Systemic Perioperative Antimicrobial Prophylaxis for Penile Prosthesis Implantation: A Systematic Review

Abstract

Background and Objectives: Penile prosthesis infection usually ends in device removal, whereas unnecessarily broad or prolonged prophylaxis causes toxicity and promotes resistance. We assessed whether the systemic perioperative antibacterial or antifungal strategy, dose or duration is associated with infection, infection-related explantation or reoperation or antimicrobial toxicity after primary or revision implantation. Materials and Methods: PubMed, Europe PMC, OpenAlex and ClinicalTrials.gov were searched from inception to 29 August 2026 using two complementary strategies that combined penile-prosthesis terms with antimicrobial-prophylaxis terms and, separately, with infection or explantation terms, without language or date limits, supplemented by related-article expansion and reference-list checking. Comparative primary studies were eligible. Risk of bias was appraised with RoB 2 and ROBINS-I, and random-effects models were fitted where independent cohorts reported compatible data. Results: Of 4947 records, 11 studies were included: one small randomised trial and ten non-randomised studies. The pooled crude frequency of infection or infection-related explantation was 2.50% (95% CI 1.78–3.50; I2 = 89%), a descriptive summary across heterogeneous outcome definitions rather than an estimate of the infection rate under any regimen. Postoperative oral antibiotics were not associated with lower risk (pooled odds ratio 1.16, 95% CI 0.89–1.53). A higher or weight-based gentamicin dose did not reduce infection (pooled odds ratio 0.75, 95% CI 0.26–2.18) but was associated with more acute kidney injury in the single study that reported comparative toxicity. Guideline-defined regimens carried higher adjusted risk in two overlapping cohorts and no difference in two others. Antifungal prophylaxis was associated with lower infection in two overlapping analyses but not in a revision-only cohort, an exploratory finding that has not been independently replicated. An explicit dose was reported by only three studies, a numerical duration by four and the interval between administration and incision by none, which limits comparison between regimens, and all non-randomised studies had serious risk of bias. Conclusions: Current evidence identifies no superior antibacterial regimen and does not support routine prolonged prophylaxis. The exploratory antifungal signal and the preliminary renal safety signal with weight-based gentamicin warrant prospective, standardised multicentre evaluation before either informs routine practice.