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Anti-Infection Dip Suggestions for the Coloplast Titan Inatable Penile Prosthesis in the Era of the Infection Retardant Coated Implant
jsm_2363 1..8

Steven K. Wilson, MD,* Emad A. Salem, MD, and William Costerton, PhD
*Urology, Institutes of Urologic Excellence, Indio, CA, USA; Department of Urology, Zagazig University, Sharkia, Egypt; Center for Genomic Sciences, Allegheny-Singer Research Institute, Pittsburg, PA, USA DOI: 10.1111/j.1743-6109.2011.02363.x

ABSTRACT

Introduction. Infection is the worst complication seen with inatable penile prosthesis (IPP). Both the American Medical Systems (AMS) and Coloplast IPP have infection retardant coatings. AMS is coated at the factory with rifampicin and minocycline (InhibiZone). The Coloplast IPP has a hydrophilic coating covalently bonded to its components that will absorb any aqueous solution before implantation and provides increased surface lubricity to decrease bacterial adherence. Aim. We tested several antibiotic dips comparing zones of inhibition (ZOI) against ve commonly infecting bacteria with coated Coloplast implants. Results were compared with those ZOI created with strips of an AMS IPP precoated with InhibiZone. Methods. Pieces of sterile Coloplast Titan IPP were dipped in (i) trimethoprim/polymixin B ophthalmic solution; (ii) trimethoprim/sulfamethoxazole infusion solution; (iii) bacitracin; (iv) rifampicin/minocycline; and (v) rifampin/ trimehtoprim/sulfamethoxazole. ZOI for the Titan strips and for AMS InhibiZone coated strips were tested against Staphylococcus epidermidis, Staphylococcus lugdunensis, Staphylococcus aureus, Pseudomonas, and Enterococcus. Main Outcome Measure. ZOIs of the Coloplast Titan for each of the medicated solutions were compared with ZOI created by undipped strips of a sterile InhibiZone coated IPP placed on plates of the identical bacteria. Results. All dips except bacitracin showed ZOI InhibiZone (P 0.005) for most organisms. Because of broadspectrum effectiveness, ease of handling, and cost, infusion vial of trimehtoprim/sulfamethoxazole seemed optimal at this time. If trimehtoprim/sulfamethoxazole is unavailable; the ZOI with Polytrim ophthalmic solution zones were almost as good. Conclusions. The Coloplast strips when dipped in several solutions showed equal or signicantly larger ZOI against commonly infecting organisms than the InhibiZone coated strips. At the present time using off the shelf trimethoprim sulfamethoxazole infusion solution seems optimum. The exibility of choosing the drug eluting from the Coloplast device seems promising in the changing bacterial environment. Wilson SK, Salem EA, and Costerton W. Anti-infection dip suggestions for the coloplast titan inatable penile prosthesis in the era of the infection retardant coated implant. J Sex Med **;**:****. Key Words. Inatable Penile Prosthesis; Implant Infection; Infection Retardant Coatings; Biolm; Antibiotics

Introduction

natable penile prostheses (IPPs) are a common treatment of medication refractory erectile dysfunction. During its 37 years of availability, the IPP has undergone continuous enhancements to improve its mechanical

Funding: Coloplast Corporation, Minneapolis, MN.

reliability. Currently, the revision rate of the IPP for mechanical reasons is among the lowest of all medical devices implanted in humans [1]. In the early years of this century, the manufacturers also began to coat their devices with infection retardant material in an attempt to improve the patients protection from revision for reasons of infection. Before the coated implant, the incidence of infection in a rst time (virgin) implant patient was
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2011 International Society for Sexual Medicine

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A B

Wilson et al.

Figure 1 Typical appearance of implant infections with skin organisms.

quoted at 35% for patients without risk factors [2], 58% for diabetics [3], and 10% for revision operations [4]. Because the application of infection retardant coatings on the IPP, the risk of infection has dropped to 12% in virgins [5] without risk factors and 23% in diabetics [6]. This reduction of infection applies to both the AMS [5,6] and Coloplast devices [7]. Prior to infection retardant coatings, IPP infections had been traditionally divided into two types [8]. Three-fourths of infections were with opportunistic skin organisms coagulase negative staphylococcus (CNS) like Staphylococcus epidermidis and Staphylococcus lugdunensis. These patients presented late (>6 weeks) and were not toxic (Figure 1). White blood cell count was not elevated, there was no fever, and the patients were not sick. These patients were excellent candidates for Mulcahys salvage operation. Salvage allowed 8090% of the skin organism infected patients to keep their implanted status [9] and not suffer the shortening of the penis that accompanies removal for infection. It also avoided the most difcult operation in prosthetic urology: the reinsertion of IPP into scarred corporal bodies [10]. The other 25% of the infection population commonly developed acute and toxic infections in less than 2 months (Figure 2). Common organisms were Enterococcus, Staphylococcus aureus, Pseudomonas, and Escherichia coli. Salvage operations were much less successful with this group [9]. Since 2003, when infection retardant coated implants became commonly available from both companies, there has been a distinct decrease in device infections. Comparisons between the IPP and other forms of erectile dysfunction (ED) therapy generally reveal a higher satisfaction rate in men with ED who chose the prosthesis [10]. Unfortunately, those infections that do present are not usually the typical opportunistic skin organJ Sex Med **;**:****

isms such as CNS we formerly saw 75% of the time before the availability of the coated product. When cultures are available, the bacteria now are more likely to be pathogenic bacteria like Enterococcus, S. aureus, E. coli, Pseudomonas, and Salmonella [11]. Bruner et al. reported similar organisms when they reported a novel technique for achieving accurate microbial cultures from infected implants. The authors sonicated the biolm found on infected IPP and sphincters and obtained different bacteria than the ones that were cultured from a simple tissue swab. It is presumed these implants were coated ones (although the article does not address this fact) because the sonication technique is quite new and coated implants have been available since 2001. Four of the six infected implants cultured CNS from tissue swab but organisms cultured from the sonicated biolm on

Figure 2 Patient with pseudomonas implant infection: temperature 104, positive blood culture.

Dip Suggestions for Coloplast Prosthesis the implant were completely different: Enterococcus faecalis, S aureus, Group B strep, Serratia marcesans, and Pseudomonas [12]. Kava et al. showed similar ndings in a study electronically published in Journal of Sexual Medicine 2/11 [13]. It is a single surgeon series of 117 primary and 72 revision implant recipients utilizing exclusively infection retardant coated implants from both companies. There were no CNS infections. Instead the infections were caused by toxic organisms like S aureus and Enterobacter aerogenes. Of further note was that during revision surgery for mechanical failure, CNS could be cultured in only 10% of the clinically uninfected cases but none of them subsequently became infections. Notably, in this 2010 study, culture positivity for skin organisms was much lower than our series of 70% dealing with mostly non-coated implants [14]. While IPP infections are markedly diminished in the era of coated implants, the coated implant patient that does become infected usually has an acute aggressive and toxic presentation as did the patients in Kava et al.s study. None of his patients were deemed candidates for salvage. It is a well-established fact that the vast majority of clinically uninfected penile prostheses have organisms living in the implant space at the time of reoperation [13,14]. The bacteria were inoculated into the implant spaces at the time of surgery and began a race for the surface during which they multiplied and tried to afx to the implant surface. If they reached a critical mass, they secreted exopolysaccharide matrix that protected them from antibiotics and the bodys defense mechanisms. The microbial community enclosed in these secretions is commonly called a biolm [14,15]. After sheltering themselves within the biolm, the bacteria may live for many years in the implant space without causing clinical symptomaA

3 tology. Bacterial biolm (Figure 3) has been detected on IPP devices removed for noninfection reasons and quantied using confocal scanning laser microscopy. This study suggested that most, if not all patients, have bacterial contamination of their implants [15,16]. The infection retardant coatings of the AMS and Coloplast devices are quite different. The InhibiZone (American Medical Systems, Inc., Minnetonka, MN, USA) coating of rifampicin and minocycline on the AMS IPP and articial urinary sphincter components was tested against S. epidermidis according to company literaturethe most common infecting organism of IPP prior to infection retardant coated implants. After implantation in over 20,000 patients, the Federal Drug Administration (FDA) recognized this coating 6/2009 as effective in reducing the incidence of reoperation for device infection. The Coloplast approach to infection prevention is dissimilar and allows the physician exibility of drug choice. After manufacturing of the components, a hydrophilic coating is covalently bonded to all the component surfaces. This coating absorbs 25 times its weight when dipped in an aqueous solution creating a lubricious component surface to deter bacterial attachment. If the solution contains medications, these drugs are absorbed supercially to elute into the implant spaces. Coloplasts hydrophilic coating allows the physician to tailor his dip. Dhabuwala et al. reported zones of inhibition (ZOI) against S. epidermidis and E. coli with a dip solution of rifampicin and gentamicin that were equal or better than those created from the AMS product or a Coloplast device dipped in vancomycin and gentamicin [16,17]. While Dhabuwala et al.s dip is attractive, it is expensive ($70290), requires time-consuming
B

Figure 3 Biolm on implant components removed for non infection reasons.

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4 mixing, and stains cloth and oor. In our opinion, the ideal dip solution would be one that would be inexpensive and off the shelf not requiring mixing. The antibiotics should be effective against the skin bacteria but also should have activity against the more pathogenic organisms that seem to be the usual infecting bacteria in the era of infection retardant coated components. We report out experience dipping the Coloplast Titan coated material into a variety of antibiotics and testing its ability to create ZOI against both common skin organisms and the more pathogenic infecting organisms. We compare ZOI created with these dips vs. InhibiZone coated strips.

Wilson et al. 4. Pseudomonas aeruginosa Strain ATCC 9027; 5. E. faecalis (vancomycin resistant E. faecalis [VRE]) Strain ATCC 51575. The antibiotic solutions for the dips were: 1. 600 mg (1 vial) rifampicin (Rifampin, Alcon Laboratories Inc. Fort Worth, TX, USA) and 100 mg (1 vial) minocycline (Minocin, Medicis Pharmaceutical Corp, Scottsdale, AZ, USA) individually reconstituted with sterile water according to the manufacturers instructions and diluted with an equal volume of saline. This was meant to duplicate InhibiZone. 2. 30 cc of ophthalmic solution of 10,000 units/mL polymyxin B and trimethoprim, and trimethoprim 1 mg/mL (Polytrim) undiluted (cost $2466). 3. 30 cc of Polytrim diluted 1:1 with sterile saline. 4. 100,000 units of bacitracin (two vials) as a powder reconstituted with sterile water as per manufacturers instruction (cost $24). 5. 800 mg/mL sulfamethoxazole and 160 mg/mL trimethoprim (trimehtoprim/sulfamethoxazole) (one 10 cc vial) meant for intravenous infusion diluted 1:1 and 1:3 with injectable saline (cost $24 and $8). 6. 600 mg rifampicin and 50 cc Trimethoprim/ sulfamethoxazole diluted with sterile saline 1:1 (cost $79299). Statistical analysis of the difference between Titan ZOIs obtained with each antibiotic dip and the ZOI achieved with InhibiZone strips was determined using paired t-test. All data are expressed as the mean standard deviation (SD). Differences between treatments were considered to be signicant at P < 0.01.
Results

Methods and Materials

We evaluated and compared the effectiveness of the coated Coloplast Titan with all the antibiotic dips using saline-dipped material as a control. The comparison was achieved through the use of the ZOI susceptibility test that is used to provide a qualitative and semiquantitative determination of antimicrobial activity. The antimicrobial activity is determined by the presence or absence of a zone of inhibition surrounding the test material. Six portions of each test material were dipped in either an antibiotic solution or a saline solution prior to exposure to the challenge organism. The wetted samples were individually placed on the surface of Mueller Hinton agar plate that had been inoculated with one of the test organisms. This inoculated plate was incubated at conditions appropriate for growth of the test organism. Following incubation for 24 hours, the plates were observed for a ZOI surrounding or under the test material. The presence of a ZOI provides a qualitative indication of the ability of the treated test material to leach out (elute) into the growth medium and inhibit of the growth of the test organisms. Width of the zones was measured in mm, and the best and worst ZOI were eliminated leaving four specic zones to be reported. ZOIs of the Coloplast Titan for each of the medicated solutions were compared with ZOI created by undipped strips of a sterile InhibiZone coated IPP placed on plates of the identical bacteria. The test organisms were: 1. S. epidermidis (methicillin resistant Staphylococcus aureus [MSRA]) Strain ATCC 51625; 2. S. lugdunensis Strain ATCC 43809; 3. S. aureus (MSRE) Strain ATCC 33591;
J Sex Med **;**:****

Hydrophilic-coated Coloplast strips dipped in bacitracin did not generate signicant bacterial death. All other solutions had ZOI as wide as or wider than a device treated with InhibiZone. Undiluted Polytrim ophthalmic solution had good ZOI to all organisms and as good as or better than the InhibiZone strips, but the ZOI were diminished if the ophthalmic solution was diluted 1:1 with saline. Interestingly enough, dipping the Coloplast strips in rifampicin and minocycline showed signicantly greater ZOI against the ve bacteria than the InhibiZone strips (Table 1). Notably there was no activity against Pseudomonas with either implant with this dip (Figure 4).

Dip Suggestions for Coloplast Prosthesis


1.52*** 0.41*** 1.1*** 0.52***

5 Trimethoprim/sulfamethoxazole showed the best ZOI against all bacteria and larger ZOI than InhibiZone strips against all bacteria (P < 0.01) including activity against Pseudomonas. The addition of rifampicin to the trimehtoprim/ sulfamethoxazole did not improve its activity and this combination adds expense and is messy to use (Figure 4).

Zones of inhibition (mm) of different antibiotics dips for Coloplast Titan IPP versus AMS InhibiZone coated IPP compared with AMS InhibiZone coated IPP

1.6 10.17

0.5

Bacitracin

Titan

0.5

0.5

0.8

3.17

0.96

0.5

0 0

0.58** 11.25

1.26** 10.75

11.25

AMS

10

0.5

10.67

11.5

11

AMS

Discussion

Bactrim/rifampin

In this article we report data that show one vial of IV trimehtoprim/sulfamethoxazole diluted with a small amount of saline creates ZOI equivalent or better than rifampicin/minocycline against common infecting skin organisms such as S. epidermidis and S. lugdunensis. Zones on the Titan prosthesis against the more pathogenic infecting organisms like S. aureus, Pseudomonas, and Enterococcus [17] are also demonstrated to be statistically signicantly better than InhibiZone. Undiluted trimethoprim/polymixin B ophthalmic solution (Polytrim) showed almost equal efcacy compared with trimehtoprim/sulfamethoxazole and more activity than InhibiZone for the more aggressive bacteria. Polytrim can be substituted as the dip if trimehtoprim/sulfamethoxazole is unavailable, as is currently the case in the United States. This common ophthalmic solution is widely available in inexpensive generic versions. It appears that the common denominator of effectiveness in both trimehtoprim/sulfamethoxazole and Polytrim is the drug trimethoprim. A criticism of this study would be that the Titan ZOI were only followed 24 hours. Future studies are planned that will remove the strips from the ZOI and replace the dipped Titan strips onto fresh agar plates with new bacteria. This will be done each 24 hours and will track how long the elution continues by measuring the new ZOIs. In our opinion, however, there is probably no need for this additional information as it is believed that bacterial biolm formation is complete by 46 hours [16]. Subsequent elution of drugs beyond this time period would not be benecial because the bacteria are protected from the antibiotics by the biolm. The infection retardant coatings allow antibiotics to elute off the implant surface into the tissue spaces surrounding the implant components. Our theory is that antibiotics eluting off the component surfaces affect the skin organisms like S. epidermidis and diminish their attachment to the compoJ Sex Med **;**:****

0.58**

0.5**

0.96 18.25

0.5

11.25

0.96** 11.25

10

0 6.25 0 0.5***

Bactrim

16.75

1.52*** 15.75

18.5

Titan

0.41***

10.17

11

11.5

Diluted polytrim

0.77 10.67 0.58** 10.75 0.5 13.25 0.96* 10.75 0.5 1

AMS

0.51***
*, **, and ***indicate signicant difference at P < 0.01, P < 0.001, and P < 0.0001, respectively. IPP = inatable penile prosthesis; AMS = American Medical Systems.

Titan

0.5* 0

1.1***

0.96 0

11.25

11.25

Undiluted polytrim

AMS

0.58*

0.96

10

0.96 10.75

8.75

11.5

Titan

0.5

0.5

11.25

11.25

Rifampin/minocycline

0.5**

0.5**

Staphylococcus 15.75 epidermidis Staphylococcus 18.25 lugdunensis Staphylococcus 16 aureus Pseudomonas 0 aeruginosa Enterococcus 15.5 faecalis

Table 1

Titan

0**

10.25

AMS

2.25

0.5*

0.5

14

0.82** 10.75

AMS

0.5**

0.1**

0.5

16.75

16.5

14.5

Titan

Wilson et al.

Figure 4 Zones of inhibition (mm) of different antibiotics dips for Coloplast Titan IPP versus AMS InhibiZone coated IPP. *, ** & *** indicate signicant difference at P < 0.01, P < 0.001 & P < 0.0001, respectively.

nents so that clinical infection is less likely to occur. Wolter and Hellstrom demonstrated antimicrobial activity of gentamicin/bacitracin-dipped Coloplast implant strips at 3 days in rabbits for S. epidermidis but no activity against S. aureus, E. coli, and Pseudomonas [7]. Bacteria can still be cultured from these patients implant spaces [13,14], but
J Sex Med **;**:****

two recent series showed the chance of the bacteria causing a clinical infection is signicantly diminished by the coated implant when compared to non-coated ones. Eid showed a diminution of risk of infection from 5% to 2% in 720 patients using both AMS and Coloplast-coated implants when compared with the non-coated components [18].

Dip Suggestions for Coloplast Prosthesis In patients prospectively followed, Dhabuwala reported nearly identical very low infection rates of rifampin/gentamicin-dipped Coloplast IPP when compared with his own series with the AMS InhibiZone-coated IPP [19]. A revision operation carries an increased risk of infection of 10% and Henry et al. has shown the infection retardant coatings have little effect of decreasing the risk of infection unless wash out and complete component exchange is performed [19,20]. Obviously, the bacteria causing revision infection are those that were inoculated into the tissue spaces surrounding the implant components at the rst operation and are protected by biolm from the antibiotics eluting off the replacement implant [20,21]. The amount of antibiotics that elute off the AMS implant is less than one oral dose of the two antibiotics according to AMS training manuals. While this small amount of antibiotics apparently is enough to discourage the growth of weakly pathogenic opportunistic skin organisms like CNS, it is difcult to believe this small amount of these specic antibiotics would, after contamination, prevent growth with a toxic organism like E. faecalis, or Pseudomonas. When we dipped the Coloplast implant in rifampicin/minocycline at concentrations similar to those produced by InhibiZone technology, there was no ZOI against Pseudomonas and only very weak ZOI against all of the more pathogenic non-skin organisms (Figure 4). The AMS devices dosage of antibiotic and specic choice of antibiotic coating was approved by the FDA and presumably would be difcult to alter without a signicant pharmacologic study. This may prove to be a disadvantage in the changing bacteriology during the era of the coated implant and it leaves no opportunity for use of newly emergent biolm control agents like signal inhibitors [22]. There has been a remarkable decrease in device-related infection with the current infection retardant coated implants. Nevertheless, while the incidence of infection is signicantly lower, in those infections that do occur, the virulence is, in our experience higher. The infection retardant coatings seemed to have reduced the skin organism infections that composed approximately three fourths of implant infections. If we are to impact the remaining more pathogenic infections, we must consider structuring the implant to elute antibiotics aimed at these organisms while still preserving activity for the weaker skin organisms. That seems to be the advantage of the Coloplast

7 hydrophilic coatingit can be tailored to the changing local pattern of microbial pathogens and to the state of the current knowledge of implant infections. Our recent testing indicates inexpensive trimethoprim/sulfa solution has a wide spectrum of activity against bacteria found on the skin and also the more pathogenic ones. Nevertheless, the Coloplast hydrophilic coating gives the physician added exibility. For example, when dipping in trimehtoprim/sulfamethoxazole, we might consider adding an antifungal drug-like ketoconazole to the dip in diabetic patients to target Candida. Similarly, when the new family of biolm blockers becomes commercially available, these would be ideal additions to the dip.
Conclusion

The Coloplast Titan IPP hydrophilic coating allows exibility in selecting dips that will allow subsequent elution of chosen antibiotics or other drugs into the implant spaces. The era of infection retardant coatings has altered the prominent bacteria causing IPP device infection. Dipping the Coloplast IPP components in a solution of trimethoprim/sulfamethoxazole is effective in providing antibiotics in the implant space tailored to current infecting organisms.
Corresponding Author: Emad A. Salem, MD, Department of Urology, Zagazig University, 42 Mostafa Foad St.Manshiet Abaza, Zagazig, Sharkia, 44511, Egypt. Tel: (2) 055 2317595; Fax: (2) 055 228 7567; E-mail: dr_emadsalem@yahoo.com Conict of Interest: Wilson SK: AMS & Coloplast consultant. Salem EA: None. Costerton W: None.
Statement of Authorship

Category 1
(a) Conception and Design Steven K. Wilson; Emad A. Salem; William Costerton (b) Acquisition of Data Steven K. Wilson; Emad A. Salem (c) Analysis and Interpretation of Data Steven K. Wilson; Emad A. Salem; William Costerton

Category 2
(a) Drafting the Article Steven K. Wilson; Emad A. Salem; William Costerton J Sex Med **;**:****

8
(b) Revising It for Intellectual Content Steven K. Wilson; Emad A. Salem

Wilson et al.
vascular surgery for erectile dysfunction. J Sex Med 2010;7(1 Pt 2):50123. Sausville J, Gupta G, Forrest G, Chai T. Salmonella infection of a penile prosthesis. J Sex Med 2009;6:148790. Bruner B, Nehra A, McPhail EF, Higuchi T, Karau M, Patel R. Sonication of infected genitourinary prosthetics for detection of microorganisms in biolms. J Urol 2010;183(No. 4):e492. Kava BR, Kanagarajah P, Ayuyathurai R. Contemporary revision penile prosthesis surgery is not associated with a high risk of colonization or infection. A single surgeon series. J Sex Med 2011;8:15406. Henry GD, Wilson SK, Delk JR, et al. Penile prosthesis culture during revision surgery: Multicenter study. J Urol 2004;172:1536. Costerton JW, Stewart DS, Greenberg EP. Bacterial biolms: A common cause of persistent infection. Science 1999;284: 131822. Silverstein AD, Henry GD, Evans B, et al. Biolm formation on clinically non-infected penile prostheses. J Urol 2006;176: 100811. Dhabuwala C, Kumar A, John A, Rajpurkar A. Search of an ideal solution for the pre-immersion of Titan penile implant and comparison with InhibiZone. J Urol 2010;183(No. 4 suppl.):e489. Henry GD, Wilson SK, Delk JR 2nd, Carson CC, Wiygul J, Tornehl C, Cleves MA, Silverstein A, Donatucci CF. Revision washout decreases penile prosthesis infection in revision surgery: A multicenter study. J Urol 2005;173:8992. Dhabuwala CB. In vitro assessment of antimicrobial properties of rifampin-coated Titan Coloplast penile implants and comparison with Inhibizone. J Sex Med 2010;7: 35169. Henry GD, Wilson SK, Delk JR, et al. Revision washout decreases penile prosthesis infection in revision surgery: A multicenter study. J Urol 2005;173:89. Wilson SK, Zumbe J, Henry GD, Salem EA, Delk JR, Cleves MA. Infection reduction using antibiotic-coated inatable penile prosthesis. Urology 2007;70:33740. Balban N. 2008. Role of signaling in biolms. J. W. Costerton series editor. Second in the 20 book series on Biolms to be published by Springer.

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Category 3
(a) Final Approval of the Completed Article Steven K. Wilson; Emad A. Salem; William Costerton
References 1 Wilson SK, Delk JR, Salem EA, Cleves M. Long-term survival of inatable penile prostheses. Single surgical group experience with 2384 rst time implants spanning two decades. J Sex Med 2007;4:10749. 2 Jarrow JP. Risk factors for penile prosthetic infection. J Urol 1996;156:4024. 3 Wilson SK, Carson CC, Cleves MA, Delk JR. Quantifying risk of penile prosthesis infection with elevated glycosylated hemoglobin. J Urol 1998;159:15379. 4 Wilson SK, Henry GD, Delk JR, Cleves MA. Prevention of infection in revision of penile prosthesis using antibiotic coated prosthesis and Mulcahy salvage protocol. 2005;173:89 92. 5 Carson CC, Mulcahy JJ. 7-year infection-related revision rates for nave inatable penile prosthesis implants: Antibiotic impregnated vs. non-impregnated. J Urol 2010;183(No. 4 suppl):e488. 6 Mulcahy JJ, Carson CC. Long-term infection rates in diabetic patients implanted with antibiotic-impregnated versus nonimpregnated inatable penile prostheses: 7-year outcomes. J Urol 2010;183(No. 4 suppl):e489. 7 Wolter CE, Hellstrom WJG. The hydrophiliccoated inatable penile prosthesis: 1-year experience. J Sex Med 2004; 1:2214. 8 Wilson SK, Delk JR. Inatable penile implant infection: Predisposing factors and treatment suggestions. J Urol 1995; 153:65961. 9 Mulcahy JJ. Long-term experience with salvage of infected penile implants. J Urol 2000;163:4812. 10 Hellstrom WJ, Montague DK, Moncada I, Carson C, Minhas S, Faria G, Krishnamurti S. Implants, mechanical devices, and

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