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

Abstract Background Penile prosthesis infection is a serious complication that often requires device explanation, leading to corporal fibrosis, penile shortening, and significant patient distress. Aim To evaluate long-term outcomes of salvage procedure outcomes using malleable penile prostheses (MP) after infected inflatable penile prosthesis (IPP) explantation within the United States Veterans Affairs (VA) healthcare system. Methods We conducted a real-world, retrospective review using the VA Informatics and Computing Infrastructure to identify men ≥18 years who underwent salvage procedures for infected penile prostheses between January 2012 and January 2023. Demographics, comorbidities, surgical details, culture results, and postoperative outcomes were analyzed. Washout protocols were categorized as Mulcahy or non-Mulcahy. Reinfection, MP retention, and IPP conversion were assessed. Outcomes The primary outcomes assessed were prosthesis reinfection, retention of the malleable implant, and subsequent elective conversion to an inflatable prosthesis. Results A total of 76 patients underwent salvage procedures at 30 VA centers, with 61 (80.3%) receiving MP. Median age was 65 years, and 36% had diabetes mellitus. Reinfection occurred in 29.5% of cases, with a significantly higher rate among diabetics (45.5% vs. 20.5%, P = .0403). No significant difference in reinfection rates was found between Mulcahy and non-Mulcahy washout protocols. Among those without reinfection, 70% retained the MP, 28% underwent elective conversion to IPP, and 2% had device removal for non-infectious reasons. The majority of non-Mulcahy protocols included antiseptic and antibiotic combinations such as normal saline, gentamicin, betadine, hydrogen peroxide, and vancomycin. Clinical Implications These findings support malleable salvage as a definitive, low-morbidity treatment option for many patients, especially within a cost-independent system such as the VA. Strengths & Limitations This is the largest real-world, national multi-site analysis of MP salvage outcomes in a national healthcare system, with robust follow-up. Limitations include its retrospective design and variability in washout protocols across centers. Conclusion Salvage with malleable prostheses is a safe and effective strategy following penile prosthesis infection, with high rates of long-term device retention and functional satisfaction.