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abstract

abstract

701

Immediate salvage of purulent inflatable penile prostheses can be safely done in insulin-dependent type II diabetics and the chronically immunosuppressed

Carlos, EC1; Davis, LG1; Peters, CE1; Lentz, AC1

1: Duke University, United States

Objective Immediate salvage of an infected penile prosthesis limits the devastating penile shortening that occurs with removal without replacement. Historically, immediate salvage is contraindicated in those with grossly purulent devices, severe diabetics, and the immunosuppressed. Severe diabetes in this context have not been classified. We considered a “severe diabetic” as someone whose disease has progressed past diet control and oral medications and, therefore, has insulin-dependent type II diabetes (IDDM II). In a case series, we aim to show that the immunosuppressed and patients with IDDM II can safely have their purulent penile implant immediately salvaged.

Material and Methods We retrospectively reviewed three patients with severe diabetes who underwent immediate salvage of their 3-piece purulent inflatable penile prosthesis. Patient #1 had also received a transplanted kidney four years prior to his salvage procedure and is immunosuppressed with prednisone and tacrolimus. In addition to immediate exchange, each received catheter-directed antibiotic/antimicrobial intracorporal irrigation, device culture and was discharged home the next day on a course of oral antibiotics.

Results Patients #1-3 were 72.5, 54, and 69.5 years old, respectively, at the time of salvage. Each patient had purulent material surrounding the pump with Patient #3 also having corporal involvement (Figure). This was evidenced by the device’s coat breaking down and meshing into the adjacent corpora. Postoperatively, all three remained infection free at their 6-8 week follow up appointment. 11-20 months later, none have returned for infection or any other post-salvage complications.

Conclusions In itself, a grossly purulent device has been considered a contraindication for immediate salvage. Nevertheless, each of our severely diabetic subjects -- one immunosuppressed -- had their purulent prosthesis immediately salvaged without reinfection. With the increased incidence of diabetes and longevity of transplant patients, we will more frequently encounter purulent device infections in these patients and immediate salvage should be considered.

Pt #

Age at Salvage (years)

Pre-salvage HbA1c

Date of

 IPP

Date of Salvage

Reason(s) for Salvage/OR Findings

Infected Device

Salvage Device

1

72.5

7.2

20/1/16

10/9/07

3/3/16

Asymptomatic, device failed to cycle. Purulence noted to surround pump in OR.

Previous generation AMS device

15+3cm

AMS CX

2

54

7.9

9/11/16

29/9/16

9/11/16

 Perineal pain, purulence from incision. Purulence around pump in OR.

22+3cm Coloplast Titan

23cm Coloplast Genesis

3

69.5

7.1

undated

3/9/14

26/4/16

Scrotal pain. 30cc purulent fluid around pump. Breakdown of the parylene coating with corporal tissue in-growth.

Unknown AMS device

22cm Coloplast Genesis

Pt #

Perioperative Antibiotics

Salvage Corporal Irrigation Protocol

Salvage Cultures

Discharge Antibiotics

Follow Up

1

80mg gentamicin

1g vancomycin

(vancomycin/gentamicin,

½ strength H2O2,

½ strength betadine) x2

vancomycin/gentamicin

coagulase negative staphylococcus, diphtheroids

5 days TMP/SMX

Last seen 18/10/16 and continues with current IPP.

2

3.375g piperacillin-tazobactam

1g vancomycin

(vancomycin/gentamicin, bacitracin, ½ strength betadine) x2

vancomycin/gentamicin

streptococcus viridans, group C streptococcus, peptostreptococcus, diphtheroids

2 weeks

Rifampin

TMP/SMX

Last seen 13/12/16, continues with malleable.

3

5mg/kg gentamicin

15mg/kg vancomycin

bacitracin, vancomycin/amphotericin/

piperacillin-tazobactam

coagulase negative staphylococcus

5 days TMP/SMX

Last seen 13/6/17, continues with malleable.

                   

Figure 1: Three patients each with IDDM II; Patient #1 has a history of renal transplantation in 2012. IPP = inflatable penile prosthesis; TMP/SMX = trimethoprim/sulfamethoxazole; AMS = American Medical Systems; Pt = Patient

 

Disclosure:

Work supported by industry: no.

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