Title:How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?
VOLUME: 22 ISSUE: 1
Author(s):Ioannis Mykoniatis*, Koenraad Van Renterghem and Ioannis Sokolakis
Affiliation:Department of Urology, Jessa Hospital, Hasselt, Belgium; 2Faculty of medicine, Hasselt University, Hasselt, Department of Urology, Jessa Hospital, Hasselt, Belgium; 2Faculty of medicine, Hasselt University, Hasselt, Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg
Keywords:Benign Prostatic Enlargement (BPE), prostate (PVP), transurethral needle ablation (TUNA), Transurethral Microwave
Therapy (TUMT), Aquablation, alprostadil injections.
Abstract:Our aim was to provide a narrative review regarding the prevalence, the associated
pathophysiologic pathways and the potential management methods of sexual dysfunction related to
ablative surgical techniques for Benign Prostatic Enlargement (BPE). Men suffering from BPE are
at high risk of sexual dysfunction due to the disease itself, comorbidities, and pharmacological/surgical
treatments. Transurethral resection of the prostate, as the gold standard treatment option for
BPE, has historically been associated with relatively high rates of postoperative sexual dysfunction
problems, mainly retrograde ejaculation but also erectile dysfunction. Ablative surgical techniques,
including photoselective vaporization of the prostate (PVP), transurethral needle ablation (TUNA),
Transurethral Microwave Therapy (TUMT), Convective Water Vapor Energy Ablation (Rezum®)
and Aquablation®, have been proposed as treatment methods able to reduce treatment-related complications
for BPE patients, including adverse effects on erectile and ejaculatory function, without
compromising the efficacy rates for BPE. The neurovascular bundles can be damaged during
TURP due to posterolateral capsular perforation. Ablative techniques and especially PVP theoretically
seem to skip this hazard, as the distance created from the necrotic area to the capsule is generally
larger compared to the distance induced after TURP. However, indirect thermal injury of erectile
nerves, which could also be induced by the majority of available ablative techniques, could potentially
lead to ED. Two special technical characteristics (physiological saline use for tissue ablation
and real time penetration depth control) of Aquablation® could be proved beneficial with regard
to the effect of the method on erectile function. In general, ablative techniques seem to have a
minor impact on sexual function. However, low methodological quality characterizes most of the
studies included in this review mainly due to the impossibility, in many cases, to perform blind randomization.
Also, many studies did not have an erectile and ejaculatory function as primary outcomes
limiting that way their statistical power to identify significant variations. Management of
sexual dysfunction problems arising from ablative surgeries for BPE treatment could be divided into
two levels. Firstly, intraoperatively the avoidance of manipulation of crucial structures regarding
ejaculatory (bladder neck or ejaculatory ducts) and erectile function (neurovascular bundles) could
possibly decrease the negative effect of these procedures on sexual function. Thus, in this direction,
modifications of classic ablative techniques have been proposed resulting in encouraging outcomes
regarding postoperative sexual function. Secondly, if EjD and/or ED are established, the already
known treatment choices should be chosen in order for sexual function rehabilitation to be
achieved. Thus, regarding ED: PDE5i daily or on-demand remains the gold standard first-line treatment
choice followed by intracavernosal alprostadil injections in cases of failure, while penile prosthesis
implantation must be kept as the final definitive solution when all the other methods have
failed. Regarding ejaculation disorders (retrograde ejaculation or anejaculation): medical therapy
with a-agonists (pseudoephedrine), sperm retrieval from the urine, bladder neck reconstruction, prostatic
massage, electroejaculation, penile vibratory stimulation and surgical sperm retrieval are the
available treatment options. Furthermore, high-quality studies are required to investigate the potential
side effects of BPE surgery on sexual function and efficient treatment methods to manage
them.
