Three Weeks Post-Implant, and the Device Is Already in Question
A single patient, three weeks post-implant with early signs of prosthesis infection. The disagreement isn't about whether the device needs to come out — it's about whether tonight's exam still matches the population where immediate salvage and reimplantation actually succeeds.
Frank D., a 61-year-old man recently remarried after losing his first wife to ovarian cancer two years ago, had an inflatable penile prosthesis placed three weeks ago for erectile dysfunction following a radical prostatectomy — a decision he and his new wife had discussed carefully, wanting a full married life together rather than treating the surgery as optional. He presented today with three days of worsening pain and redness at the reservoir site, a low-grade fever of 100.8, and mild tenderness along the pump tubing in the scrotum — no frank pus, no skin breakdown, no device visible or palpable through compromised skin, and nothing suggesting the infection has tracked beyond the implant space itself. He has type 2 diabetes, reasonably controlled, a known risk factor for this exact complication but not, on its own, a reason to change the approach once infection is confirmed.
The decision in front of the team is not whether to remove the device — biofilm on a prosthetic surface is essentially never cleared by antibiotics alone, a settled point nobody at the table is contesting — but whether to remove it and reimplant a new device in the same operation, following the salvage protocol Brant, Ludlow, and Mulcahy described in 1996, or to remove it now and stage reimplantation for months later once the infection has fully resolved. Mulcahy's own long-term series (J Urol, 2000) treated 55 men this way and reported 45 of them — 82% — free of reinfection at follow-up, a real number, but one drawn from patients who, like the original description of the technique, generally lacked frank purulence or device erosion at the time of salvage. Frank's exam matches that population on every finding the series actually selected on. What it does not match is the fever: the salvage literature was built around a local picture, and a systemic sign is the one variable that series never had to weigh, which is why tonight's disagreement is not about whether he resembles those 55 men but about whether the one way he differs from them is the way that matters.
In the operating room, before the incision
I want to salvage this tonight — remove the device, do the full multi-agent washout, and put a new one in before we close. Mulcahy's own long-term series ran 55 men through this and 45 of them, 82%, stayed free of reinfection. Frank has no purulence, no erosion, nothing on exam that puts him outside that population.
I'd hold off on reimplanting today. He has three days of worsening local findings plus a new systemic fever — that's a different trajectory than the erythema-only picture most of the original salvage cohort presented with. If we put a fresh device into a space that's still more actively infected than the exam alone can tell us, we risk losing the second device too, and now he's worse off than if we'd staged it.
Frank's exam looks clean today, but exam and what's actually happening in a closed prosthetic space don't always match — that gap is exactly why salvage series exclude patients who look more infected than his clinic exam alone tells us he is.
I don't think either of you can actually settle this from the clinic exam. Let's go in planning for both — full washout kit and a new device on the back table, but the actual call happens once we see what's really in that space. Frank pus and clear device erosion, we explant and stop there. Reactive fluid with clean margins, we proceed with salvage as planned.
The fever matters, but a low-grade fever three weeks post-implant isn't automatically the same thing as an infection too advanced for salvage — it's a reason to look carefully before deciding, not a reason to decide before looking.
Agreed: proceed to the operating room with both salvage and staged-explant plans ready; the intraoperative finding of purulence versus reactive fluid decides which path is taken, rather than committing from the clinic exam.
Not agreed in advance, deliberately: whether tonight's fever should have already ruled out salvage. The prosthetic surgeon and second urologist did not resolve that disagreement before entering the room — they resolved instead to let it be answered by what was actually found, which both accepted as the more honest approach than guessing further from outside the body.