Sexual Function Preservation
Sexual dysfunction, particularly ejaculatory dysfunction, is among the most common adverse events associated with surgical management for BPO. For example, post-TURP patients have reported worsening of ejaculatory function (65%) and erectile dysfunction (10%). Sexual health is an important preoperative consideration for BPO patients, regardless of age.[14,15] Therefore, when selecting a treatment option for BPO in sexually active men a few options are of particular interest.
Transurethral incision of the prostate (TUIP) is a technique first introduced in the 1970s that may be a good option for men with smaller prostate glands. Rather than removing prostatic tissue, a deep incision in the bladder neck is performed to liberate the urethra. In one meta-analysis comparing 7 TUIP studies, 28% of patients undergoing TUIP experienced ejaculatory dysfunction, which was about half the incidence of this event in TURP patients. Still, in the majority of the studies a higher Qmax and better symptom relief were achieved with TURP, whereas the other studies reported no difference. One prospective study of 80 patients with prostates <30cc demonstrated TUIP outperformed TURP for retrograde ejaculation (22.5% vs 52.5%; P < 0.001) and erectile dysfunction (7.5% vs 20%, P = 0.036) at 4 years postop.
Water vapor convective thermal therapy or Rezūm has been effectively used to treat BPO while preserving sexual function. A randomized trial comparing Rezūm to a sham procedure in men with prostate glands less than 80cc reported that no patient developed de novo erectile dysfunction, and the postoperative anejaculation rate decreased from 2.9% to 0% after 3 months. The long-term results of the trial did not reveal any difference in sexual function up to 2 years after surgery, measured by IIEF-15 and MSHQ-EjD scores. At 4 years postop, both scores had significantly decreased.
In 2013, water jet ablation of prostatic tissue known as Aquablation was introduced. This promising technology decreases operative time while preserving erectile and ejaculatory function, in part due to the precision of real time ultrasound guided imaging intra-operatively. In the WATER clinical trial (prostate glands sized between 30–80cc) MSHQ-EjD or IIEF-5 scores decreased more in TURP patients compared to the patients who underwent Aquablation (56% vs 33%, P = 0.0268). MSHQ-EjD scores were stable following Aquablation but worsened after TURP (P = 0.0254). Bach et al. corroborated the superiority of ejaculatory function rates with Aquablation and reported that among the subjects with antegrade ejaculation, 73% maintained ejaculatory function over the 3-month follow-up period. In WATERII, Aquablation was used to treat large prostates between 80 and 150cc. IIEF-5 did not change from baseline after one year, whereas MSHQ-EjD decreased slightly. Among 77 sexually active subjects, 81% maintained antegrade ejaculation, and no men developed de novo erectile dysfunction.
UroLift, also known as prostatic urethral lift, involves the placement of permanent mechanical implants, to rapidly expand the urethral lumen and alleviate lower urinary tract symptoms (LUTS). The LIFT study is a randomized control trial comparing 140 UroLift patients to 66 patients undergoing a sham procedure for men with prostates less than 80cc. There was no difference in 3-month postoperative sexual function according to changes in IIEF-5 and MSHQ-EjD scores. The BPO6 trial also demonstrated at 2 years postoperatively that there was no difference between UroLift and TURP in erectile function however, ejaculatory function measured by MSHQ-EjD score favored UroLift. In the same study, IPSS and Qmax change were superior with TURP, as was retreatment rate (6% vs 11%). In another study with 86 patients undergoing UroLift independent of prostate size, no procedure-related erectile or ejaculatory dysfunction developed. Although UroLift improved functional outcomes 2 years after surgery, retreatment rate was 12.8% over 2 years.
The novel temporary implantable nitinol device, or iTind, received FDA approval in 2020. The second-generation device uses three struts to gradually expand tissue through ischemic necrosis over 5–7 days of placement prior to device removal.[29–31] Six months following the procedure in the MT-06 study, the 70 patients who underwent iTind did not experience any change in erectile or ejaculatory function and even reported improvements in MSHQ-EjD scores (9.2–11.2; P < 0.01). The short-term outcomes demonstrated improved IPSS, quality of life (QoL), Qmax but no change in PVR. Long-term outcomes after iTind were analyzed in the MT-02 study and also demonstrated improvements in IPSS, QoL and Qmax, without deterioration of PVR at 2 years. No patient reported a decrease of sexual or ejaculatory function; however, this assessment used a yes/no (nonvalidated) questionnaire thus lacking the specificity of accepted questionnaires.
Curr Opin Urol. 2022;32(1):102-108. © 2022 Wolters Kluwer Health, Inc.