Erectile Function Following Benign Prostatic Hyperplasia Treatment


Despite the existence of a notable prevalence of ED after prostate surgery, a significant improvement in the International Index of Erectile Function (IIEF) erectile function domain can be found, mainly among patients reporting ED pre-operatively. On the other hand, there is an important risk of deterioration of erectile function after surgery in patients who previously had normal erectile function.33


The gold standard for surgical treatment of BPH remains transurethral resection of the prostate (TURP). Post-operative rates of ED are highly variable, ranging from 4 to 40%31,34–37


One study found no differences in the post-operative rates of ED between patients undergoing TURP and those treated with a holmium laser,46


with similar impact on erectile function.47 Both had associated


RE lowering the IIEF orgasmic function domain in both groups at similar rates. In a comparison of the holmium laser with open prostatectomy, no significant differences were identified for the IIEF erectile function domain before and after 24 months of follow-up (20.3±6.6 pre-operatively and 22.3±4 post-operatively in the laser group).48


because of the different methods


used for assessing ED. The rate of impotency in the AUA co-operative study involving 1,000 men was 13%.38


Some studies have identified the


utility of using objective parameters to evaluate the incidence of impotence. Moreover, pre-existing morbidity and patient condition before TURP, such as the presence of diabetes or an IIEF score


The ED seen immediately after TURP may be temporary. Both neuropraxia from thermal injury and/or the emotional stress of surgery have been proposed as possible mechanisms underlying the temporary nature of ED in some men following TURP.40


RE is the most


common complication of TURP, occurring in more than 50% of patients.35,41,42


This adverse effect is important for young patients and for this reason adequate patient education prior to treatment is necessary.


A few studies have shown that some patients may experience improvement in erectile function after TURP.33,43


One study followed


280 patients treated with this technique, finding that 17% reported improved sexual activity and erectile quality compared with the pre-operative report.43


Another endoscopic procedure is transurethral incision of the prostate. This technique should be reserved for young men and men with smaller prostates. The rate of RE is lower than in patients undergoing TURP (35 versus 68%) and the proportion of ED is very similar (4 versus 5%).44


Retropubic and suprapubic prostatectomy are other options for surgical treatment of BPH. As these open approaches are the most invasive procedures, they are usually last resorts, as when the prostate is quite large, the patient cannot be placed in the lithotomy position or there is a concomitant bladder condition. Both techniques are associated with rates of ED over 3–5% and rates of RE of almost 100%.45


Minimally Invasive Procedures


Several other surgical treatments for BPH have been developed. All are considered to be minimally invasive, and some can be achieved using only local anaesthetic. These techniques include laser prostatectomy, transurethral needle ablation (TUNA) and various forms of microwave therapy such as transurethral microwave thermotherapy (TUMT). A few studies have evaluated the rates of adverse sexual effects after these treatments. When reported, ED does not occur or is, at worst, minimal.


Laser surgery of the prostate can be performed with one of several lasers, such as the neodymium-doped yttrium–aluminium–garnet (ND:YAG)/potassium titanyl phosphate (KTP) laser. The results of studies in terms of sexual side effects of a laser procedure are insufficient for drawing conclusions.


EUROPEAN UROLOGICAL REVIEW


Sexual function following KTP laser vaporisation has rarely been described. One study analysed the results for sexual function using the IIEF49


and concluded that there was an improvement in all IIEF domains at six months of follow-up, particularly in the erectile function domain (from 11.3 to 14.7; p=0.015). Another study that compared KTP vaporisation with open prostatectomy found no differences in IIEF after 12 months of follow-up.50


With TUMT, tissue destruction results from coagulation necrosis caused by temperatures over 44º. Most studies show that sexual side effects are infrequent or non-existent.51 appears in fewer than 5% of patients.52


With TUMT, de novo ED Another study found that 20%


of patients treated with this modality had worsened sexual function at 26 weeks post-treatment.53


The TUNA approach involves using radiofrequency energy delivered to the prostate via two needle electrodes. There are fewer side effects than with TURP.54


after TUNA; several studies reported no ED or RE.54–56 multicentre study found RE in less than 2% and ED in 1% of patients.57 Conclusions


In making treatment decisions for BPH it is necessary to consider the balance between efficacy and side effects. Quality of life is clearly important and, from a patient perspective, a major aspect is sexual function. Treatments that improve LUTS can adversely affect sexual function and be viewed as a failure in treatment by the patient.


All medical therapies described have some effect on sexual function. Tamsulosin, for example, has an important RE rate. Finasteride and dutasteride affect libido and ED and are associated with low-volume ejaculates. However, it is important to remember that even though these reported side effects occur at statistically significant rates, they are still relatively uncommon.


Among the surgical treatments, TURP and open prostatectomy have the highest incidence of RE, while minimally invasive procedures have a much lower incidence. It is essential to provide the patient with information about the potential consequences of a given therapy for the disease, in particular the effects on quality of life and sexual function, so that patient treatment preferences can be taken into account. n


Cristina Ferrandis-Cortés is a Urology Resident in the Department of Urology at the Clinic University Hospital Valencia. She is a member of the Spanish Association of Urology.


José M Martínez-Jabaloyas is a Urologist in the Department of Urology at the Clinic University Hospital Valencia. He is an Andrologist at the Instituto Valenciano de Infertilidad (IVI) and a member of the Spanish Association of Urology, the European Association of Urology (EAU), the Spanish Association of Andrology and the European Society of Sexual Medicine (ESSM).


The incidence of sexual dysfunction is negligible One prospective


53


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84