Intraoperative Irrigation in Inflatable Penile Prosthesis Surgery: Past Lessons, Current Evidence, and Future Directions.

Intraoperative irrigation has become a mainstay in modern penile prosthesis surgery. Though exact origins are unclear, the landmark Mulcahy Salvage Protocol brought specific irrigations to the forefront of prosthesis surgery. Since then, intraoperative irrigation protocols have been modified and adapted for primary and revision cases as well. The prevalence of device biofilm and colonization in revision cases may contribute to the recognized higher risk of infection compared to primary implant surgeries. Evidence demonstrating that washout protocols reduce bacterial load and infectious risk has provided the impetus for guideline statements recommending the use of vigorous mechanical lavage and antimicrobial irrigation for revision cases. Though specific recommendations regarding optimal irrigation selection remain undefined, contemporary evidence suggests that some historic irrigation components, including hydrogen peroxide and high-concentration betadine, should be avoided. Large multi-institutional cohort studies provide a unique avenue for implanters to compare intraoperative irrigation protocols to optimize patient outcomes. PATIENT SUMMARY: We present a literature review summarizing intraoperative irrigation during inflatable penile prosthesis (IPP) surgery in the primary, revision, and salvage settings. While no specific guidelines exist regarding the optimal irrigation cocktail(s) - reflected in the wide variability in irrigant selection across implanters - intraoperative irrigation remains a key aspect of prosthesis surgery and holds meaningful consequences on the patient level to minimize infections. Evidence suggests that hydrogen peroxide and high-concentration betadine should be eliminated from IPP surgery given cytotoxicity and infection risk. Given the infrequent outcome of prosthetic infections, multi-institutional cohort studies provide a practical and unique avenue to accrue the large sample sizes needed to allow for adequately powered investigations regarding intraoperative irrigation.