IJIR: Your Sexual Medicine Journal https://doi.org/10.1038/s41443-020-0256-2 ARTICLE Prospective analysis of cultures from the Furlow insertion tool: a possible etiology for penile prosthesis infections Faysal A. Yafi 1 ● James Furr 2 ● Farouk M. El-Khatib 1 ● Koenraad van Renterghem 3 ● Luca Venturino 4 ● Robert Andrianne 5 ● Daniar Osmonov 6 ● David Ralph 4 ● Javier Romero Otero 7 ● Maxime Sempels 5 ● Georgios Hatzichristodoulou 8 ● Aaron Lentz 9 ● Steven K. Wilson 10 Received: 3 February 2020 / Revised: 2 March 2020 / Accepted: 6 March 2020 © The Author(s), under exclusive licence to Springer Nature Limited 2020 Abstract The most dreaded complication of penile prosthesis (PP) implantation is device infection. We sought to assess whether inadequate cleaning and sterilization of the reusable Furlow inserter may represent one of the last etiologies of infection in PP patients. We performed a prospective analysis of cultures of the Furlow inserter used for PP surgeries from seven centers between May 1st and June 30th, 2019. Once the Furlow was received for surgery, the surgical team inspected the device for assembly status (disassembled or not) and the presence of visible stains, pieces of tissue or discoloration on either the interior of the barrel or the plunger. Swab aerobic and anaerobic bacterial and fungal cultures were then obtained from the internal component, after removal from the external component if assembled, and after introduction and immediate removal from the external component if disassembled. A total of 83 Furlow devices were cultured. Median age of surgical instrument was 4 years (2–10 years). Methods of sterilization included autoclave, wet autoclave, steam, and Sterad. Median time from sterilization was 3 days (1–22). On initial presentation, 79 devices were disassembled (95.1%) and 4 devices were still assembled (4.9%). Three external components were discolored (3.6%), while internal components demonstrated two stains (2.4%) indicative of improper cleaning which were thought to be residual blood products. Overall, 2/83 (2.4%) devices revealed positive swab cultures for Staphylococcus epidermidis. Swab cultures were negative for fungi and anaerobic bacteria. This patient cohort will continue to be followed to see if device infection occurs but it is unlikely to be meaningful since contaminated Furlows were discarded. Improper cleaning and/or sterilization of the Furlow Insertion Instrument may represent a source of infection for patients undergoing PP implantation. Introduction In patients refractory to the medical management of erectile dysfunction, penile prosthesis (PP) has been the long- standing gold standard with excellent satisfaction and relatively low complication rates. The most dreaded com- plication, although rare, is device infection. Numerous studies over the past four decades have been devoted to the minimization of device infection. Advancement in surgical techniques, newer infection retardant coatings, optimization of patient factors and preoperative antibiotics have all led to the decrease in infections [1–4]. However, infections still occur in an albeit small <1% of primary implantations and 2–5% of diabetic patients [5, 6]. Today, nearly all implanters utilize the Furlow insertion tool to facilitate placement of the sutures via the inside of the corpora through the tip of the glans. This instrument was introduced by Dr Furlow in 1978 and consists of two * Faysal A. Yafi Fyafi@uci.edu 1 University of California Irvine, Irvine, CA, USA 2 University of Oklahoma, Oklahoma City, OK, USA 3 Jessa Hospital, Hasselt, Belgium 4 University College London Hospital, London, England 5 University Hospital of Liège, Liege, Belgium 6 University Hospital Schleswig-Holstein, Kiel, Germany 7 Hospital Universitario 12 de Octubre, Madrid, Spain 8 Martha-Maria Hospital, University of Erlangen-Nuremberg, Nuremberg, Germany 9 Duke Raleigh Hospital, Raleigh, NC, USA 10 Institute for Urologic Excellence, La Quinta, CA, USA 1234567890();,: 1234567890();,: