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Prosthetic Infection and Biofilm Protocols

Prosthetic infections in urology, of the inflatable penile prosthesis (IPP), artificial urinary sphincter (AUS) and pelvic mesh, are governed by a pharmacology fundamentally different from soft-tissue or urinary-tract infection. Bacteria and fungi adherent to synthetic surfaces form biofilms that confer antibiotic tolerance orders of magnitude greater than the planktonic state, rendering standard MIC-based antimicrobial therapy inadequate and making infection prevention far more important than infection treatment. A clinically infected implant usually requires surgical source control; asymptomatic colonization is not by itself an indication for explantation.[1][2]

This article is the pharmacology-oriented synthesis of protocols that sit at the interface of perioperative antimicrobial prophylaxis, dipping and irrigation solutions, and device-specific chemistry. For the surgical-technique deep-dive on IPP infection, see Penile implants — infection; for the general perioperative framework, see Perioperative antibiotic prophylaxis.

Biofilm biology — why prosthetic infections are different​

Within hours of implantation, planktonic bacteria and fungi adherent to a synthetic surface secrete an extracellular polymeric matrix that:

  • Reduces antibiotic penetration to the encased cell population
  • Induces a low-metabolic-activity subpopulation (persister cells) refractory to cell-wall-active and protein-synthesis-targeting agents
  • Facilitates horizontal gene transfer of resistance determinants
  • Is disrupted mechanically more effectively than chemically, which is the rationale for jet-irrigation approaches

Standard susceptibility testing alone cannot predict eradication of an established biofilm; cultures still guide antimicrobial treatment alongside source control. Measures that reduce contamination during implantation can lower infection risk, while established biofilm is difficult to eradicate with antibiotics.[1][2]

The contemporary microbial landscape​

Contemporary device-infection microbiology has shifted meaningfully over two decades. The Gross 2017 multicenter analysis of 227 intraoperative cultures from infected three-piece IPPs (2002–2016; proportions are of the 153 positive cultures) described the spectrum:[3]

Organism classApproximate share of modern IPP infections
Gram-positive organisms (including coagulase-negative Staphylococcus)73% of positive cultures
Gram-negative organisms39% of positive cultures
MRSA9.2% of positive cultures
Anaerobes10.5% of positive cultures
Candida spp.11.1% of positive cultures
Polymicrobial25% of positive cultures
No growth33% of all intraoperative cultures

A dedicated retrospective series found fungal involvement in 26/217 infected devices (12%), often in patients with diabetes or excess weight.[29] A broader review describes this evolving microbiology.[4] In the separate Gross 2017 infected-IPP culture series, the organisms cultured were covered by the then-current AUA and EAU regimens in only 62–86% of cases.[3] The current AUA Best Practice Statement (2019, published 2020) advises prophylaxis covering skin flora for prosthetic implantation, specifically coagulase-negative staphylococci and gram-negative bacilli including Pseudomonas, limited to the procedure with no dosing after wound closure; its Table V lists a duration under 24 hours for implanted prostheses.[32] For AUS, IPP and sacral neuromodulator implantation, AUA Table V lists an aminoglycoside paired with a first- or second-generation cephalosporin or vancomycin; aztreonam can replace the aminoglycoside in renal insufficiency. The procedure row lists an aminopenicillin/β-lactamase inhibitor alternative, while a table-wide footnote lists clindamycin for penicillin allergy and another discourages routine vancomycin. The ASHP/IDSA 2013 guideline lists cefazolin with or without an aminoglycoside or aztreonam for implanted urologic prostheses.[32][36]

IPP prophylaxis — the PUMP reassessment​

The Prosthetic Urology Multi-Institutional Partnership (PUMP) has reported retrospective findings that challenge the AUA-listed vancomycin-plus-gentamicin regimen for primary IPP implantation.[5][32]

  • Barham 2023. In this J Urol PUMP analysis of 4,161 primary IPPs, vancomycin plus gentamicin alone was associated with a higher adjusted hazard of infection than pooled other regimens (HR 2.7; 95% CI 1.4–5.4; p = 0.004). Crude infection rates were similar (1.0% versus 1.2%). Antifungal use was associated with lower adjusted hazard (HR 0.08).[5]
  • Abou Chawareb 2025. In 5,261 patients from 16 centers, IV antifungal use was independently associated with significantly lower infection risk (OR 0.22; p < 0.001). Postoperative oral antibiotics and IV prophylaxis >24 h showed no protective effect. Diabetes (OR 1.68) and prior IPP infection (OR 4.67) were the dominant patient-level risk factors.[6]
  • Rezaee 2020 (diabetic subgroup). AUA-adherent prophylaxis yielded 5.6% infection rates versus 1.9% for nonstandard regimens in diabetic primary IPPs. Comparator regimens included vancomycin-gentamicin-fluoroquinolone, clindamycin-fluoroquinolone, and vancomycin-fluoroquinolone combinations.[7]

Practice-pattern gap: In Brant 2023, use of AUA-adherent antimicrobial regimens increased by 42% after the April 2008 AUA Best Practice Statement.[8] Vancomycin and gentamicin use also increased separately.[8] The 2025 Sex Med Rev from the 5th International Consultation on Sexual Medicine is the current expert-consensus counterpoint pending formal BPS revision.[9]

Applying the prophylaxis evidence​

Use the institutional implant protocol, local susceptibility data and patient-specific renal function and allergies to select perioperative coverage. The PUMP antifungal association (OR 0.22, or 78% lower adjusted odds) supports considering an antifungal strategy.[6]

Administer prophylaxis before incision, allowing time for a vancomycin infusion when indicated, and avoid routine extended courses after an uncomplicated implantation.[6][10]

In a 2025 SMSNA/SUPS/GURS survey of 112 implanters, respondents reported perioperative antifungal use in 25.9% of primary, 72.3% of diabetic primary, 65.2% of salvage and 48.2% of revision IPP scenarios.[11] Addition of antifungal to hydrophilic-dip solutions preserved antibacterial activity for the studied mixtures on bench testing.[12]

See Antifungals for the detailed case for fluconazole in IPP surgery.

Device-specific dipping — InhibiZone vs hydrophilic Titan​

Dipping and irrigation chemistry is fundamentally device-specific. Confusing the two is a common and consequential error.

AMS 700 InhibiZone (Boston Scientific)​

  • Factory-applied rifampin plus minocycline antibiotic surface treatment, intended to elute from the device surface in a warm, moist environment
  • The AMS 700 IFU contraindicates implantation during active urogenital infection or skin infection in the surgical area. InhibiZone is contraindicated with rifampin, minocycline, or other tetracycline sensitivity and systemic lupus erythematosus. The IFU advises caution with hepatic or renal disease, warns that alcohol, acetone, and other nonpolar solvents may remove surface antibiotics, and says InhibiZone does not replace routine antibiotic prophylaxis.[27]
  • Do not soak InhibiZone components in saline or other solutions before implantation. The AMS 700 operating-room manual keeps prepared treated components on an empty sterile tray or basin because soaking elutes antibiotics, turning the solution orange and reducing drug on the surface. The IFU permits a brief sterile rinse or dip immediately before implantation.[27]
  • Select field irrigation separately from device preparation using the operative protocol; see the limitations of CHG evidence below
  • Carson 2004 retrospective manufacturer-form cohort: infection at 180 days was reported in 0.68% of 2,261 InhibiZone versus 1.61% of 1,944 untreated primary implants; mean follow-up was 5 versus 8 months. Carson 2011 voluntary manufacturer registry: infection-related revision occurred in 1.1% of 35,737 treated versus 2.5% of 3,268 untreated initial implants, with follow-up up to 7.7 years.[13][14]

Coloplast Titan (hydrophilic)​

  • Polyvinylpyrrolidone (PVP) surface that absorbs surgeon-applied antibiotic solution
  • Use the manufacturer's hydrophilic-device preparation instructions and a compatible aqueous solution; dipping does not replace systemic prophylaxis or aseptic technique.[28]
  • Vancomycin plus gentamicin was associated with fewer infections than other dips pooled in Towe 2020 (1.4% versus 6.4%; 468 diabetic Titan recipients with dip data). This retrospective comparison pooled other dips.[15]
  • Selected antifungal-containing mixtures retained antibacterial activity in vitro.[12]
  • Wolter and Hellstrom 2004 manufacturer data: at one year, infection was reported in 25/2,357 (1.06%) coated Titan versus 10/482 (2.07%) noncoated Alpha-1 implants. Serefoglu 2012 voluntary manufacturer registry: infection-related revision was reported for 1.4% of 29,360 hydrophilic-coated implants (follow-up up to 8 years) versus 4.6% of 7,031 noncoated implants (up to 11 years); dip agents were not tabulated.[16][17]

Irrisept (0.05% chlorhexidine gluconate) — the 2026 device-specific pivot​

Irrisept contains 0.05% CHG in sterile water and is cleared for mechanical cleansing and removal of wound debris, including microorganisms. The label calls for approximately one minute of contact followed by saline rinsing, and prohibits use with CHG allergy.[30]

Device-specific outcomes — the critical point​

Ivan 2026 reported two retrospective multicenter cohorts:

DeviceCohort exposure and outcomeInterpretation
AMS 700 InhibiZone (n = 761)Intraoperative CHG use versus no CHG: IPP infection requiring explantation, 1.9% versus 2.0% (p = 0.9); median follow-up 4 versus 8 months.[19]Few infection events and unequal follow-up preclude an equivalence or safety conclusion.
Hydrophilic-coated IPPs (n = 2,150)CHG as irrigant and/or dip versus antimicrobials as irrigant and dip: IPP explant for infection, 4.6% versus 2.1% (p < 0.001); infection in 12% of CHG-exposed revision cases.[20]Use caution with CHG.

Laboratory evidence is mixed and device dependent. Simhal 2024 found greater bacterial reduction with vancomycin plus gentamicin than CHG on hydrophilic discs; both saline and CHG irrigation could remove the adsorbed dip in that model.[21] Karpman 2023 also studied Titan, finding microbial reductions under a different in-vitro protocol.[18] Im 2024 found preserved InhibiZone antimicrobial activity after CHG exposure in vitro.[23]

Helo 2025 independently reported a concerning before-and-after Titan cohort (13/377 infections with CHG versus 0/320 with antibiotic dip/irrigation, in Coloplast hydrophilic-coated devices). Changes over time and patient selection remain potential confounders.[22]

Solutions to avoid​

  • High-concentration povidone-iodine implant irrigation. Manka 2020 (217 patients, single surgeon) associated half-strength Betadine irrigation with higher adjusted infection odds (OR 9.3) in a before-and-after comparison than vancomycin plus gentamicin.[24]
  • Hydrogen peroxide. Tissue cytotoxicity and impaired wound healing, with a theoretical risk of gas embolism in the closed corporal space; dropped from the modern Mulcahy salvage protocol.
  • Other dips in diabetic primary Titan recipients studied by Towe 2020. In 468 patients with dip data, vancomycin plus gentamicin was associated with fewer infections than all other dips pooled (1.4% versus 6.4%); the association persisted after covariate adjustment. Rifampin-containing dips trended toward more infections (p = 0.057), and adding an antifungal had no detected effect.[15]
  • 0.05% CHG on hydrophilic IPP devices. Ivan 2026 data as above.[20]

AUS prophylaxis​

Use a procedure-specific institutional prophylaxis protocol. Sun 2023 (9,775 primary AUS cases) associated guideline-adherent prophylaxis with fewer overall complications or revisions within three months, but did not detect an infection-specific difference within three months (OR 0.89; 95% CI 0.68–1.17).[25]

AUS infection. Device infection is uncommon (under 1% to about 5% in long-term series). It presents with pain, fever, scrotal warmth or erythema, or skin change and calls for explantation of all components, even when only one component appears involved; a washout with immediate replacement has not been consistently shown to work for the AUS, unlike the IPP. Isolated cuff infection without erosion is rare. Wait at least three months before reimplantation. The AUA/GURS/SUFU guideline lists this as a Clinical Principle and applies the same explantation logic to an infected male sling.[33]

IDSA suggests not screening for or treating asymptomatic bacteriuria solely before AUS or penile-prosthesis implantation (weak, very-low-quality evidence), while still giving standard perioperative prophylaxis. Active UTI, systemic infection, and planned urinary mucosal trauma are separate situations.[26] Follow the actual AMS 800 InhibiZone handling precautions rather than borrowing a Titan dipping protocol.[27]

Mesh and sacrocolpopexy​

Select antibiotic prophylaxis by the operation and any concomitant vaginal or bowel entry. Crossing the peritoneum alone is not an indication for metronidazole. Use the gynecologic or bowel-surgery protocol as applicable, including weight-based dosing and redosing for long operations or major blood loss.[31]

For vaginal preparation, povidone-iodine is a labeled option; ACOG permits selected low-alcohol CHG formulations off label. High-alcohol skin preparations must not be substituted for vaginal preparations. Follow formulation-specific instructions and the institutional vaginal-preparation protocol.[31]

Pelvic abscess after mesh sacrocolpopexy: A 2024 French national guideline recommends prompt complete mesh removal, intraoperative cultures, drainage and targeted antibiotics . Antibiotic-only management may be considered only in a nonseptic patient with type-1 macroporous monofilament polypropylene mesh, prior microbiological documentation, multidisciplinary agreement on antibiotic choice and duration, and close monitoring.[37]

Salvage — the Mulcahy washout​

Modified-Mulcahy protocol (for suspected or confirmed IPP infection). Reported infection-free rates are about 82–84% in the salvage literature, from retrospective series; salvage is less suited to systemic or virulent infections.[34][35] In the Gross multicenter retrospective series, 54/58 malleable salvage recipients (93%) remained infection-free over 1–84 months and 17/54 infection-free men (31%) later converted to an inflatable device; a 30-center VA retrospective series reported reinfection in 18/61 (29.5%) malleable salvage recipients.[35][38]

  1. Explant all prosthesis components
  2. After explantation, vigorously irrigate the corporal, scrotal-pump, and reservoir spaces with sequential antiseptic washes; avoid hydrogen peroxide and high-concentration povidone-iodine.[39]
  3. Change all gloves and instruments between explant and reimplant phases
  4. Re-prep and re-drape the field
  5. Replace with a new antibiotic-coated implant

Contemporary 2026 considerations​

  • Obtain appropriate cultures during infected explant/salvage to guide treatment. Molecular testing is not an established routine requirement.
  • Use a fresh device with model-specific surface preparation even in revisions without apparent infection: AMS 700 InhibiZone components have factory-applied rifampin/minocycline, while hydrophilic Titan absorbs a compatible aqueous antimicrobial dip.[27][28]
  • Consider fungal coverage according to infection severity, host risk, prior cultures and local protocol.[4][6]
  • In hydrophilic-device revisions, use caution with 0.05% CHG as an irrigant and/or dip: Ivan 2026 observed infection requiring explantation in 12% of CHG-exposed revision cases in a retrospective cohort.[20]
  • Prior IPP infection is the single largest patient-level risk factor (OR 4.67 in Abou Chawareb 2025)[6]

Evidence Summary​

QuestionEvidence and interpretation
Systemic IPP prophylaxisPUMP retrospective cohorts.[5][6]
Postoperative prophylactic antibioticsNo protective association in the cited cohorts; distinguish prophylaxis from treatment after infected salvage.[6][10]
Antibiotic surface treatment/dippingManufacturer instructions determine preparation; observational infection comparisons do not validate arbitrary mixing recipes.[13][14][15][16][17]
CHG and IPPConcerning hydrophilic-device cohorts; absence of an association on antibiotic-impregnated devices.[19][20][22]
Laboratory compatibilityBench findings depend on coating, organisms and assay.[18][21][23]

Clinical Positioning​

  • Keep a documented local prophylaxis and device-preparation protocol, reconciled with current IFUs and stewardship review.
  • Do not soak InhibiZone components or transfer a hydrophilic-device recipe to them. Confirm the device and coating before opening solutions.[27][28]
  • Consider recent antifungal and CHG evidence without calling observational findings causal or extending them automatically to AUS or mesh.
  • Established implant infection needs a source-control and culture-directed treatment plan.
  • Track local infections, organisms, device type and regimen so changes can be assessed against actual outcomes.

See Also​

References​

1. Wilson SK, Costerton JW. "Biofilm and penile prosthesis infections in the era of coated implants: a review." J Sex Med. 2012;9(1):44–53. doi:10.1111/j.1743-6109.2011.02428.x

2. Eid JF. "Penile implant: review of a 'no-touch' technique." Sex Med Rev. 2016;4(3):294–300. doi:10.1016/j.sxmr.2016.01.002

3. Gross MS, Phillips EA, Carrasquillo RJ, et al. "Multicenter investigation of the microorganisms involved in penile prosthesis infection: an analysis of the efficacy of the AUA and EAU guidelines for penile prosthesis prophylaxis." J Sex Med. 2017;14(3):455–463. doi:10.1016/j.jsxm.2017.01.007

4. Natsos A, Tatanis V, Lekkou A, et al. "Unveiling the hidden perils: a comprehensive review of fungal infections in inflatable penile prosthesis surgery." J Pers Med. 2024;14(6):644. doi:10.3390/jpm14060644

5. Barham DW, Pyrgidis N, Gross MS, et al. "AUA-recommended antibiotic prophylaxis for primary penile implantation results in a higher, not lower, risk for postoperative infection: a multicenter analysis." J Urol. 2023;209(2):399–409. doi:10.1097/JU.0000000000003071

6. Abou Chawareb E, Hammad MAM, Azad B, et al. "Perioperative antimicrobial strategies in inflatable penile prosthesis surgery: associations between antifungals, oral antibiotics, and intravenous antibiotic duration, and infection outcomes." J Urol. 2025;214(6):642–653. doi:10.1097/JU.0000000000004716

7. Rezaee ME, Towe M, Osman MM, et al. "A multicenter investigation examining American Urological Association recommended antibiotic prophylaxis vs nonstandard prophylaxis in preventing device infections in penile prosthesis surgery in diabetic patients." J Urol. 2020;204(5):969–975. doi:10.1097/JU.0000000000001158

8. Brant A, Lewicki P, Punjani N, et al. "Trends in antimicrobial prophylaxis for inflatable penile prosthesis surgery from a large national cohort." Urology. 2023;172:131–137. doi:10.1016/j.urology.2022.11.010

9. Köhler T, Munarriz R, Parker J, et al. "Penile prosthesis for erectile dysfunction: recommendations from the 5th International Consultation on Sexual Medicine." Sex Med Rev. 2025;13(2):144–171. doi:10.1093/sxmrev/qeaf001

10. Dropkin BM, Chisholm LP, Dallmer JD, et al. "Penile prosthesis insertion in the era of antibiotic stewardship — are postoperative antibiotics necessary?" J Urol. 2020;203(3):611–614. doi:10.1097/JU.0000000000000578

11. Abou Chawareb E, Barham DW, Hammad MAM, et al. "Multicenter examination of contemporary penile prosthesis surgery infection prophylaxis practices." J Sex Med. 2025;22(8):1531–1533. doi:10.1093/jsxmed/qdaf145

12. Im B, Giordano A, Winslow A, Hickok N, Chung P. "Addition of antifungal agents to antibiotic solutions does not diminish the antibacterial properties of penile prosthesis hydrophilic surface dips." J Sex Med. 2026;23(2). doi:10.1093/jsxmed/qdaf372

13. Carson CC. "Efficacy of antibiotic impregnation of inflatable penile prostheses in decreasing infection in original implants." J Urol. 2004;171(4):1611–1614. doi:10.1097/01.ju.0000118245.66976.e1

14. Carson CC III, Mulcahy JJ, Harsch MR. "Long-term infection outcomes after original antibiotic impregnated inflatable penile prosthesis implants: up to 7.7 years of follow-up." J Urol. 2011;185(2):614–618. doi:10.1016/j.juro.2010.09.094

15. Towe M, Huynh LM, Osman MM, et al. "Impact of antimicrobial dipping solutions on postoperative infection rates in patients with diabetes undergoing primary insertion of a Coloplast Titan inflatable penile prosthesis." J Sex Med. 2020;17(10):2077–2083. doi:10.1016/j.jsxm.2020.07.009

16. Wolter CE, Hellstrom WJG. "The hydrophilic-coated inflatable penile prosthesis: 1-year experience." J Sex Med. 2004;1(2):221–224. doi:10.1111/j.1743-6109.2004.04032.x

17. Serefoglu EC, Mandava SH, Gokce A, et al. "Long-term revision rate due to infection in hydrophilic-coated inflatable penile prostheses: 11-year follow-up." J Sex Med. 2012;9(8):2182–2186. doi:10.1111/j.1743-6109.2012.02830.x

18. Karpman E, Griggs R, Twomey C, Henry GD. "Dipping Titan implants in Irrisept solution (0.05% chlorhexidine gluconate) and exposure to various aerobic, anaerobic, and fungal species." J Sex Med. 2023;20(7):1025–1031. doi:10.1093/jsxmed/qdad055

19. Ivan SJ, Abou Chawareb E, Hammad M, et al. "0.05% chlorhexidine gluconate is not associated with infection in antibiotic-impregnated inflatable penile prosthesis surgery: results from a large multi-institutional collaborative." J Sex Med. 2026;23(1):qdaf368. doi:10.1093/jsxmed/qdaf368

20. Ivan SJ, Abou Chawareb E, Hammad M, et al. "Intraoperative 0.05% chlorhexidine gluconate utilization is associated with an increased incidence of infection in hydrophilic inflatable penile prosthesis surgery: a multi-institutional cohort study." J Urol. 2026;215(4):460–471. doi:10.1097/JU.0000000000004853

21. Simhal R, Im BH, Shah S, et al. "Antibiotic dip and irrigation solutions confer increased antimicrobial efficacy of inflatable penile prosthesis hydrophilic surfaces compared with 0.05% chlorhexidine gluconate." J Sex Med. 2024;21:816–822. doi:10.1093/jsxmed/qdae073

22. Helo S, Bonakdar Hashemi M, Ziegelmann MJ, et al. "Chlorhexidine gluconate application, diabetes, revision surgery, and extended operative time increase risk for penile implant infection." J Sex Med. 2025;22:508–516. doi:10.1093/jsxmed/qdaf009

23. Im BH, Giordano A, Shah S, et al. "Minocycline-rifampin-impregnated penile prosthesis surfaces retain antimicrobial activity following irrigation with 0.05% chlorhexidine gluconate and antibiotic solutions." J Sex Med. 2024;21:823–826. doi:10.1093/jsxmed/qdae093

24. Manka MG, Yang D, Andrews J, et al. "Intraoperative use of Betadine irrigation is associated with a 9-fold increased likelihood of penile prosthesis infection: results from a retrospective case-control study." Sex Med. 2020;8:422–427. doi:10.1016/j.esxm.2020.05.010

25. Sun HH, Callegari M, Zhou E, et al. "Trends over 20 years of antimicrobial prophylaxis for artificial urinary sphincter surgery." Neurourol Urodyn. 2023;42(6):1421–1430. doi:10.1002/nau.25206

26. Nicolle LE, Gupta K, Bradley SF, et al. "Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America." Clin Infect Dis. 2019;68(10):e83–e110. doi:10.1093/cid/ciy1121

27. Boston Scientific. AMS 700 operating-room manual, 92127382-01C, AMS 700 with MS Pump instructions for use, 92162915-01B, and AMS 800 safety and handling information. Accessed October 3, 2026.

28. Coloplast. Titan penile implants: hydrophilic coating and product information. Accessed September 12, 2026; follow the packaged model-specific IFU.

29. Gross MS, Reinstatler L, Henry GD, et al. "Multicenter investigation of fungal infections of inflatable penile prostheses." J Sex Med. 2019;16:1100–1105. doi:10.1016/j.jsxm.2019.05.003

30. Irrimax. Irrisept product indications and instructions. Accessed September 12, 2026.

31. ACOG. Perioperative pathways: enhanced recovery after surgery. Antimicrobial prophylaxis and vaginal preparation; accessed September 12, 2026.

32. Lightner DJ, Wymer K, Sanchez J, et al. "Best Practice Statement on Urologic Procedures and Antimicrobial Prophylaxis." J Urol. 2020;203(2):351–356. doi:10.1097/JU.0000000000000509

33. Sandhu JS, Breyer B, Comiter C, et al. "Incontinence After Prostate Treatment: AUA/GURS/SUFU Guideline (2019; amended 2024)." American Urological Association; approved June 2024. Statement 32 and accompanying text on AUS/sling infection and erosion.

34. Mellon MJ, Broghammer JR, Henry GD. "The Mulcahy salvage: past and present innovations." J Sex Med. 2015;12(Suppl 7):432–436. doi:10.1111/jsm.12986

35. Gross MS, Phillips EA, Balen A, et al. "The malleable implant salvage technique: infection outcomes after Mulcahy salvage procedure and replacement of infected inflatable penile prosthesis with malleable prosthesis." J Urol. 2016;195(3):694–697. doi:10.1016/j.juro.2015.08.091

36. Bratzler DW, Dellinger EP, Olsen KM, et al. "Clinical practice guidelines for antimicrobial prophylaxis in surgery." Am J Health Syst Pharm. 2013;70(3):195–283. doi:10.2146/ajhp120568

37. Deffieux X, Perrouin-Verbe MA, Campagne-Loiseau S, et al. "Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice." Eur J Obstet Gynecol Reprod Biol. 2024;294:170–179. doi:10.1016/j.ejogrb.2024.01.015

38. Angulo-Llanos L, Sandler MD, Howell NB, Williams A, Masterson TA III. "Outcomes of salvage procedures with malleable implants for penile prosthesis infections in the Veterans Affairs National Medical System: a real-world, multi-surgeon retrospective analysis over a decade." J Sex Med. 2026;23(3):qdag042. doi:10.1093/jsxmed/qdag042

39. Adams ES, Tua-Caraccia RD, Lentz AC. "Narrative review of immediate salvage for penile prosthesis infection." Transl Androl Urol. 2024;13(4):584–595. doi:10.21037/tau-23-277