How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?

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 (R)) and Aquablation (R), 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 TURF. 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 (R) 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 intracavemosal 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.