Impact of Surgery for Benign Prostatic Hyperplasia on Sexual Function: A Systematic Review and Meta-analysis of Erectile Function and Ejaculatory Function - Beyond the Abstract

It is widely accepted that surgical procedures for benign prostatic hyperplasia (BPH) may determine sexual dysfunctions (SD). Several sexual side effects, including erectile ejaculatory and orgasmic dysfunctions, were reported with most surgical treatments for BPH. Nevertheless, some studies showed no change or even a possible improvement in sexual function after BPH surgery.

We have recently published the most up-to-date and comprehensive meta-analysis currently available on the topic. A total of 151 studies investigating 20,531 patients were included and 48 RCTs evaluating 5,045 subjects were eligible for the meta-analysis. During the screening phase, we noticed that most of the available literature focused on surgical and functional outcomes of BPH surgery, while sexual outcomes were often uninvestigated or under-investigated. Indeed, in 80.8% of selected articles only erectile and/or ejaculatory functions were assessed. More specifically, 66.9% of selected studies used at least one between the International Index of Erectile Function (IIEF) and Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD) as validated questionnaires to evaluate these outcomes. However, a substantial number of papers (44.4%) also used non-validated tools to evaluate erectile and ejaculatory functions. RE rate after the treatment was reported in 53.6% of articles. TURP was the reference procedure in most comparative studies.

We think it might be interesting to focus this brief commentary on minimally invasive surgical treatments (MISTs). In recent years, there was an increased interest in the development of these procedures. Prostatic urethral lift (PUL), Rezum, Aquablation, prostatic artery embolization (PAE), and Temporarily Implanted Nitinol Device (iTIND) are some examples. They aim to achieve symptomatic improvement similar to traditional surgery while maintaining sexual function. It is important to point out that PUL is the only surgical treatment for which there is a clear recommendation regarding sexual function in the current European Association of Urology Guidelines. According to guidelines, PUL should be offered to men who are particularly interested in preserving ejaculatory function. No statistically significant difference in postoperative IIEF-5 scores was found for the entire group of MISTs (p=0.14) nor between subgroups (p=0.43). More extensive data regarding the ejaculatory function was available for PUL. After PUL no statistically significant increase in RE rate was found (p≈1). Besides, the pooled analysis showed no statistically significant difference between baseline and post-PUL MSHQ-EjD Function scores (p=0.33). However, a statistically significant higher MSHQ-EjD Bother score after PUL (p=0.006) was found. Therefore, the impact of PUL on ejaculatory function cannot be defined as null, this could be due to the presence of a foreign body in the prostatic urethra which can trigger the bothers.

Finally, a limited influence of PAE, Aquablation, and Rezum on ejaculatory function was described, although this result was derived from the analysis of single studies rather than a pooled analysis. Overall, a significantly lower risk (p<0.00001) of postoperative RE was found with MISTs than with other procedures. According to our results, it may be reasonable to propose MISTs to well-selected and informed patients to reduce the risk of ejaculatory dysfunction, in the face of less evidence available on the efficacy of these treatments, especially when the risk of bleeding, comorbidities, or other factors direct towards this choice. However, it should be underlined to patients that the risk of ejaculatory dysfunction is present, albeit low, even with MISTs.

IIEF-5 after MISTs for BPH
IIEF-5: International Index of Erectile Function-5 item version; MIST: Minimally Invasive Surgical Treatment; BPH: Benign Prostatic Hyperplasia; SD: Standard Deviation; IV: Interval Variable; PUL: Prostatic Urethral Lift; PAE: Prostatic Artery Embolization

RE after MISTs for BPH
RE: Retrograde Ejaculation; MIST: Minimally Invasive Surgical Treatment; BPH: Benign Prostatic Hyperplasia; M-H: Mantel-Haenszel; PUL: Prostatic Urethral Lift; PAE: Prostatic Artery Embolization

Written by: Celeste Manfredi, MD1 & Javier Romero-Otero, MD, PhD, FEBU, FECSM2

  1. Urology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples, Italy.
  2. Unit of Urology, HM Hospitales, Madrid, Spain.

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