Perioperative Prevention of Penile Prosthesis Infection: Practice Patterns among Surgeons of SMSNA and ISSM

Antibiotic dip and irrigation solutions confer increased antimicrobial efficacy of inflatable penile prosthesis hydrophilic surfaces compared with 0.05% chlorhexidine gluconate

BACKGROUND

Chlorhexidine gluconate (CHG) (0.05%) has recently been suggested as both a dip for the hydrophilic surface and an irrigation solution in the setting of penile prosthesis (PP) surgery.

AIM

The study sought to compare the antimicrobial efficacy of 0.05% CHG with vancomycin and gentamicin (VG) antibiotics as dip and/or irrigation solutions in the setting of a hydrophilic PP surface in vitro.

METHODS

Sterile PPs with a hydrophilic coating were obtained. A series of experiments were performed to evaluate the efficacy of normal saline (NS), 0.05% CHG, or VG as dip and/or irrigation solutions to reduce methicillin-sensitive Staphylococcus aureus adhesion to PP surfaces. The 8-mm discs from PPs were incubated in 105 colony-forming units/mL of methicillin-sensitive S aureus for 48 hours, plated, and counted. Disc-diffusion tests were conducted by suspending 6-mm discs for 2 minutes in NS, 0.05% CHG, or VG, then placing them coated side down onto plates streaked with the following organisms: methicillin-sensitive S aureus, S epidermidis, Enterococcus, and Escherichia coli. After 24 hours of growth, zones of inhibition were measured.

OUTCOMES

We found average bacterial counts (colony-forming units/mL) and zones of inhibition (mm) following a series of treatment protocols of PP discs.

RESULTS

PP discs dipped in VG reduced bacterial adhesion to the implant surface >0.05% CHG (~5.5 log vs ~1.5 log; P < .01). Discs irrigated with either 0.05% CHG or NS removed all dip solution adsorbed to the hydrophilic surface, allowing bacterial growth. VG irrigation adsorbed to the hydrophilic surface even after 0.05% CHG or NS dips, reducing bacterial adherence (~3 log). Dipping and irrigating discs with VG was most effective in reducing adherent bacteria (~5.5 log) and was the only irrigation that showed antimicrobial activity.

CLINICAL TRANSLATION

VG, when used both as a prophylactic dip and as an intraoperative irrigation solution for hydrophilic penile implant surfaces, has improved efficacy to 0.05% CHG and NS.

STRENGTHS AND LIMITATIONS

This is the first study to compare the use of VG, 0.05% CHG, and NS as prophylactic dips and intraoperative irrigations for hydrophilic penile implant surfaces. Limitations include the use of in vitro studies, which serve as a proxy for in vivo practices and may not be entirely accurate nor translatable clinically.

CONCLUSION

We demonstrated the superior efficacy of VG as a combined dip and irrigation solution for hydrophilic penile implant surfaces compared with 0.05% CHG.

Tips and tricks in the management of inflatable penile prosthesis infection: A review

Objective:

To review the management of inflatable penile prosthesis (IPP) infection.

Methods: The ‘gold-standard’ treatment for medication-refractory erectile dysfunction is the IPP, wherein the most dreaded complication is infection. To prevent and manage an infected IPP requires a strict protocol during the pre-, intra-, and postoperative course. A variety of techniques and antibiotics are used in conjunction with IPP implantation to prevent contamination. This modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review of the literature examines the current practices by leading urologists in the management of IPP infection, as well as provides insights for improved patient outcomes.

Results

: Patient selection is important to reduce IPP infections, and those with risk factors need to be optimised prior to surgery. Proper antibiotic prophylaxis includes pre-, intra-, and postoperative administration. As most infections derive from normal skin flora, every measure must be taken to sterilise the skin and avoid direct device skin contact. Up to 3% of virgin IPPs develop infections and this number increases to 18% in revision cases. Antibiotic coverage depends on the presenting microbe, which can vary significantly between patients.

Conclusions

: A greater success in IPP implantation can be attributed to appropriate prophylaxis, field sterilisation, and surgical technique. For those implants that do become infected, often erectile function can be preserved by immediate antibiotic coverage combined with salvage procedures.

Urethral instillation of chlorhexidine gel is an effective method of sterilisation

Objective: To examine the effectiveness of preoperative urethral sterilisation with chlorhexidine gel in rendering the urethra as sterile as the skin of the genital area, with the skin sterilised as per the International Society for Sexual Medicine guidelines for penile prosthesis implantation. Patients and methods: A total of 111 male patients undergoing sterile andrological surgical procedures were divided into a control group (N = 61) and a chlorhexidine gel group (N = 50). Patients in the chlorhexidine group received urethral instillation with 6 mL of chlorhexidine preoperatively and on table. Patients from both groups received on-table skin preparation using povidone iodine and chlorhexidine povidone iodine. At the end of surgery, swabs were obtained from urethra and the penile skin. Skin and urethral swabs were compared for bacterial colonisation by culture and sensitivity. Results: Of the 111 patients, 16 had urethral colonisation and 10 had skin contamination, and they were all in the control group. The most common organism detected in both the urethral and skin samples was coagulase-negative Staphylococcus aureus. Urethral colonisation was significantly greater in the control group compared to the chlorhexidine group, at 16/61 vs 0/50 (P = 0.001). Similarly, skin colonisation was significantly greater in the control group compared to the chlorhexidine group, at 10/61 vs 0/50, (P = 0.002). Conclusion: Chlorhexidine gel is a powerful sterilising agent that will render the urethra sterile.

Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery?

The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.

Perioperative management of patients undergoing penile prosthesis surgery in the UK: A survey of current practice

Objectives:

This study aimed to define contemporary perioperative management of patients undergoing penile implant surgery in the UK.

Methods:

All consultant urological surgeons responsible for the insertion of penile prostheses in the UK were invited to complete an online survey comprising of 25 questions relating to surgeon demographics, patient selection, preoperative work-up, intraoperative management and postoperative care. Anonymised responses underwent descriptive statistical analysis, with particular focus on measures employed to reduce the risk of perioperative infection.

Results:

Of the 34 invited surgeons, 26 (76.5%) responded to the survey. The majority reported undertaking between 10 and 30 cases in 2018 ( n=17; 65.4%). A total of 23 (88.5%) respondents reported employing a threshold for diabetic control, although the exact limit varied between surgeons. Most respondents ( n=22; 84.6%) reported routinely sampling urine for microscopy, culture and sensitivity. All but one ( n=25; 96.2%) reported routinely performing cavernosal washouts, with the most common solution being a mixture of gentamicin and vancomycin (42.3%). All reported routinely giving intravenous antibiotics on induction of anaesthesia, and although there was no clear consensus, most surgeons preferentially used an aminoglycoside in combination with one other agent (including penicillins or teicoplanin).

Conclusion:

The variation in current perioperative management demonstrates a potential need for the development and introduction of evidence-based guidelines to standardise practice nationwide. Level of evidence: 5

Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America

Asymptomatic bacteriuria (ASB) is a common finding in many populations, including healthy women and persons with underlying urologic abnormalities. The 2005 guideline from the Infectious Diseases Society of America recommended that ASB should be screened for and treated only in pregnant women or in an individual prior to undergoing invasive urologic procedures. Treatment was not recommended for healthy women; older women or men; or persons with diabetes, indwelling catheters, or spinal cord injury. The guideline did not address children and some adult populations, including patients with neutropenia, solid organ transplants, and nonurologic surgery. In the years since the publication of the guideline, further information relevant to ASB has become available. In addition, antimicrobial treatment of ASB has been recognized as an important contributor to inappropriate antimicrobial use, which promotes emergence of antimicrobial resistance. The current guideline updates the recommendations of the 2005 guideline, includes new recommendations for populations not previously addressed, and, where relevant, addresses the interpretation of nonlocalizing clinical symptoms in populations with a high prevalence of ASB.

Concurrent Penile Prosthesis and Artificial Urinary Sphincter versus Penile Prosthesis and Male Sling: A National Multi-Institutional Analysis of National Surgical Quality Improvement Program Database Comparing Postoperative Morbidity

Purpose

We aimed to assess the 30-day morbidity in patients undergoing combined insertion of penile prosthesis (PP) and artificial urinary sphincter (AUS) vs. PP and male sling (MS).

Materials and Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent placement of AUS or MS combined with PP. Patient demographics, postoperative morbidity including complications, readmission and reoperation rates were recorded. Student t-test and chi-square or Fischer's exact test were used as appropriate.

Results

Forty-one patients met selection criteria between 2010 and 2016. Overall, 26 patients received PP and AUS vs. 15 that received PP and MS. Average age was similar in both groups (64.8±6.6 years vs. 62.3±6.3 years, p=0.254). Diabetes mellitus was more prevalent in PP+MS group compared to AUS+PP group (46.7% vs. 11.5%, p=0.022). Average length of stay was higher in PP+AUS group compared to PP+MS group (2.2±0.6 days vs. 1.8±0.4 days, p=0.017). Postoperative morbidity was reported in four patients in PP+AUS group. No reported complications in PP+MS group. In PP+AUS group, complications included one patient who developed urinary tract infection, one developed surgical site infection, readmission in two for postoperative infection, and one return to the operating room. No reported prosthesis explantation or revision in either groups.

Conclusions

Our results showed that 30-day morbidity was recorded in the PP+AUS group and none in the PP+MS group. The complication and readmission rates remain comparable to the previous reports in both groups.

Prospective analysis of cultures from the Furlow insertion tool: a possible etiology for penile prosthesis infections

The most dreaded complication of penile prosthesis (PP) implantation is device infection. We sought to assess whether inadequate cleaning and sterilization of the reusable Furlow inserter may represent one of the last etiologies of infection in PP patients. We performed a prospective analysis of cultures of the Furlow inserter used for PP surgeries from seven centers between May 1st and June 30th, 2019. Once the Furlow was received for surgery, the surgical team inspected the device for assembly status (disassembled or not) and the presence of visible stains, pieces of tissue or discoloration on either the interior of the barrel or the plunger. Swab aerobic and anaerobic bacterial and fungal cultures were then obtained from the internal component, after removal from the external component if assembled, and after introduction and immediate removal from the external component if disassembled. A total of 83 Furlow devices were cultured. Median age of surgical instrument was 4 years (2-10 years). Methods of sterilization included autoclave, wet autoclave, steam, and Sterad. Median time from sterilization was 3 days (1-22). On initial presentation, 79 devices were disassembled (95.1%) and 4 devices were still assembled (4.9%). Three external components were discolored (3.6%), while internal components demonstrated two stains (2.4%) indicative of improper cleaning which were thought to be residual blood products. Overall, 2/83 (2.4%) devices revealed positive swab cultures for Staphylococcus epidermidis. Swab cultures were negative for fungi and anaerobic bacteria. This patient cohort will continue to be followed to see if device infection occurs but it is unlikely to be meaningful since contaminated Furlows were discarded. Improper cleaning and/or sterilization of the Furlow Insertion Instrument may represent a source of infection for patients undergoing PP implantation.

Treatment of Estrogen Levels in the Management of Hypogonadism: An Anonymous Survey of ISSM Members

OBJECTIVE

To assess the variability in management of estrogen levels in men treated with testosterone therapy (TTh). With the significant increase in the last 2 decades in the treatment of hypogonadism and the use of TTh, detailed guidelines for the management of estrogen levels are necessary.¹ MATERIALS AND METHODS: An anonymous survey was electronically distributed to the membership of the International Society for Sexual Medicine including questions on demographics, symptoms, and their approach to management of estrogen in patients on TTh. Chi-square test was used to determine associations.

RESULTS

The response rate was 22.5% (489/2168). A total 62.4% of respondents indicated that they check serum estrogen at initial evaluation, but only 54.7% monitor levels in patients on TTh (P = .02). Fellowship-trained and North American respondents were more likely to monitor patients (P < .05). A total of 69.4%, 47.7%, and 14.4% respondents prescribe antiestrogenic medications in symptomatic patients with elevated estrogen levels, for asymptomatic-elevated estrogen levels, and prophylactically, respectively. Academic respondents were more likely to prescribe an antiestrogen medication to symptomatic patients and prophylactically (P < .05). Anastrozole was the most common medication prescribed for symptomatic hyperestrogenemia (62.3%), but starting doses varied significantly, from 1 mg weekly to 1 mg daily.

CONCLUSION

Approximately 50% of practitioners treating men with TTh monitor estrogen levels. Symptoms play a role in prescribing patterns and significant variability in aromatase inhibitors regimens exists. Increased monitoring of estrogen levels in men on TTh will facilitate an understanding of the symptoms, effects of high and low estrogen levels, and aid in standardization of research and therapy.

Multicenter investigation on the influence of climate in penile prosthesis infection

The purpose of this study is to investigate the relationship between inflatable penile prosthesis (IPP) infection, time of year, climate, temperature and humidity. This is a retrospective IRB-approved analysis of 211 patients at 25 institutions who underwent salvage procedure or device explant between 2001 and 2016. Patient data were compiled after an extensive review of all aspects of their electronic medical records. Climate data were compiled from monthly norms based on location, as well as specific data regarding temperature, dew point, and humidity from dates of surgery. Rigorous statistical analysis was performed. We found that penile prosthesis infections occurred more commonly in June (n = 24) and less frequently during the winter months (n = 39), with the lowest number occurring in March (n = 11). One-hundred thirty-nine infections occurred at average daily temperatures greater than 55 °F, compared to 72 infections at less than 55 °F. The incidence rate ratio for this trend was 1.93, with a p-value of <0.001. Humidity results were similar, and fungal infections correlate with daily humidity. Infected implants performed in the fall and summer were over 3 and 2.3 times, respectively, more likely to grow Gram-positive bacteria compared to implants performed in spring (p = 0.004; p = 0.039). This was consistent across geographic location, including in the Southern hemisphere. We found trends between climate factors and IPP infection like those seen and proven in other surgical literature. To our knowledge these data represent the first exploration of the relationship between temperature and infection in prosthetic urology.

Current practice in the management of ischemic priapism: an anonymous survey of ISSM members

Penile shunting is the standard of care in management of ischemic priapism refractory (IPR) to non-surgical interventions. Due to high rates of impotence, corporal fibrosis, and loss of penile length, recent literature suggests these patients benefit from immediate penile prosthesis (PP) placement. An IRB-exempt anonymous electronic survey of the 2168 members of the International Society for Sexual Medicine (ISSM) was conducted. The survey included demographic information, confidence, and experience-related management of IPR. The aim was to evaluate current practice patterns in management of IPR and to investigate the role of immediate PP implantation in the management of prolonged (>36 h) IPR. The survey response rate was 11.6% (n = 251). Most respondents were urologists (173), from the USA (49.1%), and had completed a fellowship in male sexual medicine, men's health, reconstruction, or andrology (71.1%). The majority (91.3%) see at least one case of prolonged priapism (>36 h) that requires surgical management yearly. When looking at volume in training and after, our respondents had a significantly higher experience with penile prostheses (over 70%, > = 10) as compared with shunts (less than 40%, > = 10). Overall, 70.9% of respondents felt more comfortable with a malleable PP than a shunt. However, penile shunts are still preferred as the first line of surgical management by ~80% of respondents as compared with 12.7% who instead prefer a PP. We also found that under 40% of respondents currently use penile MRI or corporal biopsies in their management of prolonged assessment. This is the first study to assess current clinical practices in management of IPR globally. As in any anonymous self-reported survey-based research, recall and sampling bias are an inherent limitation. Penile shunting for IPR continues to be the preferred treatment despite emerging data. Respondents performed PP surgery routinely and feel more confident placing PP than performing penile shunting procedures.

Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation

Introduction

Prosthesis-assisted penile reconstruction has been performed extensively to restore a cosmetically acceptable phallus. However, a large number of patients will undergo revision surgery for various prosthesis-related complications.

Aim

To develop a 1-stage prosthesis-free dynamic cavernosa reconstruction method using bilateral innervated gracilis muscles and to investigate the feasibility and reliability of the surgical design.

Methods

10 fresh cadavers were dissected to assess the availability of bilateral gracilis muscles for functional cavernosa rebuilding. 11 mongrel female dogs were involved in the penile reconstruction surgery. The neophallus consisted of bilateral gracilis muscles as the neo-cavernosa, a right gracilis skin flap as the neourethra, and a lower abdominal flap with an anterior rectus sheath as the skin envelope and neo-tunica albuginea. The function and structure of the neo-phalli were assessed 7 months postoperatively.

Main Outcome Measures

The neurovascular pedicle length of the gracilis muscles and the volume of the gracilis venter musculi were measured in the cadaveric investigation. The average dimensions of the canine neo-phalli at rest and during electrostimulated erection were obtained and the muscular fatigue-resistant curve was drawn. Histologic evaluations also were performed.

Results

The neurovascular pedicle length and volume of the gracilis muscles were sufficient to yield a nearly normal appearance of the neo-cavernosa in the cadaveric and animal studies. The muscular fatigue-resistant curve demonstrated adequate length, stiffness, and duration of erection of the neo-phalli to accomplish normal coitus. Histologic evaluations showed an intact neourethra and nearly normal muscle structure in the inner layer of the canine neo-cavernosa, except for significantly increased amount of collagen fibers and type I/III collagen ratio in the outer layer of the neo-cavernosa. The percentage of type II (fatigue-prone) muscle fibers did not change significantly.

Conclusion

Our preclinical investigation proves that corpora cavernosa reconstruction using bilateral innervated gracilis muscles is technically feasible and functionally efficacious.

Yin Z, Liu L, Xue B, et al. Dynamic Penile Corpora Cavernosa Reconstruction Using Bilateral Innervated Gracilis Muscles: A Preclinical Investigation. Sex Med 2018;6:162–170.

Is Hba1c level of diabetic patients associated with penile prosthesis implantation infections?

BACKGROUND AND OBJECTIVES

Diabetes mellitus is an important risk factor for erectile dysfunction (ED). Penile prosthesis implantation surgery is the final solution for diabetic patients with ED, but infections thereof are still a serious risk factor. While some studies suggest that most infections associated with penile prosthesis implantation are associated to high glycated hemoglobin (HbA1c) levels, other research did support such relationship.

MATERIALS AND METHODS

The current study assessed retrospectively, the association between HbA1c level and penile prosthesis surgery infection. We retrieved and reviewed the records of 300 diabetic patients who had penile prosthesis surgery at our Institution (January 2012-November 2016). Patients' mean age was 55.26 ± 10.9 years (31% patients were <50 years of age), and mean HbA1c was 7.60 ± 1.90%.

RESULTS

Infection rate among diabetics was 0.67%. Prevalence of prosthesis infection among patients with HbA1c ≤ 9% was 0.9%, compared with 0% among patients with HbA1c > 9%. Prosthesis infection risk did not significantly increase with higher HbA1c levels, with no meaningful difference in the median or mean level of HbA1c in the infected and non-infected diabetic patients.

CONCLUSION

Findings do not support the use of HbA1c values among diabetic patients who are candidates for penile prosthesis implantation surgery in order to identify and exclude those who might be prone to increased risk of prosthesis infections. Future studies would benefit from larger sample sizes in order to support or refute our findings.

Medical pre-operative considerations for patients undergoing penile implantation

Penile prosthesis surgery has become the standard treatment for patients with erectile dysfunction refractory to medical management. Refinements in the both the surgical technique and device manufacturing have made this a safe and reliable treatment with excellent patient satisfaction. In this review, we will overview the basic medical and pre-operative considerations for patients undergoing penile prosthesis implantation. We intend to provide a simple and practical checklist for the implanter to reference when considering implantation of a penile prosthesis.

Preoperative hair removal on the male genitalia: clippers vs. razors

INTRODUCTION

In an effort to reduce the incidence of postoperative surgical site infections (SSIs), many hospitals have adopted a strict practice of preoperative hair removal using clippers, as opposed to razors. However, the skin of the male genitalia is delicate, elastic with irregular skin folds and may be ill-suited for clippers.

AIM

To compare shave quality and the degree of skin trauma using two methods of preoperative hair removal on the scrotal skin: clippers vs. razors.

METHODS

Patients undergoing surgery involving the male genitalia requiring preoperative hair removal were randomized to hair removal using clippers or a razor. Immediately following hair removal, a standardized digital photograph was taken of the male genitalia. All digital photos were evaluated in a blinded fashion by groups of urologic surgeons and surgical nurses using a standardized five-point global rating scale. The incidence of SSIs was monitored.

MAIN OUTCOME MEASURES

Primary outcomes included blinded global ratings of (i) the completeness of the preoperative hair removal within the surgical field and (ii) degree of skin trauma following hair removal. The incidence of SSIs within 3 months of surgery was monitored throughout the study period.

RESULTS

Two hundred fifteen consecutive patients were randomized (107 clipper, 108 razor). Overall, preoperative hair removal on the male genitalia using a razor resulted in significantly less skin trauma (P = 2.5E-10) and a more complete hair removal within the surgical field (P = 0.017) compared with clippers. SSIs were identified in four patients during follow-up (1.8%--two using clippers; two, razors).

CONCLUSIONS

Our data suggest that preoperative hair removal on the scrotal skin using a razor results in less skin trauma and improved overall shave quality with no apparent increased risk of SSIs. Based on these findings, surgeons should be permitted their choice of razors or clippers for preoperative preparation of the male genitalia.