Modified prosthesis salvage technique shows efficacy

Chicago-Aggressive washout of the implant space using only normal saline followed by immediate replacement with a malleable prosthesis is a safe and effective salvage technique for men presenting with an infected penile prosthesis, according to research presented at the 2012 World Meeting on Sexual Medicine in Chicago.

Outcomes were reviewed for 21 men who were managed with this approach in a dual-institution retrospective study conducted by Jean-François Eid, MD, who developed the technique, and Puneet Masson, MD. There were no intraoperative complications, and during a median follow-up of 12 months, the salvage operation had a 100% success rate, as defined by continued freedom from infection with a functional device postoperatively.

“Based on the work of John Mulcahy, MD, PhD, and colleagues, we know that a salvage operation for an infected penile prosthesis with complete implant removal and a regimented salvage irrigation protocol comprising seven steps with four different anti-infective solutions has a success rate of more than 90% with long-term follow-up. We have tremendous respect for this approach, which is widely used in the management of prosthesis infections,” said Dr. Masson, who was chief urology resident at New York Presbyterian Hospital/Weill Cornell Medical College, New York, at the time of the study. He is currently an andrology fellow at the Northwestern University Feinberg School of Medicine, Chicago.

“However, we believe the findings from our study suggest that aggressive washout rather than the specificity of the irrigant solution, along with a meticulous sterile technique, may contribute to an even lower post-salvage infection and reoperation rate,” Dr. Masson said.

Dr. Mulcahy commented about the utility of the normal saline washout.

“The protocol we developed 20 years ago represented an empiric shotgun approach to eliminating the infection that incorporated whatever antibiotic and antiseptic agents we could think of. After using it to treat a number of patients, we found it worked well,” he said.

“However, because of pseudocapsule formation, these prosthesis infections are generally confined to the implant space without invading tissues. The results of this retrospective study indicate it is the mechanical action of compulsive and copious pressure washing and not the content of the irrigating solution that underlies the efficacy of the salvage ­regimen.”

The 21 men who underwent the normal saline washout salvage protocol were identified from among 2,551 consecutive patients who underwent insertion of a three-piece inflatable penile prosthesis between January 2002 and December 2011. All of the operations and salvage procedures were performed by Dr. Eid, clinical associate professor of urology at Weill Cornell Medical College.

The salvage protocol involved hospital admission and institution of intravenous treatment with a broad-spectrum antibiotic. The surgery involved a 10-minute skin prep with a povidone-iodine scrub followed by use of an alcohol solution. Then, the entire three-piece prosthesis was removed, and all prosthesis parts along with specimens from the wound site were sent to the microbiology lab for culture and sensitivity testing. The corpora, scrotal cavity, and reservoir pockets were all copiously irrigated with 10-12 L of normal saline using pulse irrigation (Simpulse irrigator, Davol, Warwick, RI). During the procedure, gloves were frequently changed. All implants were replaced with a semi-rigid implant, and one to four Penrose drains were placed based on Dr. Eid’s clinical discretion.

Patients remained in the hospital for 48 to 72 hours while receiving IV antibiotics. They were discharged after all drains were removed and continued treatment for 4 to 6 weeks with a culture-specific antibiotic. Follow-up ­visits were routine at 3, 6, and 12 months and as needed thereafter.

38% of patients have negative culture

Dr. Masson reported that consistent with previous information in the literature, Staphylococcus epidermidis was the most commonly isolated pathogen (38%). Surprisingly,

38% of men had a negative culture, despite purulence being noted in many.

Six (29%) of the 21 patients had future revision surgery with removal of the malleable prosthesis and replacement with a three-piece inflatable prosthesis. All revision surgeries were delayed for at least 3 months after the salvage procedure.

Follow-up duration for each patient was based on a documented office visit, and Dr. Masson acknowledged that the median follow-up for the series of 12 months is somewhat limited when judging success of the salvage protocol. However, he noted that all of the cases of initial infection presented within 9 months after surgery and the vast majority occur within 3 months. Moreover, follow-up of between 5 and 10 years after the salvage operation was available for an appreciable number of the men in the series as the majority of the infections occurred among men operated on before 2006.

Dr. Eid is a consultant to American Medical Systems and Coloplast. He is also a speaker and receives grants/research support and honoraria from Coloplast. Dr. Mulcahy receives grants/research support from American Medical Systems and is a consultant, speaker, and receives honoraria from ­Coloplast.UT