No touch surgical technique for penile prosthesis implantation

Infection Prevention

As advancements in the design and manufacturing process of the IPP improved its mechanical survival infection has emerged as the leading cause of implant failure. Although relatively infrequent (varying from .06% to 8.9%) infection of a penile prosthesis results in serious medical consequences for the bearer, requiring complete removal of the device and permanent loss of penile size and anatomy. Bacterial contamination of the device occurs during the surgery, and is caused by allowing direct or indirect contact of the prosthesis with the patient's skin. Over 70% of infections form from skin organisms including Staphylococcus epidermis, aureus, streptococcus and Candida albicans.

Traditional strategies to combat infections aim at decreasing skin colony count such as scrubbing skin preparation with alcohol and chlorhexidine or kill bacteria once the implant is contaminated by skin flora such as intravenous antibiotics, antibiotic irrigation and antibiotic-coated implants. The “No-Touch” technique is unique in that it aims at preventing bacterial contamination of the prosthesis by completely eliminating contact of the device with the skin.

Paired with the antibiotic-coated implant, the “No Touch” Technique decreases infection to a rate of 0.46%, opposing the traditional method which has an infection rate of 5%. The use of an antibiotic-coated implant and a no-touch surgical technique with skin preparation measures and peri-operative antibiotic use has been found to be of high importance in the prevention of infection among penile implants. J. Francois Eid developed his no-touch technique in 2006 on the hypothesis that eliminating any contact between the prosthesis and the skin, either directly or indirectly via surgical instruments or gloves, should reduce the incidence of contamination of the device with skin flora responsible for infection.

“No-Touch” Surgical Technique

Three days prior to the procedure, a patient is placed on oral fluoroquinolone, an antibacterial drug. During this time, the patient scrubs their lower abdomen and genitals daily with chlorhexidine soap. On the day of the surgery, Vancomycin and Gentamicin are administered intravenously one to two hours prior to the procedure. The lower abdomen and genitals are shaved, scrubbed for five minutes with a Chlorhexidine sponge and prepped with Chorhexidine/Alcohol applicator. The area is then draped with a surgical drape and a Vi Drape® over the genitalia. Before the incision is made, a Foley catheter is inserted in the bladder through the urethra.

A 3-cm scrotal incision is made on the penoscrotal raphe and carried down through the subcutaneous tissue to the Buck's fascia. A Scott retractor, a flexible device that holds open the skin of the surgical site, is applied to the area.

Up until this stage of the surgery, the process has been consistent with the sanitary practices associated with standard surgical sterility. At this stage of the “No-Touch” Technique, after the incision has been made, all instruments, including surgical gloves that have touched skin are discarded. A loose drape is then deployed over the entire surgical field and secured at the periphery with adhesive strips. A small opening in the drape is then made overlying the incision and yellow hooks utilized to secure the edges of the opening to the edges of the incision, completely covering and isolating the patient's skin. At this point new instruments and equipment are replaced and the entire prosthesis is inserted through the small opening of the loose drape. The loose drape allows for manipulation of the penis and scrotum required for this procedure without touching the skin.

Implantation of the Inflatable Penile Pump (IPP)

Implantation of the device continues with an incision and dilation of corpora, sizing and placing the penile cylinders, and placement of the pump in the scrotum and the reservoir in the retropubic space. Saline is used throughout the implantation for irrigation. Once the corporotomies are closed and all of the tubing and components of the prosthesis covered with a layer of Buck's fascia, subcutaneous tissues are closed and the “No-Touch” drape is removed and skin closed.