AFU/SFMS guidelines

CONTEXT

Erectile dysfunction (ED) is a common sexual disorder. In France, recent evidence-based guidelines are lacking.

AIM

To provide practice guidelines on ED therapeutic management.

EVIDENCE ACQUISITION

Publications indexed in PubMed/Medline® between January 1999 and October 2023, were reviewed. For each clinical question, a level of evidence was attributed to the conclusions. These conclusions and the working group arguments were used to develop and grade (A-C) the recommendations.

RECOMMENDATIONS

ED management must be personalized. Phosphodiesterase 5 inhibitors (PDE5I) are recommended as first-line treatment (A). In patients with severe ED, a combination of PDE5I may be proposed as first- or second-line treatment (Expert Agreement, EA). Extra-cavernous or intra-urethral injections of alprostadil may be offered as first-line alternative to PDE5I or as second-line treatment (B). In case of unsatisfactory response to PDE5I or alprostadil alone, the combination of a PDE5I with intra-cavernosal or intra-urethral alprostadil may be proposed (EA). Vacuum therapy can be offered to all patients (B). Low-intensity extracorporeal shockwave therapy may be proposed to patients with mild or moderate ED, alone or in combination with PDE5I (B). Penile implants are indicated for patients with ED who are refractory or intolerant to pharmacological or mechanical treatments, or if they wish a permanent solution (B). Revascularization surgery may be offered to patients without comorbidities following pelvic trauma and ED with isolated arterial insufficiency (B). In addition to pharmaceutical, mechanical and/or surgical treatments, it is suggested to always consider educational interventions and counseling, lifestyle modifications and management of co-morbidities and curable causes.

Risk factors for reoperation of inflatable penile prosthesis among an ethnically diverse urban population in a high-volume center

Inflatable penile prosthesis (IPP) is a surgical treatment for erectile dysfunction refractory to medical therapy or for those who desire permanent treatment. Complications like mechanical failure and infection may necessitate reoperation, and patients with certain risk factors remain predisposed to reoperation. We retrospectively analyzed 530 patients undergoing primary IPP implantation at a large, urban, multiethnic hospital with a high volume of IPP implantations. Primary outcomes were reoperation due to any reason and reoperation due to infection. Patient characteristics and intraoperative factors were compared between those requiring reoperation and those not requiring reoperation. Overall, 12.1% of patients underwent reoperation, primarily due to infection, with a median time to reoperation of 4 months. Analysis revealed an increased likelihood of reoperation with Peyronie's disease (OR = 2.47), hemoglobin A1c over 8 (OR = 2.25), active smoking (OR = 2.75), and estimated blood loss (EBL) ≥ 25cc (OR = 2.45). A decreased likelihood of reoperation was observed when Arista™ powder was used intraoperatively (OR = 0.38). Reoperation specifically due to infection was associated with an infrapubic approach (OR = 2.56) and hypertension (OR = 9.12). Our findings confirm smoking and diabetes as risk factors for reoperation, while also providing insights into factors like estimated blood loss and Arista™ powder use. However, long-term survival rates were limited by loss to follow-up. (Clinical trial registration N/A).

Testicular prostheses: a historical and current review of the literature

INTRODUCTION

Testicular prosthesis can be placed at the time of orchiectomy for many benign and malignant testicular conditions. The American Urological Association guidelines recommend discussing the implant prior to the procedure.

OBJECTIVES

We review the literature on testicular prosthesis placement with respect to the history, psychological impact, surgical technique, complications, satisfaction, and novel emerging medical implications.

METHODS

A Medline search was conducted with several terms related to and including "testicular implant," "testicular prosthesis," "testicular implant satisfaction," and "testicular implant history." Twenty articles were identified with patient satisfaction data. Satisfaction with the comfort, shape, size, and weight was reported in addition to satisfaction with the device from 13 studies.

RESULTS

Overall satisfaction of testicular prosthesis is reported as high. Patients should be offered an implant at the time of orchiectomy or at any subsequent time based on their preference.

CONCLUSION

This article presents a contemporary and comprehensive review of the literature on testicular prostheses. Satisfaction rates following implantation remain consistently high. Additionally, innovative approaches are being investigated, including the exploration of novel implants for treating hypogonadism. Moreover, the utilization of 3-dimensional printing technology is revolutionizing the creation of testicular implants, aiming to achieve a texture and density closely resembling human testicles.

Perioperative infection prevention during inflatable penile prosthesis surgery: a narrative review

Background and Objective

Penile prostheses are an option for the management of erectile dysfunction (ED). Over the years penile prosthesis surgery has become increasingly safe owing to improvements such as antibiotic usage, coated devices, and surgical techniques. However, infection remains a dreaded complication during prosthesis surgery. Efforts to minimize risk of infection in the perioperative period have been extensively studied. Herein, we performed a narrative review on preoperative, intraoperative, and postoperative strategies for infection prevention during placement of a penile prosthesis with a comparison of infection prevention strategies to other surgical fields.

Methods

A literature review was performed using PubMed and Google Scholar. Studies evaluating perioperative management of penile prosthesis infection were included. The following search terms were used to for our literature search: penile prosthesis, inflatable penile prosthesis, infection, prevention, perioperative management. Articles were graded based on the 2011 Oxford Centre for Evidence Based Medicine (OCEBM) guidelines and a table was generated with each intervention discussed and its level of evidence based on current literature.

Key Content and Findings

Optimization of patient's comorbid conditions can help reduce risk during prosthesis operations. Monitoring and optimizing a patient's glycemic control has been investigated, but the current literature does not necessarily support a strict hemoglobin A1c (HbA1c) or pre-operative blood glucose level. Surgical field preparation using chlorhexidine-based solutions has been shown to be superior to iodine-based solutions. Appropriately selected peri-operative antibiotics have also been shown to reduce infection risk. Intraoperatively, the use of coated devices in addition to a 'no touch' technique have been shown to significantly reduce the risk of inflatable penile prosthesis (IPP) infection. Post operatively, available evidence of antibiotic use has not been demonstrated to be effective in reducing infection rates.

Conclusions

Surgical infection following placement of an IPP is a devastating and morbid complication with infection rate up as high as 1-3% in virgin cases and 7-18% in revision cases. While perioperative techniques exist and have reduced risk of infection, more prospective data is needed to evaluate the clinical significance of these different approaches. More research in these areas, along with future options such as nanoparticles, antibiotic coated suture, and next generation sequencing (NGS) for bacterial pathogens, may shed light on further ways to optimize infection reduction strategies for prosthesis surgery.

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.