Background: Penile prosthesis infection (PPI) is a common and devastating complication for patients, partners, and surgeons alike. PPI rates range between 0 and 24.6%, with 5% being the most commonly reported rate. 82.7% of PPIs in the United States are managed with device removal alone, which results in corporal fibrosis, up to 3.7 cm loss of penile length, and impotence. Delayed PP reimplantation requires advanced surgical techniques and is associated with high complication, revision, and patient dissatisfaction rates. Less than 20% of PPIs undergo a salvage procedure, consisting of immediate reimplantation, which in comparison has an excellent success rate (82-93%). The aim of this study is to evaluate data behind each step of the salvage procedure. Methods: This is a retrospective review of urologic and non-urologic literature supporting every step the salvage procedure, including pre and postoperative antibiotics (coverage and duration), intraoperative irrigation protocol (antiseptic choice and contact time), and type of penile prosthesis (malleable vs. inflatable; coated vs. non-coated). Results: Preoperative antibiotics: Broad spectrum intravenous antibiotics are recommended, but the duration prior to surgical intervention is unknown. Cultures should be obtained before starting antibiotics, since as many as 33% of intraoperative cultures are negative. Culture data in PPI shows 73% gram positive, 25% multiple organisms, 9.2% MRSA, 11.1% fungi, and 10.5% anaerobes, which suggests the use of antibiotic combinations that cover gram positives, gram negatives, MRSA, and fungi such as vancomycin, metronidazole, fluconazole, and gentamicin or ceftriaxone, or vancomycin with piperacillin-tazobactam and fluconazole. Intraoperative irrigation: Though there is no universal protocol, it remains accepted that salvage should include irrigation with antiseptic solutions. Diluted Povidone-iodine (0.35 - 3.5%) with a contact time of at least 3 minutes has shown the most robust effect without significant cytotoxicity against native tissue. Chlorhexidine may also be as effective as povidone-iodine, but controlled studies are limited. Hydrogen peroxide should be avoided due to significant deleterious properties on native tissue and the risk of air emboli. Device choice: Reimplantation of malleable prostheses at the time of salvage has better infection-free rates compared to inflatable prostheses (93% vs. 82%). Multiple device choices are available including hydrophilic coated and uncoated devices, but there is no evidence that antibiotic coated devices result in better outcomes. Postoperative antibiotics: Postoperative antibiotic choice should be directed by pre and intraoperative culture data and institutional antibiograms. There is no consensus regarding postoperative antibiotic duration. Conclusions: Salvage procedure for PPI has a high success rate, but the protocol must be standardized and updated with current literature. Pre and intraoperative culture data is critical for the selection of postoperative antibiotics. Irrigation with diluted Povidone-iodine or chlorhexidine is indicated, but hydrogen peroxide should be avoided. Placement of malleable penile prosthesis at the time of the salvage procedure is simpler and has better outcomes. Future studies investigating specific questions such as duration of postoperative antibiotics are needed to further improve outcomes.
