Implantation of a penile prosthesis for treatment of erectile dysfunction has been around for almost 100 years. The inflatable penile prosthesis was introduced 50 years ago. It has been estimated that somewhere between 20,000 and 25,000 of these devices are implanted annually in the US. A penile prosthesis remains one of the most successful ways to treat advanced erectile dysfunction, particularly when oral therapy, injection therapy, or vacuum therapy are found not to provide satisfactory rigidity or when they are not acceptable to the patient. Patient and partner satisfaction rates remain high.^1,2 But as with any surgery, there are potential complications. The most dreaded complication with any implant is infection, as it invariably means the device has to be removed. Explant of an infected penile prosthesis causes significant distress for the patient and his partner, but also creates significant stress on the medical system as well as a financial burden.³ Therefore, efforts to reduce prosthesis infection have been pursued over the past 4 to 5 decades. Infection rates currently with the initial placement of a 3-piece prosthesis are typically reported in the 1% to 3% range.⁴ But it was not long ago when these rates were substantially higher, before infection-retardant coatings were introduced.^5,6 A variety of infection control approaches have been suggested in a penile prosthesis checklist, which includes pre-, intra-, and postoperative measures that are recommended to reduce the risk of infection.⁷ In addition, properly selected preoperative antibiotics have likely also reduced infection rates and are now included in medical society guidelines worldwide.^8-10 We have also learned that revision of a noninfected penile prosthesis is associated with a higher infection rate, likely due to activation of quiescent bacteria on the surface of the prosthesis, and that intraoperative irrigation with antibiotics, antifungals, and antiseptics can reduce postoperative infection in this population as well.¹¹ There are also certain patient populations who may be at higher risk for infection including uncontrolled diabetics, immunosuppressed individuals, and others who are prone to UTI such as those with neurogenic bladder.¹²

This session of the Plenary Second Opinion Panel will review several topics associated with penile prosthesis infection. First, Dr Lawrence Hakim, chairman of urology at Cleveland Clinic Florida, will review the evidence behind pre- and perioperative techniques to reduce the risk of infection. The second topic will be addressed by Dr John Mulcahy, professor of urology at the University of Alabama, who introduced the major breakthrough of immediate salvage of the infected prosthesis using a combination of different solutions to irrigate the field.¹³ Immediate salvage has been shown to be useful as it prevents corporal fibrosis, preserves penile length, avoids subsequent staged reimplant, and accelerates return to sexual activity. Dr Mulcahy will review how the salvage procedure has evolved over the past 25 years to using different antibiotic and antiseptic solutions based upon reduced toxicity and better coverage for the most frequent organisms found today.^13,14 Most recently, immediate salvage has had a reported success rate of 93%.¹⁵ Salvaging with a malleable implant has emerged as the preferred approach as compared to a 3-piece inflatable device, as it reduces operation time, avoids a scrotal and reservoir component, and preserves penile space should a switch-out to an inflatable device be desired at a later time (usually >3 months to allow full healing).^16,17 Historically, the contraindications to immediate salvage included local soft tissue necrosis, device erosion, diabetic ketoacidosis, sepsis, significant purulence, immunosuppression, or urethral injury. As a result of the advancements in this field, many more of these patients may now be candidates for immediate salvage. Interestingly, one would think that most men would be offered immediate salvage with the reported success rate, but in a review of national trends 10 years ago, only 17.3% did undergo this procedure.¹⁸

Finally, Dr Ricardo Munarriz, professor of urology at Boston University Medical Center, will review techniques to optimize delayed replacement of a penile prosthesis following explantation of an infected penile prosthesis. This can be a rather complex surgical procedure due to severe corporal fibrosis. Techniques have emerged that have facilitated placement of a new full-size prosthesis, such as several months of daily vacuum therapy, but when severe corporal fibrosis persists a variety of techniques may be needed by the surgeon including extended or multiple corporotomies, use of cavernotomes, or even full corporal scar excavation to be able to place a full-size or narrow-base prosthesis.^19,20

The key is penile prostheses remain a critically important and successful modality to restore the ability of a man to have a rigid penis on demand without compromising sensation, orgasm, ejaculation, and urination. It is usually a straightforward and simple operation, typically performed today as an outpatient, but can also be a complex operation requiring advanced surgical skills, particularly when an infection develops or there is a fibrotic corpus cavernosum. Clearly prevention of infection is of the utmost importance at the time of prosthesis placement.