Sexual Function after Transurethral Resection of the Prostate (TURP): Results of an Independent Prospective Multicentre Assessment of Outcome

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1 european urology 52 (2007) available at journal homepage: Benign Prostatic Enlargement Bladder Outlet Obstruction Sexual Function after Transurethral Resection of the Prostate (TURP): Results of an Independent Prospective Multicentre Assessment of Outcome Michael Muntener a, Sonja Aellig b, Rolf Kuettel b, Christoph Gehrlach b, Tullio Sulser a, Raeto T. Strebel a, * a Department of Urology, University Hospital Zurich, Zurich, Switzerland b Verein Outcome, Zurich, Switzerland Article info Article history: Accepted January 24, 2007 Published online ahead of print on February 5, 2007 Keywords: Complications Erectile function Outcome assessment Prostatic hyperplasia Transurethral resection of prostate Abstract Objectives: The influence of surgical treatment of bladder outlet obstruction on sexual function is uncertain and available evidence is conflicting. Transurethral resection of the prostate (TURP) causes retrograde ejaculation, but its effect on erectile function is controversial. We have prospectively investigated the influence of TURP on erectile and ejaculatory function. Methods: Between January 2000 and January 2005, 11 hospitals in Switzerland informed the Verein Outcome (VO), an independent institution specialising in outcome measurements in the Swiss health care system, about patients scheduled for TURP. VO obtained the Danish Prostate Symptom Score (DAN-PSS) including the sexual function domain (DAN- PSSsex) before and 4 mo after surgery and compared the respective scores. Results: Data from 1014 patients were evaluated. Mean patient age was 69 yr. DAN-PSSsex questionnaires were returned by 988 patients before and 642 patients after TURP; 722 (73.1%) and 474 (73.8%) of the patients, respectively, stated that they were still sexually active. The mean erectile function score improved insignificantly from 1.66 to 1.47 ( p = 0.11), the mean ejaculatory function score worsened from 1.27 to 2.34 ( p < 0.00) and the mean discomfort on ejaculation score improved from 0.37 to 0.29 ( p = 0.10) before and after TURP, respectively. Conclusion: The results confirm that TURP has no negative influence on the quality of erections measured by self-assessment questionnaires. The loss of ejaculatory function is significant and is associated with considerable bother. However, three of four patients undergoing TURP are still sexually active and the surgery has no influence on this ratio. # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Department of Urology, University Hospital Zurich, Frauenklinikstr. 10, 8091 Zurich, Switzerland. Tel ; Fax: address: raeto.strebel@usz.ch (R.T. Strebel) /$ see back matter # 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 european urology 52 (2007) Introduction Lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) and sexual dysfunction are highly prevalent in aging men [1]. Both disorders may significantly deteriorate the quality of life of affected men and their potentially shared pathophysiologic background is of considerable current interest [2,3]. Transurethral resection of the prostate (TURP) continues to be the gold standard in the surgical treatment of BOO and one of the most frequently performed procedures in urologic practice [4]. The effect of TURP on urinary flow rate, postvoid residual volume, and LUTS and its long-term results are well established [5]. The influence of surgical treatment of BOO on sexual function, however, is uncertain and available evidence is conflicting [4,6 9]. TURP is known to cause retrograde ejaculation, but its effect on erectile function is still controversial [7,8,10]. This study investigated the influence of TURP on erectile and ejaculatory function. 2. Methods Data collection and analysis were performed by the Verein Outcome (VO). VO is an independent institution implemented by the public health care authorities of Switzerland. It is appointed to measure outcomes in various fields of the Swiss health care system. One assignment of VO was to assess the quality of TURP in public hospitals. Between January 2000 and January 2005, 10 community hospitals and one university hospital participated in this study. The hospitals were required to inform VO about patients with benign prostatic hyperplasia (BPH) scheduled for TURP. Patients with known prostate cancer were excluded. All participating hospitals were requested to provide data on at least 80 consecutive patients. The date of study entry was different for each hospital and data acquisition was not strictly parallel. VO mailed the Danish Prostate Symptom Score (DAN-PSS) questionnaire including the sexual function domain (DAN-PSSsex) to the patients prior to as well as 4 mo after the operation [11]. The DAN-PSS rates the severity and the associated bother of three sexual symptoms: quality of erection, ejaculatory function, and pain/discomfort on ejaculation. A weighted score (rated 0 9 with 9 equalling maximum bothersome dysfunction) is calculated by multiplying the symptom severity (range: 0 3) by its respective bother severity (range: 0 3). Additionally, patients were asked if they were sexually active or not during the last month before TURP or before urinary retention. Sexual activity was specified as sexual intercourse, masturbation, or petting. Patients returned the completed questionnaire to the VO. The hospitals provided data on patients comorbidities using the Charlson Comorbidity Index (CCI) [12] and on perioperative complications, using a standardised form, which was mailed to VO. VO performed the statistical analysis using standard commercial software (SPSS, Chicago IL). DAN-PSS values before and after TURP were compared using the Wilcoxon signed rank test. The Pearson x 2 test was used to test the influence of comorbidity and complications on sexual activity and DAN-PSSsex, respectively. The Pearson correlation coefficients were calculated to assess the correlation between the DAN-PSS and DAN-PSSsex. The level of significance was set at p < Results Data from 1014 patients were evaluated (Fig. 1). The median number of patients per participating hospital was 89 (range: ). The participating hospitals completed the patient accrual within a median of 16 mo (range: 9 31 mo). VO received the follow-up questionnaires within a mean of 4.6 mo after TURP (standard deviation = 23.7 d). The mean patient age was 69 yr (range: yr). Patient characteristics, changes of LUTS before and after TURP, and complications are shown in Tables 1 and 2. More detailed data about the outcome of TURP in regard to perioperative morbidity and changes in LUTS have been published previously [13]. Preoperatively, 988 patients returned DAN-PSSsex questionnaires that were deemed evaluable. Of these patients, 722 (73.1%) stated that they were sexually active. Sexual activity decreased significantly with increasing age ( p < 0.00; Fig. 2) and comorbidity according to the CCI ( p < 0.00). The DAN-PSS score (ie, LUTS) showed a positive correlation with increasing DAN-PSSsex that was statistically significant (Pearson s r = 0.29, p < 0.00). In a logistic regression analysis LUTS remained an Table 1 Patient characteristics and DAN-PSS before and 4 mo after TURP Mean age, yr (range) 69 (43 91) Patients with one or more comorbidities (CCI) 347 (37.5%) Patients with indwelling catheter 222 (21.9%) DAN-PSS before TURP 25.2 DAN-PSS after TURP * 6.2 DAN-PSS = Danish Prostate Symptom Score; TRUP = transurethral resection of the prostate; CCI = Charlson Comorbidity Index. * p < Table 2 Perioperative complications of TURP (n = 1014) Complication No. of patients Postoperative urinary retention Transurethral revision Blood transfusion Newly diagnosed urinary tract infection TURP = transurethral resection of the prostate. %

3 512 european urology 52 (2007) Fig. 1 Trial profile. Number of patients answering to the specific question of the DAN-PSSsex before and 4 mo after transurethral resection of the prostate. independent risk factor for sexual dysfunction regardless of age and comorbidity. Postoperatively, 642 questionnaires were returned and evaluable for analysis. Therein 474 patients (73.8%) declared that they were sexually active. Patients experiencing any of the complications listed in Table 2 were not at an increased risk of becoming sexually inactive after TURP ( p = 0.583). Of 579 sexually active patients before TURP, 37.5% quoted having normal erections without any impairment, 58.7% reported of slightly or markedly reduced erections, and 3.8% of the sexually active patients had no erections. After TURP of 405 sexually active men 40.4% reported normal erections, 53% slightly or markedly reduced erections, and 6.3% of the patients were sexually active without having erections. Changes of the mean bothersome dysfunction score of the three DAN-PSSsex questions in patients with questionnaires before and after TURP are shown in Table 3. The proportion of patients reporting an improvement or worsening in the respective DAN-PSSsex question score is shown in Fig Discussion Fig. 2 Sexual activity per age groups prior to transurethral resection of the prostate (n = 988). Several recently published epidemiologic studies demonstrated a relationship between LUTS and sexual dysfunction [1,14 16]. Our data confirm the increasing evidence of this relationship (between LUTS and sexual dysfunction) in aging men. LUTS were an independent risk factor for sexual

4 european urology 52 (2007) Table 3 DAN-PSSsex and mean weighted scores Before TURP After TURP p Erectile function Weighted score erectile function Ejaculatory function <0.00 Weighted score ejaculatory function <0.00 Discomfort on ejaculation Weighted score discomfort on ejaculation DAN-PSSsex = sexual function domain of the Danish Prostate Symptom Score; TURP = transurethral resection of the prostate. Fig. 3 Changes in the respective DAN-PSSsex question weighted score after transurethral resection of the prostate (%). DAN-PSSsex = sexual function domain of the Danish Prostate Symptom Score. dysfunction irrespective of age and comorbidity in our study population. The fact that a neutral third party collected the data, significantly adds to the quality of our results. Data collection by the treating institution or surgeon is a source of bias as unfavourable outcomes tend to be underreported. Therefore, third-party assessment is considered to be the ideal method to evaluate treatment success of surgical interventions [17,18]. To our knowledge this is the first large-scale study providing an independent outcome assessment of the influence of TURP on sexual function. On the opposite side, however, 36.7% of patients did not return the follow-up questionnaire that was sent out 4 mo after TURP. Therefore, our results might be subject to a response bias. This limitation is inherent to our study design but, as pointed out, outcome assessment by a neutral third party adds to the quality of the collected data. We believe that this improvement of data quality outweighs the limitation of a low response rate and of providing subjective data only. Based on the patients self-assessments, our data demonstrate that TURP has no negative influence on general sexual activity and very effectively alleviates bothersome LUTS due to BPH. Moreover, in 81% of the treated men erectile function remained unchanged or improved after TURP (Fig. 3). Thus, these data confirm the findings of several studies investigating the consequences of TURP on sexual function [6,7,19]. Assessment of sexual function after TURP needs to address not only de novo erectile and ejaculatory dysfunction but also any improvement of sexual function because treatment of LUTS possibly leads to an improvement of sexual function [20,21]. However, most studies report only on the incidence of de novo erectile dysfunction after TURP and not on the proportion of patients experiencing an improvement of sexual function [8,22]. Our results suggest that there are more patients who will experience an improvement of their erectile function and of their discomfort during ejaculation than there are patients who will end up with worsened symptoms. This is in accordance with the results of Brookes et al who found that the proportion of men reporting erectile dysfunction and painful ejaculation decreased after TURP [7]. The well-known effect of TURP on ejaculation, that is, retrograde ejaculation or decreased ejaculate volume, was confirmed in our study. Furthermore the independent outcome assessment revealed that this deterioration of ejaculatory function was associated with considerable bother for many patients. In 16.9% of the patients, however, the weighted score showed an improvement in ejaculatory function. This demonstrates that in a minority of patients TURP can relieve bothersome ejaculatory dysfunction. Because patients may confuse retrograde ejaculation with impotence, this functional consequence should receive extra attention when counselling patients before TURP [10,23]. Neither patients with comorbidities nor patients with perioperative complications had an increased risk of becoming sexually inactive after TURP in our study. Several authors reported that certain conditions (eg, capsular penetration or diabetes mellitus) are potential risk factors for developing erectile dysfunction after TURP [22,24]. However, because no

5 514 european urology 52 (2007) data on capsular perforation during TURP were collected and comorbidities were assessed with the CCI, no analysis of specific risk factors for developing erectile function following TURP were possible in our study. The DAN-PSSsex is a well-recognised and validated questionnaire to assess sexual function and it was used in several large-scale studies [1,14,25]. We selected the DAN-PSSsex because it is a very short and easy to complete questionnaire that considers how much bother is associated with a respective dysfunction [26]. Due to our study design patients could not be interviewed in an office setting and therefore having a brief and concise questionnaire was crucial to achieve acceptable response rates. Preoperatively and postoperatively, 98.4% and 63.3% of patients, respectively, returned the DAN-PSSsex questionnaires to VO. However, not all patients did respond to all three items of the DAN-PSSsex and the response rate for some of the questions is rather low (Fig. 1). Whether patients who did not return the questionnaires or who did not answer all questions differed significantly from the patients who responded is not known. Therefore, as pointed out earlier our results might be subject to a response bias. 5. Conclusion Based on self-assessment questionnaires, three of four patients undergoing TURP were still sexually active and surgery had no influence on this ratio. The loss of ejaculatory function after TURP is associated with considerable bother. However, TURP does not reduce the quality of erections, and it even seems to decrease the rate of bothersome erectile dysfunction and discomfort on ejaculation. Conflicts of interest The authors have nothing to disclose. Acknowledgments We would like to thank the Verein Outcome as well as the urologists and administrators of the following hospitals for their help and cooperation in collecting these data: Spital Bulach, Spital und Gesundheitszentrum Sanitas Kilchberg, Spital Limmattal, Kantonsspital Olten, Spital Zimmerberg Wädenswil, GZO Wetzikon, Kantonsspital Winterthur, Spital Zollikerberg, Stadtspital Triemli Zurich, Stadtspital Waid Zurich, and University Hospital Zurich. References [1] Rosen R, Altwein J, Boyle P, et al. Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male (MSAM-7). Eur Urol 2003;44: [2] McVary K. Lower urinary tract symptoms and sexual dysfunction: epidemiology and pathophysiology. BJU Int 2006;97(Suppl 2):23 8, discussion [3] Rosen RC, Giuliano F, Carson CC. Sexual dysfunction and lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Eur Urol 2005;47: [4] AUA Practice Guidelines committee. AUA guideline on management of benign prostatic hyperplasia (2003). Chapter 1: Diagnosis and treatment recommendations. J Urol 2003;170: [5] Reich O, Gratzke C, Stief CG. Techniques and long-term results of surgical procedures for BPH. Eur Urol 2006; 49:970 8 (discussion 978). [6] Arai Y, Aoki Y, Okubo K, et al. Impact of interventional therapy for benign prostatic hyperplasia on quality of life and sexual function: a prospective study. J Urol 2000;164: [7] Brookes ST, Donovan JL, Peters TJ, Abrams P, Neal DE. Sexual dysfunction in men after treatment for lower urinary tract symptoms: evidence from randomised controlled trial. BMJ 2002;324: [8] Emberton M, Neal DE, Black N, et al. The effect of prostatectomy on symptom severity and quality of life. Br J Urol 1996;77: [9] Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP) incidence, management, and prevention. Eur Urol 2006;50: [10] Soderdahl DW, Knight RW, Hansberry KL. Erectile dysfunction following transurethral resection of the prostate. J Urol 1996;156: [11] Hald T, Nordling J, Andersen JT, Bilde T, Meyhoff HH, Walter S. A patient weighted symptom score system in the evaluation of uncomplicated benign prostatic hyperplasia. Scand J Urol Nephrol Suppl 1991;138: [12] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40: [13] Muntener M, Aellig S, Kuttel R, Gehrlach C, Hauri D, Strebel RT. Peri-operative morbidity and changes in symptom scores after transurethral prostatectomy in Switzerland: results of an independent assessment of outcome. BJU Int 2006;98: [14] Vallancien G, Emberton M, Harving N, van Moorselaar RJ. Sexual dysfunction in 1,274 European men suffering from lower urinary tract symptoms. J Urol 2003;169: [15] Boyle P, Robertson C, Mazzetta C, et al. The association between lower urinary tract symptoms and erectile dysfunction in four centres: the UrEpik study. BJU Int 2003;92:

6 european urology 52 (2007) [16] Braun MH, Sommer F, Haupt G, Mathers MJ, Reifenrath B, Engelmann UH. Lower urinary tract symptoms and erectile dysfunction: co-morbidity or typical Aging Male symptoms? Results of the Cologne Male Survey. Eur Urol 2003;44: [17] McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised trials in surgery: problems and possible solutions. BMJ 2002;324: [18] Månsson Å, Henningsohn L, Steineck G, Månsson W. Neutral third party versus treating institution for evaluating quality of life after radical cystectomy. Eur Urol 2004;46: [19] Kunelius P, Hakkinen J, Lukkarinen O. Sexual functions in patients with benign prostatic hyperplasia before and after transurethral resection of the prostate. Urol Res 1998;26:7 9. [20] van Moorselaar RJ, Hartung R, Emberton M, et al. Alfuzosin 10 mg once daily improves sexual function in men with lower urinary tract symptoms and concomitant sexual dysfunction. BJU Int 2005;95: [21] De Rose AF, Carmignani G, Corbu C, et al. Observational multicentric trial performed with doxazosin: evaluation of sexual effects on patients with diagnosed benign prostatic hyperplasia. Urol Int 2002;68:95 8. [22] Poulakis V, Ferakis N, Witzsch U, de Vries R, Becht E. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. Asian J Androl 2006; 8: [23] Thorpe AC, Cleary R, Coles J, Reynolds J, Vernon S, Neal DE. Written consent about sexual function in men undergoing transurethral prostatectomy. Br J Urol 1994;74: [24] Hanbury DC, Sethia KK. Erectile function following transurethral prostatectomy. Br J Urol 1995;75:12 3. [25] Nickel JC, Elhilali M, Emberton M, Vallancien G. The beneficial effect of alfuzosin 10 mg once daily in real-life practice on lower urinary tract symptoms (LUTS), quality of life and sexual dysfunction in men with LUTS and painful ejaculation. BJU Int 2006;97: [26] Schou J, Holm NR, Meyhoff HH. Sexual function in patients with symptomatic benign prostatic hyperplasia. Scand J Urol Nephrol Suppl 1996;179: Editorial Comment on: Sexual Function after Transurethral Resection of the Prostate (TURP): Results of an Independent Prospective Multicentre Assessment of Outcome Alexander Bachmann Department of Urology, University Hospital Basel, Basel, Switzerland bachmanna@uhbs.ch Muntener et al [1] discuss an interesting issue in prostatic surgery. The authors report on a prospective study measuring the patient s estimation of sexual function before and after transurethral resection of the prostate (TURP). Sexual activity was measured and analyzed by an independent outcome association, based on the Danish Prognostic Symptom Score. Lower urinary tract symptoms (LUTS) due to obstructive voiding caused by benign prostatic hyperplasia (BPH) are together regarded as one of the most common problems in men. In particular, with increasing importance of lifestyle issues in older men, sexual function, including the ability to have an antegrade ejaculation after TURP, becomes increasingly more significant. However, typically the issue of retrograde ejaculation after TURP is inconsistently discussed among urologists as a complication or a result of a correctly performed operation. The main statement of the paper is that most likely the same number of patients will remain sexually active, despite surgery. Probably, erectile dysfunction is not significantly improved after TURP. Additionally, the advantages of the study are the Multicentre character and the independent acquisition of data. Unfortunately, some important drawbacks make a comprehensive conclusion not possible. First, because of the drop-out rate of 37% a comprehensive interpretation of the impact of the surgery on sexual function is not possible. This leaves the question as to why almost all of the patients answered the questionnaires before surgery, but only two thirds at the second interview postoperatively, in particular because patients were informed to participate fully in this study. This could lead to a certain bias if patients who had had more problems did not answer the questionnaires. Another problem of the study design is that sexual activity in terms of objective penile erection or penetration was not studied. The term sexual activity is not exactly defined and ranges from sexual wishes and desires to penetration. Others have shown that self-(over)estimation of sexual function prior to surgery is really a bias [2]. In particular, in patients within this age range erectile function is significantly influenced by comorbidities, the natural decline of erectile function because of older age, and drug therapy. Unfortunately, Muntener et al have gambled away the chance to conduct an urgently needed comprehensive well-designed prospective Multicentre study if objective data (eg, measurement of tumescence) on erectile function prior to and 6,

7 516 european urology 52 (2007) , and 24 mo after TURP had been added. Thus, a definitive and comprehensive conclusion about sexual function after TURP is, unfortunately, not possible. of the prostate (TURP): results of an independent prospective Multicentre assessment of outcome. Eur Urol 2007;52: [2] Salonia A, Zanni G, Gallina A, et al. Baseline potency in candidates for bilateral nerve-sparing radical retropubic prostatectomy. Eur Urol 2006;50: References [1] Muntener M, Aellig S, Kuettel R, Gehrlach C, Sulser T, Strebel RT. Sexual function after transurethral resection DOI: /j.eururo DOI of original article: /j.eururo

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