ORIGINAL ARTICLE Effect of transurethral resection of the prostate on erectile function: a prospective comparative study

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1 (2010) 22, & 2010 Nature Publishing Group All rights reserved /10 $ ORIGINAL ARTICLE Effect of transurethral resection of the prostate on erectile function: a prospective comparative study M Jaidane, NB Arfa, W Hmida, A Hidoussi, A Slama, NB Sorba and F Mosbah Department of Urology, Sahloul University Hospital, Sousse, Tunisia The effect of transurethral resection of the prostate (TURP) on erectile function is still controversial, and available evidence is conflicting. One of the possible mechanisms of post-turp erectile dysfunction (ED) is direct thermal injury to the erectile nerves. The aim of this study was to investigate the effect of TURP on erectile function. Fifty patients undergoing TURP for obstructive benign prostatic hyperplasia (HBP) were prospectively included in the study, and 50 age-matched patients undergoing transurethral resection of the superficial bladder tumor were also prospectively included as a control group. All patients completed the international index of erectile function (IIEF-15), the international prostatic symptom score (IPSS) and the Hospital Anxiety and Depression Scale at inclusion in the study and then at the 3- and 6-month follow-up evaluation. Capsular perforations during TURP were prospectively reported by the operating surgeon. There was a significant improvement of erectile function in the TURP group despite the onset of ejaculation disorders in 70% of the patients. Improvement of erectile function was also found in the subgroup of patients with capsular perforation during TURP. Comparison with the control group showed that at preoperative evaluation, patients in the TURP group had more severe urinary symptoms and worse erectile function than did those of the control group. At the postoperative period, the IPSS score became comparable in the two groups, with major improvement of erectile function in the TURP group. We concluded that TURP improved erectile function in HBP patients with severe urinary symptoms. This improvement of erectile function was observed even in case of capsular perforation. (2010) 22, ; doi: /ijir ; published online 26 November 2009 Keywords: ED; HBP; TURP; lower urinary tract symptoms Introduction Despite many recent innovations, transurethral resection of the prostate (TURP) remains the gold standard for treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia (HBP). The effect of TURP on urinary flow rate and lower urinary tract symptoms (LUTS) and its long-term results are actually well established. Its effects on global sexual function and erectile function in particular are controversial, and the available evidence is conflicting. Some studies showed negative effects, whereas others showed the absence of notable effects or even improvement of erectile function Correspondence: Dr M Jaidane, Urology Department, Sahloul University Hospital, Sousse 4042, Tunisia. mehdi@jaidane.org Received 18 September 2009; revised 15 October 2009; accepted 22 October 2009; published online 26 November 2009 One of the possible mechanisms of post-turp erectile dysfunction (ED) is direct thermal injury to the erectile nerves, which run a few millimeters from the prostatic capsule. 2,18,21 Other possible mechanisms are psychological effects of surgery and hospitalization, and cessation of sexual activity during the postoperative period. 8,21 23 To assess the effects of TURP on erectile function, we conducted a prospective study using validated measurement tools. For specifically investigating the potential thermal injuries of the erectile nerves, while controlling for other psychogenic factors, we chose an age-matched control group of patients who underwent transurethral resection of the superficial bladder tumor (TURBT). TURBT is a fairly similar operation to TURP, without the use of the coagulation current at the prostatic lodge. Materials and methods Between August 2008 and June 2009, a total of 134 patients were prospectively enrolled in this study.

2 Informed consent was obtained from all of the patients. From these patients, 100 fulfilled the inclusion criteria and completed the study. Group 1, which is the study group, included 50 patients with HBP, in which TURP was performed. Inclusion criteria were HBP with LUTS and/or postvoid residual volume and reporting of sexual activity over the last 6 months. Exclusion criteria included cancer, previous prostatic surgery and completion of other concomitant procedure(s) with TURP. Mean age was 71.6 years (range 54 to 88 years). Approximately 82% of the patients had severe urinary symptoms with preoperative international prostatic symptom score (IPSS) of X20. All preoperative capsular perforations were prospectively reported by the operating surgeon. Group 2, which is the control group, included 50 patients with superficial bladder tumor in which TURBT was performed. Inclusion criteria were pathology-confirmed superficial tumor, reporting of sexual activity over the last 6 months and age 455 years. Exclusion criteria included muscle-invasive bladder tumors and other cancers, bladder outlet obstruction secondary to HBP, previous prostatic surgery and completion of other concomitant procedure(s) with TURBT. Mean age was 69.5 years (range years). Evaluation of patients included medical history, physical examination with digital rectal examination, urinalysis, urologic ultrasound and completion of three self-administered questionnaires: the international index of erectile function in its 15-question version (IIEF-15), the IPSS and the hospital anxiety and depression scale (HADS). 24,25 Arabic validated versions of the three questionnaires were used. For IPSS-15, total score and score of the five domains of sexual function were calculated, as previously described. 26,27 The five domains are erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. Answers to question no. 9 (Q9) of the IPSS-15, evaluating ejaculatory function, were also specifically assessed. Values Q9 ¼ 1 or 2 reported important diminution of ejaculation frequency or anejaculation. 27 For HADS, total score and scores of subscales for anxiety (HADS-A) and depression (HADS-D) were calculated, as previously described. 24,25 For IPSS, total score and value of answer to the quality-of-life question (IPSS-QoL) were assessed. All of the patients in both groups were evaluated in the preoperative period at inclusion in the study and then at 3 and 6 months following TURP or TURBT. Statistical analysis was performed using the Mann Whitney U-test, w 2 -test, or Fisher s exact test when tables were too sparse. The values were considered statistically significant at Po0.05. This study was approved by the Institutional Review Board of Sahloul University Hospital. Results In group 1, at 3 months, there was a statistically significant improvement in the mean IIEF-15 global score, mean IPSS global score and mean IPSS-QoL value (Table 1). There was also a statistically significant improvement in mean score in four of the five subdomains of the IIEF-15 (namely, erectile function, orgasmic function, intercourse satisfaction and overall satisfaction). No significant change was observed in the mean value of the sexual desire subdomain score. The rate of patients reporting Q9 ¼ 1 or 2 increased significantly to 70%, reflecting probably retrograde ejaculation caused by TURP. Furthermore, there was a statistically significant improvement in the mean HADS global score and mean HADS-A value but not in the HADS-D value. At 6 months, all the improved variables remain stable, with no significant differences between the 3- and 6-month evaluation values. At 6 months, there was also a slight but statistically significant decrease in the mean value of the sexual desire subdomain score (mean value ¼ 7.59, P ¼ 0.041). In group 1, there was capsular perforation in 19 cases (38%). Of these 19 capsular perforations, 18 were posterior. In this subgroup of patients with capsular perforation, statistical analysis found exactly the same variable variations at 3 and 6 months than in the whole group 1. Table 1 Scores changes in group 1 patients (TURP group) between preoperative and 3-month evaluation Preoperative 3 months P-value IIEF-15 a o IIEF-15 subdomains a : Erectile function o Intercourse satisfaction o Orgasmic function o Sexual desire Overall satisfaction o Q9 ¼ 1or2 b 6 70 o IPSS a o IPSS-QoL a o HADS a HADS subscales a HADS-A o HADS-D Abbreviations: HADS, hospital anxiety and depression scale; HADS-A, HADS for anxiety; HADS-D, HADS for depression; IIEF- 15, international index of erectile function in its 15-question version; IPSS, the international prostatic symptom score; QoL, quality of life; Q9, question no. 9 of the IPSS-15; TURP, transurethral resection of the prostate. 147

3 148 Table 2 Comparison between group 1 (TURP) and group 2 (TURBT) for patient characteristics Table 3 Comparison between group 1 (TURP) and group 2 (TURBT) for scores at preoperative evaluation Group 1 (TURP) Group 2 (TURBT) P-value Group 1 (TURP) Group 2 (TURBT) P-value Age a (years) HTA b Diabetes b Duration of bladder drainage a (days) Total hospital stay a (days) Postoperative hospital stay a (days) Abbreviations: HTA, arterial hypertension; TURP, transurethral resection of the prostate; TURBT, transurethral resection of the superficial bladder tumor. In group 2, there was a statistically significant improvement in the mean IPSS global score and the mean IPSS-QoL value at 3 months (with P ¼ and P ¼ 0.014, respectively). These two values remain stable at 6 months with no significant variations. There was also a statistically significant improvement in the mean HADS and HADS-A scores at 6 months (with P ¼ and P ¼ 0.031, respectively). There was no statistically significant change at 3 or 6 months for all of the other variables. Groups 1 and 2 were comparable for mean age, diabetes and hypertension prevalence rates, mean duration of bladder drainage by urethral catheter, mean duration of hospital stay, and mean preoperative values of HADS global score and its two subscales (Tables 2 and 3). At preoperative evaluation, the mean global IIEF- 15 score, mean value of all IIEF-15 subdomain scores except the sexual desire subdomain score, mean IPSS global score and mean IPSS-QoL value were statistically significantly lower in group 1 than in group 2 (Table 3). At 3 months, comparison of the two groups showed that the mean IIEF-15 global score significantly increased by almost twofold in group 1. However, it remained slightly, but statistically significantly, inferior to the mean IIEF-15 global score in group 2. The same variation was observed in three of the five IIEF-15 subdomain scores (Table 4). Furthermore, the two groups became comparable for the mean IPSS global score and IPSS-QoL score (Table 4). Exactly the same findings were observed when comparing the two groups at 6-month evaluation. Discussion The effect of TURP on erectile function is still debated. Many studies are available in the literature, IIEF-15 a o IIEF-15 subdomains a : Erectile function o Intercourse satisfaction o0.001 Orgasmic function o Sexual desire Overall satisfaction o Q9 ¼ 1or2 b IPSS a o IPSS-QoL a o HADS a HADS subscales a HADS-A HADS-D Abbreviations: HADS, hospital anxiety and depression scale; HADS-A, HADS for anxiety; HADS-D, HADS for depression; IIEF-15, international index of erectile function in its 15-question version; IPSS, the international prostatic symptom score; QoL, quality of life; Q9, question no. 9 of the IPSS-15; TURP, transurethral resection of the prostate; TURBT; transurethral resection of the superficial bladder tumor. Table 4 Comparison between group 1 (TURP) and group 2 (TURBT) for scores at 3-month evaluation Group 1 (TURP) Group 2 (TURBT) P-value IIEF-15 a IIEF-15 subdomains a : Erectile function Intercourse satisfaction Orgasmic function Sexual desire Overall satisfaction Q9 ¼ 1or2 b o IPSS a IPSS-QoL a HADS a HADS subscales a HADS-A HADS-D Abbreviations: HADS, hospital anxiety and depression scale; HADS-A, HADS for anxiety; HADS-D, HADS for depression; IIEF- 15, international index of erectile function in its 15-question version; IPSS, the international prostatic symptom score; QoL, quality of life; Q9, question no. 9 of the IPSS-15; TURP, transurethral resection of the prostate; TURBT; transurethral resection of the superficial bladder tumor.

4 Table 5 Available studies in the English language literature 149 Reference Patients (n) a Type Measurement tool b Control(s) group(s) Effect on erectile function Mebust et al Retrospective Nonvalidated No Negative Lindner et al Prospective Nonvalidated SPP Negative Hanbury and 268 Prospective Nonvalidated No Negative Sethia 8 Tscholl et al Prospective Snap-Gauge test No Negative Bieri et al Prospective Nonvalidated No Negative Uygur et al Prospective BFMSI TUVP, medical treatment, SPP Negative Hammadeh 52 Prospective Nonvalidated TUVP Negative et al. 7 Gupta et al Prospective Nonvalidated No Negative Taher et al Prospective IIEF-5 þ Rigiscan No Negative Poulakis et al Prospective IIEF-5 No Negative Wasson et al Prospective Nonvalidated Watchful waiting No effect Soderhal et al Prospective Rigiscan No No effect Kunelius et al Prospective Nonvalidated No No effect Kaplan et al Prospective Nonvalidated TUVP No effect Arai et al Prospective SMUSF-Q TUNA TUMT ILCP No effect Leliefeld et al Prospective Nonvalidated Medical treatment, watchful waiting No effect Deliveliotis 98 Prospective BMSFI Age-matched healthy men No effect et al. 5 Briganti et al Prospective IIEF-15 HoLEP No effect Muntener 642 Prospective DAN-PSS No No effect et al. 14 Brookes et al Prospective ICSex TUVP, watchful waiting Positive Present study 100 Prospective IIEF-15 TURBT Positive Abbreviations: DAN-PSS, danish prostate symptom score; HoLEP, holmium laser enucleation of the prostate; ICSex, international continence society; IIEF-15, international index of erectile function in its 15-question version; ILCP, interstitial laser coagulation of the prostate; SMUSF-Q, sapporo medical university sexual function questionnaire; SPP, suprapubic transvesical prostatectomy; TUMT, transurethral microwave thermotherapy; TUNA, transurethral needle ablation of the prostate; TUVP, transurethral electrovaporization of the prostate; BFMSI, brief male sexual function inventory; TURBT; transurethral resection of the superficial bladder tumor. a Number of patients of the study group who underwent TURP. b Examples of nonvalidated measurement tools: retrospective charts review, 13 interview 2,8 or nonvalidated questionnaires. 6,7,9 12,20 with conflicting conclusions. An analytic review of these studies shows that most had some uncontrolled methodological bias such as the use of nonvalidated measurement tools or no control group. Table 5 shows the most important English language papers of interest Use of validated questionnaires is essential in sexual function assessment. Soderdhal et al. 16 showed that a nonvalidated questionnaire may cause false reports of ED. An adequate control group is also essential, as ED is frequent in the aged male population, most affected by HBP, and its frequency spontaneously increases with time. 28,29 Therefore, an age-matched control group would be needed for any study on TURP effect on erectile function. Suspected mechanisms in ED following TURP are thermal and/or chemical injuries of the erectile nerves traveling just beneath the prostatic capsule. These two types of injuries are supposed to be induced by the preoperative use of coagulation current or extravasation from irrigation fluid. 2,8,18 Supporting these hypotheses, studies reported the risk of post-turp ED to be related to capsular perforation at the time of surgery, 2,8,15,21 small size adenoma 2,18 and diabetes. 15,17 Extravasation of irrigation fluid, a thinner layer of adenomatous tissue between the resecting loop and erectile nerves, and a higher susceptibility of the erectile nerves of patients to damage from heat would be the putative mechanisms, respectively. 2,8,15,17,18,21 Other suspected mechanisms of post-turp ED are the psychological effects of transurethral surgery and relatively prolonged cessation of sexual activity during the postoperative period. 8,21 23 For specifically investigating the potential thermic or chemical injuries of erectile nerves, while controlling for other factors (psychological effect of transurethral surgery, sexual activity cessation), we chose agematched patients who underwent TURBT as a control group. TURBT is a fairly similar operation to TURP, without the potential thermal or chemical injuries at the prostatic capsule. The two groups were comparable for duration of urethral catheterization, hospital stay, and preoperative and postoperative anxiety (Tables 2, 3 and 4). Erectile function and other sexual function parameters were assessed by IIEF-15, a validated questionnaire. Surprisingly, we found that TUPR improved erectile function, as well as other sexual function parameters, despite the onset of ejaculation disorders in 70% of the patients. A slight decrease in sexual desire at 6 months, which may be related to

5 150 retrograde ejaculation, was also observed, as in other studies. 21 Further studies are needed to clarify this point. Improvement of erectile function was found even in the subgroup of patients with capsular perforation, which is contradictory to the erectile nerve injuries theory. This improvement of erectile function in the TURP group was associated with parallel improvement in urinary symptoms. Comparison with the control group showed that at preoperative evaluation, patients in the TURP group had more severe urinary symptoms and worse erectile function. At the postoperative period, the IPSS score became comparable in the two groups with major improvement of erectile function in the TURP group. Several recent studies have shown a strong association between LUTS and ED. 28,30 32 In the Multinational Survey of the Aging Male, LUTS were an independent risk factor for ED after controlling for age and comorbidities. 28 We presume that the improvement observed in erectile function in the TURP group in our study was caused by relief of obstructive urinary symptoms. A strong correlation between LUTS relief and erectile function improvement had already been shown after alpha-blocker treatment. 33 The main limitation of this study is that the TURP group included mainly HBP patients in whom TURP was indicated for severe urinary symptoms. In our TURP group, the mean preoperative IPSS was 26, and 82% of the patients had an IPSS of X20. Further studies are needed to assess the effect of TURP on erectile function in HBP patients with less severe urinary symptoms. Conclusion Transurethral resection of the prostate improved erectile function in HBP patients with severe urinary symptoms. 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