Ejaculation-Sparing Enucleation of the Prostate with Thulium: Yag Laser (ES-ThuLEP) Versus Thulium Fiber Laser (ES-ThuFLEP): Outcomes on Sexual Function - Beyond the Abstract
Studies on the physiology of ejaculation focus on the preservation of the tissue surrounding the veru montanum, rather than the bladder neck, in order to preserve anterograde ejaculation. How different types of laser with peculiar physical features interact with soft tissues should be considered. This may cause surgeons to prefer one laser over the others when treating patients interested in ejaculation.
In our study patients with surgical indication for BPH interested in preserving ejaculation underwent enucleation of the prostate using Thulium:YAG laser (ES-ThuLEP, Group A) versus continuous-wave Thulium Fiber Laser (ES-ThuFLEP, Group B). An ejaculation-sparing technique was applied. The initial incision was shifted 1.5 cm cranial to the veru montanum. The incision was then extended towards the lateral lobes, leaving a small hill of prostatic tissue at the apex, each side of the veru montanum. Sexual function was assessed through the IIEF-5 score, the four-item Male Sexual Health Questionnaire (MSHQ-EjD), and by asking patients to report the presence of anterograde ejaculation, their subjective perception of a satisfactory ejaculation (satisfied vs. non-satisfied) and the occurrence of painful ejaculation and haemospermia.
Six months after surgery, no significant differences were observed in IIEF-5 score and MSHQ-EjD questionnaire. The rate of anterograde ejaculation and ejaculatory satisfaction were comparable. No differences were reported according to painful ejaculation and haemospermia.
In Group A a significantly higher rate of anterograde ejaculation (82.4% vs. 79.2%, p=0.05) and ejaculatory satisfaction (73.5% vs. 70.8%, p=0.05) was observed among patients with prostate volume ≥ 80 ml compared to smaller volume. In Group B a significantly higher proportion of patients with prostate volume ≥ 80 ml reported ejaculation (85.7% vs. 76.9%, p=0.05) and personal satisfaction (78.6% vs. 69.2%, p=0.05).
The assessment of the IIEF-5 score is limited. Indeed, patients’ satisfaction is more complex. The IIEF-5 score focuses on the presence and maintenance of erections, whereas ejaculation and orgasm are unregarded and often underestimated. In our cohort, the rate of anterograde ejaculation was 81.0% after ES-ThuLEP and 81.5% after ThuFLEP at both 3-month and 6-month follow-up. However, if we consider the number of patients who reported to be subjectively satisfied with the quality of their ejaculation, rates are lower (72.4% and 74.1% after 6 months).
Our study should encourage urologists to go beyond the presence of anterograde ejaculation and to focus on patients’ satisfaction. Ejaculation pain and haemospermia are other often unconsidered factors. Interestingly, the only significant differences were observed in the rate of anterograde ejaculation and personal satisfaction when comparing patients with prostate volume < 80 ml with those with volume ≥ 80 ml. Patients with bigger prostates were more likely to preserve ejaculation and to be sexually satisfied.
Written by: Davide Perri, MD, FEBU, Department of Urology, Sant'Anna Hospital, San Fermo della Battaglia, Italy.
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