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Patient Perception of Ejaculatory Volume Reduction After Holmium Laser Enucleation of the Prostate (HoLEP)
Accepted Manuscript Title: Patient Perception of Ejaculatory Volume Reduction after Holmium Laser Enucleation of the Prostate (HoLEP) Author: Jung Kwon Kim, Min Chul Cho, Hwancheol Son, Ja Hyeon Ku, Seung-June Oh, Jae-Seung Paick PII: DOI: Reference:
S0090-4295(16)30687-2 http://dx.doi.org/doi: 10.1016/j.urology.2016.09.037 URL 20055
To appear in:
Urology
Received date: Accepted date:
11-5-2016 21-9-2016
Please cite this article as: Jung Kwon Kim, Min Chul Cho, Hwancheol Son, Ja Hyeon Ku, Seung-June Oh, Jae-Seung Paick, Patient Perception of Ejaculatory Volume Reduction after Holmium Laser Enucleation of the Prostate (HoLEP), Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.09.037. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE Patient perception of ejaculatory volume reduction after Holmium Laser Enucleation of the Prostate (HoLEP)
RUNNING TITLE Patient perception after HoLEP
AUTHORS AND INSTITUTIONS Jung Kwon Kim1, Min Chul Cho2, Hwancheol Son2, Ja Hyeon Ku1, Seung-June Oh1, Jae-Seung Paick1 1
Department of Urology, Seoul National University Hospital, Seoul, Korea
2
Department of Urology, Seoul Metropolitan Government - Seoul National University
Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
CORRESPONDENCE Jae-Seung Paick, M.D. PhD. Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
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Tel: 82-2-2072-2422 Fax: 82-2-742-4665 E-mail: [email protected]
KEYWORDS: Benign prostatic hyperplasia; HoLEP; Patient perception; Retrograde ejaculation
WORD COUNTS: 2,401 (manuscript without abstract or reference), 250 (abstract)
DISCLOSURE STATEMENT: The authors declare that they have no conflict of interest.
ACKNOWLEDGEMENTS: None
ABSTRACT Objectives: To investigate patient perception of ejaculatory volume reduction after HoLEP. Methods: A total of 192 patients were included in the analysis. All patients completed six self-developed, non-validated questionnaires. The questionnaires
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were composed of questions involving overall satisfaction, voiding symptom change, current experience of sexual intercourse, ejaculatory volume change, change of orgasmic intensity, and the patient’s perception of postoperative ejaculatory volume reduction. Questionnaire results and clinical parameters were analyzed, and subgroup analysis according to the patient’s perception was also performed. Results: The median patient age was 66.0 years, and the mean total prostate volume and enucleated prostate volume was 61.9±24.1 ml and 22.4±14.0 ml, respectively. Among 192 patients, 91 patients had had sexual intercourse within the past 3 months. Ejaculatory volume changes after HoLEP were as follows: ‘total loss’(76.9%), ‘decreased’(18.7%), and ‘no change’(4.4%). Among the 87 patients who reported ejaculatory volume reduction, their perceptions of this issue were as follows: ‘feels better’(2.3%), ‘not a problem’(16.1%), ‘disappointed, but able to tolerate, owing to improvement of voiding symptoms’(73.6%), and ‘dissatisfied and want to reverse the situation’(8.0%). Decreased orgasmic intensity was present in 48(52.8%) patients. There were significantly more patients who reported decreased orgasmic intensity among those who wanted to reverse the situation compared with the others (p=0.027). Conclusions: Our study showed that most of the patients reported ejaculatory volume reduction and more than half of the patients reported decreased orgasmic intensity after HoLEP. We also found that patients’ perception of ejaculatory volume reduction and orgasmic intensity were closely related to each other.
INTRODUCTION
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Holmium laser enucleation of the prostate (HoLEP) is the mainstay of current treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The European Association of Urology guideline recommends HoLEP as a primary treatment for patients with BPH whose prostate volume is ≥80 mL, and as an alternative to transurethral resection of the prostate (TURP) in men with moderate-to-severe LUTS due to benign prostatic obstruction, leading to immediate, objective, and subjective improvements comparable to the outcomes of TURP.1 However, the incidence of new-onset retrograde ejaculation (RE) in patients treated with HoLEP was significantly higher than that in patients treated with other laser surgeries such as holmium laser ablation of the prostate or photoselective vaporization of the prostate (77.3% vs. 31.1% vs. 33.2%, p < 0.05).2 The influence of HoLEP on sexual function has been eagerly researched; however, the results have been conflicting.2-7 Nevertheless, studies investigating postoperative RE are still lacking.2,5,6 Among the sexual function-related questionnaires used worldwide, the International Index of Erectile Function (IIEF) is considered insufficient and limited for the evaluation of ejaculation status, orgasm perception, and sexual satisfaction. 3,8,9 Other questionnaires including the Male Sexual Health Questionnaire (MSHQ) and the Danish Prostate Symptom Score Sexual Function Questionnaire are complicated and difficult to fill out for older patients.3,5,6,10 In addition, patient perceptions of ejaculatory volume changes are not included in these questionnaires. In the present study, we investigated the patients’ perceptions of ejaculatory volume changes after HoLEP by using self-developed, non-validated questionnaires.
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MATERIALS AND METHODS Ethical statements The institutional review boards of Seoul National University Hospital approved this study (approval no. H-1601-037-733). Our study was conducted according to the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Study design A total of 192 patients who visited the outpatient clinic in the study period, among 578 patients who underwent HoLEP performed by a single urologist (JSP) from August 2008 to September 2014, were included in the analysis. Their medical records were retrospectively reviewed. All patients underwent baseline evaluations before surgery as follows: medical histories of comorbidities and previous medications, physical examinations including a digital rectal examination, subjective symptoms scored by using the International Prostate Symptom Score (IPSS) and IIEF-15, transrectal ultrasonography, uroflowmetry, and multichannel urodynamic study (MMS UD-2000; Medical Measurement System, Enschede, The Netherlands). A survey was performed from March to September 2014. All patients who visited the outpatient clinic during the survey period underwent uroflowmetry, and answered the IPSS, IIEF-15, and our non-validated questionnaires. The six non-validated questionnaires were composed of questions involving overall satisfaction after the surgery, voiding symptom change after the surgery, current experience of sexual intercourse, ejaculatory volume change after the surgery, change of orgasmic intensity, and the patient’s perception of postoperative ejaculatory volume reduction
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(Appendix). The questionnaires were designed to begin with questions on the overall satisfaction and voiding
symptoms before introducing specific questions about
ejaculatory volume change, orgasmic intensity, and the patient’s perception. Among 192 patients at least 3 months after surgery, 91 (47.4%) had had sexual intercourse or masturbated within the last 3 months after the surgery, and were included in the final analysis. Intervention All surgical procedures were conducted in a routine manner by a single experienced urologist (JSP) as described previously.11 A 26-Fr resectoscope (Karl Storz GmbH and Co., Tuttlingen, Germany) was introduced into the bladder. Continuous irrigation with normal saline was performed during enucleation and morcellation. Enucleation of the prostate was conducted by using a 550-µm endfiring laser fiber (SlimLine; Lumenis Ltd., Yokneam, Israel) and a 100 W holmium neodymium: yttrium aluminum-garnet laser (VersaPulse Power-Suite, Lumenis Ltd.). Morcellation was conducted with a VersaCut morcellator (Lumenis Ltd.) through a 0° rectangular nephroscope (Karl Storz GmbH and Co.). The urethral catheter (24 Fr, three-way) was generally removed on the first postoperative day. The patients were discharged if they were able to void well and had a post-void residual urine volume of <50mL. Statistical analysis The questionnaire results and clinical parameters were analyzed by using the Pearson chi-square test, Student’s t-test, Wilcoxon signed rank test, and Fisher’s exact test. Subgroup analysis was also performed according to the patient’s
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perception of postoperative ejaculatory volume reduction: favorable perception group (scale 1 to 3) vs. unfavorable perception group (scale 4) (Q6, Appendix). All statistical analyses were performed with a commercially available software (SPSS Statistics ver. 21.0; IBM, Armonk, NY, USA), and a p-value of <0.05 was considered statistically significant. RESULTS The median patient age was 66.0 (range 54–79) years, and the median body mass index (BMI) was 24.6 (range 19.6–31.8) kg/m2. The mean total prostate volume and enucleated prostate volume was 61.9 ± 24.1 mL and 22.4 ± 14.0 mL, respectively. The mean enucleation and morcellation time was 51.1 ± 16.8 min and 12.6 ± 34.2 min, respectively. No major perioperative complications requiring blood transfusions or invasive interventions were reported. Parameters including postoperative IPSSs and uroflowmetry showed that the patients experienced both symptomatic and functional improvements after HoLEP (Table 1). The concomitant medications at the time of surgery were as follows: among 91 patients who were included in the final analysis, 84 patients (92.3%) were using an alpha blocker, 25 patients (27.5%) were using a 5-alpha reductase inhibitor, and 23 patients (25.3%) were using both an alpha blocker and a 5- alpha reductase inhibitor. The ejaculatory volume changes after the surgery were as follows: ‘total loss of ejaculatory volume’ (n=70, 76.9%), ‘decreased ejaculatory volume’ (n=17, 18.7%), and ‘no change of ejaculatory volume’ (n=4, 4.4%) (Fig. 1). Decreased orgasmic intensity was present in 48 patients (52.8%), whereas 43 patients (47.2%) reported no change or increased orgasmic intensity (Fig. 1). All patients who reported ‘no
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change of ejaculatory volume’ (n=4) described no change of orgasmic intensity. Among the 87 patients who reported a total loss or reduction of ejaculatory volume, their perceptions of this issue were as follows: (1) ‘feels better’ (n=2, 2.3%), (2) ‘not a problem’ (n=14, 16.1%), (3) ‘disappointed, but able to tolerate, owing to improvement of voiding symptom’ (n=64, 73.6%), and (4) ‘dissatisfied and want to reverse to the situation before surgery’ (n=7, 8.0%). These patients were categorized into the ‘favorable perception group’ (scale 1 to 3) (group A) and the ‘unfavorable perception group’ (scale 4) (group B). There were no significant differences in patient ages at surgery, prostate volume on transrectal ultrasonography, comorbidities, current medication(s), preoperative IPSS and IIEF-15 scores, and maximal flow rate and post-void residual urine volume between group A and B (Table 2). In addition, there were no significant postoperative parameter changes between the two groups (Table 2). On the other hand, there were significantly more patients in group B who reported overall dissatisfaction (71.4% vs. 11.3%) and decreased orgasmic intensity (100% vs. 48.8%) than those in group A (Fig. 1 and Table 3). Conversely, more than half of the patients in group A reported ‘no change’ or ‘improved’ orgasmic intensity after the surgery (Fig. 1 and Table 3). Notably, more than half of the patients in group B, even with substantial improvement in maximal flow rate compared with that in patients in group A (Table 2), reported voiding symptom deterioration in our questionnaire (57.1% vs. 42.9%, respectively; p=0.057) (Table 3).
COMMENT In a recent systematic review including a total of eight randomized clinical trials with
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855 patients, Li et al.12 reported that both HoLEP and TURP significantly improved the symptoms of patients with BPH. In addition, the HoLEP group showed lower IPSS at 12 months, higher maximal flow rates at 3 and 12 months, and less postvoid residual urine volumes at 6 and 12 months than the TURP group (p < 0.05). In this review, HoLEP also had a better safety profile, including fewer blood transfusions and shorter catheterization times and hospital stays. In the current study, in concordance with previous studies, the postoperative IPSS and uroflowmetry showed both symptomatic and functional improvements with a statistical significance after HoLEP (Table 1). In addition, there were no major complications requiring blood transfusions or invasive interventions. These results provide further support for the widespread use of HoLEP as one of the standard surgical procedures for patients with BPH. It is well known that a strong correlation exists between male sexual function and quality of life (QoL). Several studies have investigated the postoperative changes in sexual function after HoLEP; however, the results have been conflicting owing to the absence of prospective and randomized clinical data.2-7,13,14 Some of the studies showed no influence of HoLEP on sexual function including erection or satisfaction.2,3,6,7,14 In our previous study, overall sexual function decreased slightly in the early postoperative period, but recovered to baseline at 12 months postoperatively.14 In the current study, the mean IIEF-15 score among the total study cohort significantly decreased at 1 month postoperatively, but recovered to baseline at 3 months postoperatively (Table 1). Conversely, other recent studies reported a negative impact on sexual function.4,5,13 Briganti et al.13 reported a significant deterioration of the mean IIEF orgasmic function domain scores in both the TURP
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and HoLEP groups. They also found a high prevalence of postoperative RE, and decreased ejaculatory volume. Specifically, in the current study, we further focused on the ejaculatory volume change after HoLEP, followed by the patient’s perception of this change. RE is one of the most common complications of BPH surgery including HoLEP. Previous studies have reported that the prevalence of RE in TURP was as high as 70%,15-17 and more recent studies showed similar or even higher rates of RE after HoLEP.2,6,13 Our data also showed a high prevalence of RE (95.6%, Fig. 1). Several modified ejaculation preservation techniques were introduced with the aim of sparing the ejaculatory hood, especially the supra-montanal tissue.16,18 However, owing to its surgical characteristics, involving the removal of the whole prostatic adenoma including the prostatic apical tissue, HoLEP exhibited a low success rate in orthostatic ejaculation.16 Although the prevalence of RE after HoLEP is high, its effect on sexual function has not been extensively researched.6 Despite its widespread use in current clinical settings, the IIEF has some limitations in evaluating the relationship between RE and QoL.3,8-10,19,20 In addition, the other validated questionnaire, MSHQ, is a very generalized and extended assessment tool for ejaculation dysfunction. 3,20 In the current study, we further focused on the relationship between ejaculatory volume reduction and other subjective parameters, especially not only for the overall satisfaction but also for the patient’s perception of postoperative ejaculatory volume reduction. With this concern, we developed and surveyed our non-validated questionnaires composed of questions involving the patient’s perception of
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postoperative ejaculatory volume reduction, and change of orgasmic intensity. Subsequently, we found that ‘perception’ and ‘orgasmic intensity’ were closely related to each other; all patients who reported an unfavorable perception (group B) also reported decreased orgasmic intensity (Fig. 1 and Table 3). Conversely, a substantial number of patients who reported a favorable perception (group A) reported overall satisfaction even with decreased orgasmic intensity (Fig. 1 and Table 3). In short, an unfavorable perception of decreased ejaculatory volume change might contribute to decreased orgasmic intensity and overall dissatisfaction. In addition, the current study also showed that most patients reported favorable perceptions (group A, 92.0%), even with the total loss of or reduced ejaculatory volume. However, most of the patients in this group reported ‘disappointed, but able to tolerate, owing to improvement of voiding symptoms’ (n = 64, 73.6%). Previous studies also showed that the amelioration of sexual function in the erectile domain after HoLEP may arise from improvements in LUTS.3,21,22 On the other hand, with regard to group B, most of the patients, even with substantial improvement in the maximal flow rate compared with that in patients in group A, reported voiding symptom deterioration in our questionnaire (Table 3). Consequently, decreased orgasmic intensity was closely related to an unfavorable perception of decreased ejaculatory volume change, and even the improvement of voiding symptoms was offset by decreased orgasmic intensity leading to an unfavorable perception (Fig.1 and Table 3). The preserved IIEF-15 score at 3 months postoperatively would also further support this hypothesis; decreased orgasmic intensity was derived from decreased ejaculatory volume rather than decreased erectile function (Fig.1 and Table 1).
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The current study has several limitations. First, the small number of cases and the retrospective design might not have completely accounted for possible confounders. Further long-term follow-up data and a reliable number of cases are needed to clarify our findings. Second, the current study used self-developed, non-validated questionnaires, rather than validated questionnaires such as the MSHQ. However, our study was intended to focus on the relationship between ejaculatory volume loss and other subjective parameters after HoLEP, not on the generalized question of ejaculatory dysfunction. In addition, our questionnaires contained definitive and straightforward questions for investigating the relationship between RE and QoL (i.e. patient perception), especially among older patients. Finally, we did not survey sexual partners. Postoperative sexual function assessment should be correlated with the satisfaction of the interested partner. CONCLUSION Our study showed that most of the patients reported ejaculatory volume reduction and more than half of the patients reported decreased orgasmic intensity after HoLEP. We also found that ‘perception’ and ‘orgasmic intensity’ were closely related to each other. Subsequently, an unfavorable perception of decreased ejaculatory volume change might contribute to decreased orgasmic intensity and overall dissatisfaction. Therefore, we recommend performing counseling for all patients before surgery, to inform them not only about the risk of ejaculatory volume reduction but also about the risk of decreased orgasmic intensity after HoLEP. APPENDIX. Six non-validated questionnaires Q1: “How would you grade your overall satisfaction after surgery?”
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(1) very dissatisfied (2) moderately dissatisfied (3) equally satisfied & dissatisfied (4) moderately satisfied (5) very satisfied Q2: “How would you grade your voiding symptom improvement after surgery?” (1) much deteriorated (2) deteriorated (3) no change (4) improved (5) much improved Q3: “Have you had sexual intercourse (including masturbation) in the past 3 months?” (1) Yes (2) No Q4: “How would you grade your ejaculatory volume change after surgery?” (1) total loss of ejaculatory volume (2) much decreased (3) slightly decreased (4) no change (5) increased Q5: “How would you grade your orgasmic intensity change after surgery?” (1) much decreased (2) slightly decreased (3) no change (4) slightly increased (5) much increased Q6: “If your postoperative ejaculatory volume was reduced, how would you feel about that?” (1) feels better (2) not a problem (3) disappointed, but able to tolerate, owing to improvement of voiding symptoms (4) dissatisfied, and want to reverse to the situation before surgery
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REFERENCES 1. Oelke M, Bachmann A, Descazeaud A et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118-40. 2. Elshal AM, Elmansy HM, Elkoushy MA, Elhilali MM. Male sexual function outcome after three laser prostate surgical techniques: a single center perspective. Urology 2012;80:1098-104 3. Kim SH, Yang HK, Lee HE, Paick JS, Oh SJ. HoLEP does not affect the overall sexual function of BPH patients: a prospective study. Asian J Androl 2014;16:873-7. 4. Marra G, Sturch P, Oderda M, Tabatabaei S, Muir G, Gontero P. Systematic review of lower urinary tract symptoms/benign prostatic hyperplasia surgical treatments on men's ejaculatory function: Time for a bespoke approach? Int J Urol 2016;23:22-35. 5. Placer J, Salvador C, Planas J et al. Effects of Holmium Laser Enucleation of the Prostate on Sexual Function. J Endourol 2015; 29:332-9. 6. Meng F, Gao B, Fu Q et al. Change of sexual function in patients before and after Ho: YAG laser enucleation of the prostate. J Androl 2007;28:259-61. 7. Klett DE, Tyson MD 2nd, Mmeje CO, Nunez-Nateras R, Chang YH, Humphreys MR. Patient-reported sexual outcomes after holmium laser enucleation of the prostate: A 3-year follow-up study. Urology 2014;84:421-6. 8. Cappelleri JC, Siegel RL, Osterloh IH, Rosen RC. Relationship between patient self-assessment of erectile function and the erectile function domain of the international index of erectile function. Urology 2000;56:477-81. 9. Rynja S, Bosch R, Kok E, Wouters G, de Kort L. IIEF‐15: Unsuitable for Assessing Erectile Function of Young Men? J Sex Med 2010;7:2825-30.
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10. Rosen RC, Catania J, Pollack L, Althof S, O’Leary M, Seftel AD. Male Sexual Health Questionnaire (MSHQ): scale development and psychometric validation. Urology 2004;64:777-82. 11. Bae J, Choo M, Park JH, Oh JK, Paick JS, Oh SJ. Holmium laser enucleation of prostate for benign prostatic hyperplasia: seoul national university hospital experience. Int Neurourol J 2011;15:29-34. 12. Li S, Zeng XT, Ruan XL et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One 2014;9:e101615. doi:10.1371/journal.pone.0101615 13. Briganti A, Naspro R, Gallina A et al. Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2center, randomized trial. J Urol 2006;175:1817-21. 14. Jeong MS, Ha SB, Lee CJ, Cho MC, Kim SW, Paick JS. Serial Changes in Sexual Function Following Holmium Laser Enucleation of the Prostate: A Short-term Follow-up Study. Korean J Urol 2012;53:104-8. 15. Zong HT, Peng XX, Yang CC, Zhang Y. The Impact of Transurethral Procedures for Benign Prostate Hyperplasia on Male Sexual Function: A Meta‐Analysis. J Androl 2012;33:427-34. 16. Kim M, Song SH, Ku JH, Kim HJ, Paick JS. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate. Int J Impot Res 2015;27:20-4. 17. Jaidane M, Arfa N, Hmida W et al. Effect of transurethral resection of the prostate
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on erectile function: a prospective comparative study. Int J Impot Res 2010;22:14651. 18. Leonardi R. Preliminary results on selective light vaporization with the side-firing 980 nm diode laser in benign prostatic hyperplasia: an ejaculation sparing technique. Prostate cancer Prostatic Dis 2009;12:277-80. 19. Rosen RC, Cappelleri JC, Gendrano N 3rd. The International Index of Erectile Function (IIEF): a state-of-the-science review. Int J Impot Res 2002;14:226-44. 20. Rosen RC, Catania JA, Althof SE et al. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejaculatory dysfunction. Urology 2007;69:805-9. 21. Nakamura M, Fujimura T, Nagata M et al. Association between lower urinary tract symptoms and sexual dysfunction assessed using the core lower urinary tract symptom score and International Index of Erectile Function-5 questionnaires. Aging Male 2012;15:111-4. 22. Jung JH, Jae SU, Kam SC, Hyun JS. Correlation between Lower Urinary Tract Symptoms (LUTS) and sexual function in benign prostatic hyperplasia: impact of treatment of LUTS on sexual function. J Sex Med 2009;6:2299-304.
FIGURE LEGENDS Fig. 1. The proportion of answers for orgasmic intensity (Q5) and overall satisfaction (Q1) questionnaire in group A and group B patients among 87 patients who reported total loss or decreased ejaculatory volume after HoLEP. TABLES
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Table 1. Comparison of uroflowmetry parameters, IPSS, and IIEF-15 measures before and after HoLEP Pre-operative
Postop. 1mo
Postop. 3mos
Postop. 6mos
Postop. 12mos
11.0 ± 5.6
18.5 ± 8.6*
21.5 ± 10.4*
20.6 ± 9.3*
19.2 ± 8.8*
PVR volume (ml)
81.1±109.2
16.6 ± 17.9*
17.7 ± 26.0*
17.5 ± 49.8*
7.2 ± 16.7*
Total IPSS score
19.2 ± 7.1
11.7 ± 6.2*
7.2 ± 4.6*
7.1 ± 4.3*
7.1 ± 4.8*
Total score
39.2 ± 22.6
11.1 ± 17.3*
28.9 ± 22.3
32.5 ± 23.1
37.8 ± 21.2
Uroflowmetry Peak flow rate -1 (ms )
IIEF-15
* p < 0.01, Paired t-test IIEF: International Index of Erectile Function, IPSS: international prostate symptom score, PVR: postvoid residual
Table 2. Comparative analysis results according to the perception of decreased ejaculatory volume after HoLEP.
Age at surgery, years Prostate volume, mL Total volume, median (range) Transitional zone volume, median (range) Comorbidity, n (%) Hypertension Diabetes CVD BPH medication(s), n (%) alpha blocker 5-alpha reductase inhibitor both IPSS Score
Favorable perception Unfavorable perception (Group A, N=80) (Group B, N=7) Baseline characteristics 65.2 ± 5.2 66.6 ± 5.4
p-value 0.274
57.8 (28.6 – 140.0)
54.0 (32.5 – 94.5)
0.626
31.2 (10.0 – 92.0)
32.0 (13.0 – 61.2)
0.903
42 (52.5) 13 (16.3) 3 (3.8)
3 (42.9) 1 (14.3) 0 (0)
0.648 0.633 0.811
76 (95.0) 20 (25.0)
7 (100) 2 (28.6)
0.684 0.662
20 (25.0)
2 (28.6)
0.662
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Total score Emptying score Storage score QoL Score IIEF-15 score Uroflowmetry Maximal flow rate, mL/sec Post-voided residual urine, mL
19.1 ± 7.3 12.4 ± 6.4 6.9 ± 3.6 4.2 ± 0.8 36.4 ± 23.8
19.8 ± 5.7 12.8 ± 4.7 6.5 ± 2.5 3.9 ± 1.2 37.5 ± 22.4
0.822 0.655 0.642 0.630 0.928
11.0 ± 5.9
12.4 ± 3.2
0.472
84.4 ± 60.2
70.0 ± 27.7
0.232
Operative parameters 69.1 ± 23.1
Total operative time 56.3 ± 15.9 (min) Enucleation 51.3 ± 17.0 48.0 ± 16.1 Morcellation 13.2 ± 35.7 6.4 ± 2.0 Total energy used (KJ) 80.3 ± 30.7 80.1 ± 28.7 Total removed prostate 22.0 ± 13.7 26.4 ± 18.5 volume (g) Postoperative parameter changes at the time of survey Follow-up periods 23.7 ± 17.8 22.0 ± 17.3 (month) IPSS score change Total score change - 8.4 ± 6.1 - 8.7 ± 3.6 Emptying score change - 3.6 ± 4.7 - 4.5 ± 3.7 Storage score change - 4.8 ± 2.8 - 4.2 ± 2.5 QoL score change - 2.0 ± 1.5 - 2.3 ± 1.2 IIEF-15 score change - 3.6 ± 23.2 - 7.0 ± 13.2 Maximal flow rate 18.4 ± 9.0 27.8 ± 13.5 change, mL/sec Post-voided residual - 16.2 ± 47.1 - 10.2 ± 9.4 urine volume change, mL
0.195 0.676 0.674 0.990 0.507 0.762 0.961 0.805 0.611 0.526 0.677 0.111 0.234
BPH: benign prostatic hyperplasia, CVD: cardio-vascular disease, IIEF: International Index of Erectile Function, IPSS: international prostate symptom score, QoL: quality of life
Table 3. Comparative analysis results for non-validated general assessment questionnaires according to the perception of decreased ejaculatory volume after HoLEP.
(Q6) Favorable perception (Group A, N=80) (Q1) Overall satisfaction after surgery, n (%) Unsatisfied 9 (11.3)
Unfavorable perception (Group B, N=7)
p-value 0.007
5 (71.4)
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Satisfied (Q2) Voiding symptom change, n (%) Deteriorated No change or improved (Q5) Orgasmic intensity change on ejaculation, n (%) Decreased No change or improved
71 (88.8)
2 (28.6) 0.057
11 (13.8) 69 (86.3)
4 (57.1) 3 (42.9) 0.027
39 (48.8) 41 (51.3)
7 (100) 0 (0)
* Patients answered ‘(1) Yes’ in Q3, and ‘(1) total loss or (2-3) decreased ejaculatory volume’ in Q4 of our questionnaire were included in this table.
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S0090-4295(16)30687-2 http://dx.doi.org/doi: 10.1016/j.urology.2016.09.037 URL 20055
To appear in:
Urology
Received date: Accepted date:
11-5-2016 21-9-2016
Please cite this article as: Jung Kwon Kim, Min Chul Cho, Hwancheol Son, Ja Hyeon Ku, Seung-June Oh, Jae-Seung Paick, Patient Perception of Ejaculatory Volume Reduction after Holmium Laser Enucleation of the Prostate (HoLEP), Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2016.09.037. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
TITLE Patient perception of ejaculatory volume reduction after Holmium Laser Enucleation of the Prostate (HoLEP)
RUNNING TITLE Patient perception after HoLEP
AUTHORS AND INSTITUTIONS Jung Kwon Kim1, Min Chul Cho2, Hwancheol Son2, Ja Hyeon Ku1, Seung-June Oh1, Jae-Seung Paick1 1
Department of Urology, Seoul National University Hospital, Seoul, Korea
2
Department of Urology, Seoul Metropolitan Government - Seoul National University
Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
CORRESPONDENCE Jae-Seung Paick, M.D. PhD. Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
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Tel: 82-2-2072-2422 Fax: 82-2-742-4665 E-mail: [email protected]
KEYWORDS: Benign prostatic hyperplasia; HoLEP; Patient perception; Retrograde ejaculation
WORD COUNTS: 2,401 (manuscript without abstract or reference), 250 (abstract)
DISCLOSURE STATEMENT: The authors declare that they have no conflict of interest.
ACKNOWLEDGEMENTS: None
ABSTRACT Objectives: To investigate patient perception of ejaculatory volume reduction after HoLEP. Methods: A total of 192 patients were included in the analysis. All patients completed six self-developed, non-validated questionnaires. The questionnaires
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were composed of questions involving overall satisfaction, voiding symptom change, current experience of sexual intercourse, ejaculatory volume change, change of orgasmic intensity, and the patient’s perception of postoperative ejaculatory volume reduction. Questionnaire results and clinical parameters were analyzed, and subgroup analysis according to the patient’s perception was also performed. Results: The median patient age was 66.0 years, and the mean total prostate volume and enucleated prostate volume was 61.9±24.1 ml and 22.4±14.0 ml, respectively. Among 192 patients, 91 patients had had sexual intercourse within the past 3 months. Ejaculatory volume changes after HoLEP were as follows: ‘total loss’(76.9%), ‘decreased’(18.7%), and ‘no change’(4.4%). Among the 87 patients who reported ejaculatory volume reduction, their perceptions of this issue were as follows: ‘feels better’(2.3%), ‘not a problem’(16.1%), ‘disappointed, but able to tolerate, owing to improvement of voiding symptoms’(73.6%), and ‘dissatisfied and want to reverse the situation’(8.0%). Decreased orgasmic intensity was present in 48(52.8%) patients. There were significantly more patients who reported decreased orgasmic intensity among those who wanted to reverse the situation compared with the others (p=0.027). Conclusions: Our study showed that most of the patients reported ejaculatory volume reduction and more than half of the patients reported decreased orgasmic intensity after HoLEP. We also found that patients’ perception of ejaculatory volume reduction and orgasmic intensity were closely related to each other.
INTRODUCTION
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Holmium laser enucleation of the prostate (HoLEP) is the mainstay of current treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The European Association of Urology guideline recommends HoLEP as a primary treatment for patients with BPH whose prostate volume is ≥80 mL, and as an alternative to transurethral resection of the prostate (TURP) in men with moderate-to-severe LUTS due to benign prostatic obstruction, leading to immediate, objective, and subjective improvements comparable to the outcomes of TURP.1 However, the incidence of new-onset retrograde ejaculation (RE) in patients treated with HoLEP was significantly higher than that in patients treated with other laser surgeries such as holmium laser ablation of the prostate or photoselective vaporization of the prostate (77.3% vs. 31.1% vs. 33.2%, p < 0.05).2 The influence of HoLEP on sexual function has been eagerly researched; however, the results have been conflicting.2-7 Nevertheless, studies investigating postoperative RE are still lacking.2,5,6 Among the sexual function-related questionnaires used worldwide, the International Index of Erectile Function (IIEF) is considered insufficient and limited for the evaluation of ejaculation status, orgasm perception, and sexual satisfaction. 3,8,9 Other questionnaires including the Male Sexual Health Questionnaire (MSHQ) and the Danish Prostate Symptom Score Sexual Function Questionnaire are complicated and difficult to fill out for older patients.3,5,6,10 In addition, patient perceptions of ejaculatory volume changes are not included in these questionnaires. In the present study, we investigated the patients’ perceptions of ejaculatory volume changes after HoLEP by using self-developed, non-validated questionnaires.
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MATERIALS AND METHODS Ethical statements The institutional review boards of Seoul National University Hospital approved this study (approval no. H-1601-037-733). Our study was conducted according to the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Study design A total of 192 patients who visited the outpatient clinic in the study period, among 578 patients who underwent HoLEP performed by a single urologist (JSP) from August 2008 to September 2014, were included in the analysis. Their medical records were retrospectively reviewed. All patients underwent baseline evaluations before surgery as follows: medical histories of comorbidities and previous medications, physical examinations including a digital rectal examination, subjective symptoms scored by using the International Prostate Symptom Score (IPSS) and IIEF-15, transrectal ultrasonography, uroflowmetry, and multichannel urodynamic study (MMS UD-2000; Medical Measurement System, Enschede, The Netherlands). A survey was performed from March to September 2014. All patients who visited the outpatient clinic during the survey period underwent uroflowmetry, and answered the IPSS, IIEF-15, and our non-validated questionnaires. The six non-validated questionnaires were composed of questions involving overall satisfaction after the surgery, voiding symptom change after the surgery, current experience of sexual intercourse, ejaculatory volume change after the surgery, change of orgasmic intensity, and the patient’s perception of postoperative ejaculatory volume reduction
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(Appendix). The questionnaires were designed to begin with questions on the overall satisfaction and voiding
symptoms before introducing specific questions about
ejaculatory volume change, orgasmic intensity, and the patient’s perception. Among 192 patients at least 3 months after surgery, 91 (47.4%) had had sexual intercourse or masturbated within the last 3 months after the surgery, and were included in the final analysis. Intervention All surgical procedures were conducted in a routine manner by a single experienced urologist (JSP) as described previously.11 A 26-Fr resectoscope (Karl Storz GmbH and Co., Tuttlingen, Germany) was introduced into the bladder. Continuous irrigation with normal saline was performed during enucleation and morcellation. Enucleation of the prostate was conducted by using a 550-µm endfiring laser fiber (SlimLine; Lumenis Ltd., Yokneam, Israel) and a 100 W holmium neodymium: yttrium aluminum-garnet laser (VersaPulse Power-Suite, Lumenis Ltd.). Morcellation was conducted with a VersaCut morcellator (Lumenis Ltd.) through a 0° rectangular nephroscope (Karl Storz GmbH and Co.). The urethral catheter (24 Fr, three-way) was generally removed on the first postoperative day. The patients were discharged if they were able to void well and had a post-void residual urine volume of <50mL. Statistical analysis The questionnaire results and clinical parameters were analyzed by using the Pearson chi-square test, Student’s t-test, Wilcoxon signed rank test, and Fisher’s exact test. Subgroup analysis was also performed according to the patient’s
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perception of postoperative ejaculatory volume reduction: favorable perception group (scale 1 to 3) vs. unfavorable perception group (scale 4) (Q6, Appendix). All statistical analyses were performed with a commercially available software (SPSS Statistics ver. 21.0; IBM, Armonk, NY, USA), and a p-value of <0.05 was considered statistically significant. RESULTS The median patient age was 66.0 (range 54–79) years, and the median body mass index (BMI) was 24.6 (range 19.6–31.8) kg/m2. The mean total prostate volume and enucleated prostate volume was 61.9 ± 24.1 mL and 22.4 ± 14.0 mL, respectively. The mean enucleation and morcellation time was 51.1 ± 16.8 min and 12.6 ± 34.2 min, respectively. No major perioperative complications requiring blood transfusions or invasive interventions were reported. Parameters including postoperative IPSSs and uroflowmetry showed that the patients experienced both symptomatic and functional improvements after HoLEP (Table 1). The concomitant medications at the time of surgery were as follows: among 91 patients who were included in the final analysis, 84 patients (92.3%) were using an alpha blocker, 25 patients (27.5%) were using a 5-alpha reductase inhibitor, and 23 patients (25.3%) were using both an alpha blocker and a 5- alpha reductase inhibitor. The ejaculatory volume changes after the surgery were as follows: ‘total loss of ejaculatory volume’ (n=70, 76.9%), ‘decreased ejaculatory volume’ (n=17, 18.7%), and ‘no change of ejaculatory volume’ (n=4, 4.4%) (Fig. 1). Decreased orgasmic intensity was present in 48 patients (52.8%), whereas 43 patients (47.2%) reported no change or increased orgasmic intensity (Fig. 1). All patients who reported ‘no
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change of ejaculatory volume’ (n=4) described no change of orgasmic intensity. Among the 87 patients who reported a total loss or reduction of ejaculatory volume, their perceptions of this issue were as follows: (1) ‘feels better’ (n=2, 2.3%), (2) ‘not a problem’ (n=14, 16.1%), (3) ‘disappointed, but able to tolerate, owing to improvement of voiding symptom’ (n=64, 73.6%), and (4) ‘dissatisfied and want to reverse to the situation before surgery’ (n=7, 8.0%). These patients were categorized into the ‘favorable perception group’ (scale 1 to 3) (group A) and the ‘unfavorable perception group’ (scale 4) (group B). There were no significant differences in patient ages at surgery, prostate volume on transrectal ultrasonography, comorbidities, current medication(s), preoperative IPSS and IIEF-15 scores, and maximal flow rate and post-void residual urine volume between group A and B (Table 2). In addition, there were no significant postoperative parameter changes between the two groups (Table 2). On the other hand, there were significantly more patients in group B who reported overall dissatisfaction (71.4% vs. 11.3%) and decreased orgasmic intensity (100% vs. 48.8%) than those in group A (Fig. 1 and Table 3). Conversely, more than half of the patients in group A reported ‘no change’ or ‘improved’ orgasmic intensity after the surgery (Fig. 1 and Table 3). Notably, more than half of the patients in group B, even with substantial improvement in maximal flow rate compared with that in patients in group A (Table 2), reported voiding symptom deterioration in our questionnaire (57.1% vs. 42.9%, respectively; p=0.057) (Table 3).
COMMENT In a recent systematic review including a total of eight randomized clinical trials with
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855 patients, Li et al.12 reported that both HoLEP and TURP significantly improved the symptoms of patients with BPH. In addition, the HoLEP group showed lower IPSS at 12 months, higher maximal flow rates at 3 and 12 months, and less postvoid residual urine volumes at 6 and 12 months than the TURP group (p < 0.05). In this review, HoLEP also had a better safety profile, including fewer blood transfusions and shorter catheterization times and hospital stays. In the current study, in concordance with previous studies, the postoperative IPSS and uroflowmetry showed both symptomatic and functional improvements with a statistical significance after HoLEP (Table 1). In addition, there were no major complications requiring blood transfusions or invasive interventions. These results provide further support for the widespread use of HoLEP as one of the standard surgical procedures for patients with BPH. It is well known that a strong correlation exists between male sexual function and quality of life (QoL). Several studies have investigated the postoperative changes in sexual function after HoLEP; however, the results have been conflicting owing to the absence of prospective and randomized clinical data.2-7,13,14 Some of the studies showed no influence of HoLEP on sexual function including erection or satisfaction.2,3,6,7,14 In our previous study, overall sexual function decreased slightly in the early postoperative period, but recovered to baseline at 12 months postoperatively.14 In the current study, the mean IIEF-15 score among the total study cohort significantly decreased at 1 month postoperatively, but recovered to baseline at 3 months postoperatively (Table 1). Conversely, other recent studies reported a negative impact on sexual function.4,5,13 Briganti et al.13 reported a significant deterioration of the mean IIEF orgasmic function domain scores in both the TURP
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and HoLEP groups. They also found a high prevalence of postoperative RE, and decreased ejaculatory volume. Specifically, in the current study, we further focused on the ejaculatory volume change after HoLEP, followed by the patient’s perception of this change. RE is one of the most common complications of BPH surgery including HoLEP. Previous studies have reported that the prevalence of RE in TURP was as high as 70%,15-17 and more recent studies showed similar or even higher rates of RE after HoLEP.2,6,13 Our data also showed a high prevalence of RE (95.6%, Fig. 1). Several modified ejaculation preservation techniques were introduced with the aim of sparing the ejaculatory hood, especially the supra-montanal tissue.16,18 However, owing to its surgical characteristics, involving the removal of the whole prostatic adenoma including the prostatic apical tissue, HoLEP exhibited a low success rate in orthostatic ejaculation.16 Although the prevalence of RE after HoLEP is high, its effect on sexual function has not been extensively researched.6 Despite its widespread use in current clinical settings, the IIEF has some limitations in evaluating the relationship between RE and QoL.3,8-10,19,20 In addition, the other validated questionnaire, MSHQ, is a very generalized and extended assessment tool for ejaculation dysfunction. 3,20 In the current study, we further focused on the relationship between ejaculatory volume reduction and other subjective parameters, especially not only for the overall satisfaction but also for the patient’s perception of postoperative ejaculatory volume reduction. With this concern, we developed and surveyed our non-validated questionnaires composed of questions involving the patient’s perception of
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postoperative ejaculatory volume reduction, and change of orgasmic intensity. Subsequently, we found that ‘perception’ and ‘orgasmic intensity’ were closely related to each other; all patients who reported an unfavorable perception (group B) also reported decreased orgasmic intensity (Fig. 1 and Table 3). Conversely, a substantial number of patients who reported a favorable perception (group A) reported overall satisfaction even with decreased orgasmic intensity (Fig. 1 and Table 3). In short, an unfavorable perception of decreased ejaculatory volume change might contribute to decreased orgasmic intensity and overall dissatisfaction. In addition, the current study also showed that most patients reported favorable perceptions (group A, 92.0%), even with the total loss of or reduced ejaculatory volume. However, most of the patients in this group reported ‘disappointed, but able to tolerate, owing to improvement of voiding symptoms’ (n = 64, 73.6%). Previous studies also showed that the amelioration of sexual function in the erectile domain after HoLEP may arise from improvements in LUTS.3,21,22 On the other hand, with regard to group B, most of the patients, even with substantial improvement in the maximal flow rate compared with that in patients in group A, reported voiding symptom deterioration in our questionnaire (Table 3). Consequently, decreased orgasmic intensity was closely related to an unfavorable perception of decreased ejaculatory volume change, and even the improvement of voiding symptoms was offset by decreased orgasmic intensity leading to an unfavorable perception (Fig.1 and Table 3). The preserved IIEF-15 score at 3 months postoperatively would also further support this hypothesis; decreased orgasmic intensity was derived from decreased ejaculatory volume rather than decreased erectile function (Fig.1 and Table 1).
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The current study has several limitations. First, the small number of cases and the retrospective design might not have completely accounted for possible confounders. Further long-term follow-up data and a reliable number of cases are needed to clarify our findings. Second, the current study used self-developed, non-validated questionnaires, rather than validated questionnaires such as the MSHQ. However, our study was intended to focus on the relationship between ejaculatory volume loss and other subjective parameters after HoLEP, not on the generalized question of ejaculatory dysfunction. In addition, our questionnaires contained definitive and straightforward questions for investigating the relationship between RE and QoL (i.e. patient perception), especially among older patients. Finally, we did not survey sexual partners. Postoperative sexual function assessment should be correlated with the satisfaction of the interested partner. CONCLUSION Our study showed that most of the patients reported ejaculatory volume reduction and more than half of the patients reported decreased orgasmic intensity after HoLEP. We also found that ‘perception’ and ‘orgasmic intensity’ were closely related to each other. Subsequently, an unfavorable perception of decreased ejaculatory volume change might contribute to decreased orgasmic intensity and overall dissatisfaction. Therefore, we recommend performing counseling for all patients before surgery, to inform them not only about the risk of ejaculatory volume reduction but also about the risk of decreased orgasmic intensity after HoLEP. APPENDIX. Six non-validated questionnaires Q1: “How would you grade your overall satisfaction after surgery?”
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(1) very dissatisfied (2) moderately dissatisfied (3) equally satisfied & dissatisfied (4) moderately satisfied (5) very satisfied Q2: “How would you grade your voiding symptom improvement after surgery?” (1) much deteriorated (2) deteriorated (3) no change (4) improved (5) much improved Q3: “Have you had sexual intercourse (including masturbation) in the past 3 months?” (1) Yes (2) No Q4: “How would you grade your ejaculatory volume change after surgery?” (1) total loss of ejaculatory volume (2) much decreased (3) slightly decreased (4) no change (5) increased Q5: “How would you grade your orgasmic intensity change after surgery?” (1) much decreased (2) slightly decreased (3) no change (4) slightly increased (5) much increased Q6: “If your postoperative ejaculatory volume was reduced, how would you feel about that?” (1) feels better (2) not a problem (3) disappointed, but able to tolerate, owing to improvement of voiding symptoms (4) dissatisfied, and want to reverse to the situation before surgery
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REFERENCES 1. Oelke M, Bachmann A, Descazeaud A et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol 2013;64:118-40. 2. Elshal AM, Elmansy HM, Elkoushy MA, Elhilali MM. Male sexual function outcome after three laser prostate surgical techniques: a single center perspective. Urology 2012;80:1098-104 3. Kim SH, Yang HK, Lee HE, Paick JS, Oh SJ. HoLEP does not affect the overall sexual function of BPH patients: a prospective study. Asian J Androl 2014;16:873-7. 4. Marra G, Sturch P, Oderda M, Tabatabaei S, Muir G, Gontero P. Systematic review of lower urinary tract symptoms/benign prostatic hyperplasia surgical treatments on men's ejaculatory function: Time for a bespoke approach? Int J Urol 2016;23:22-35. 5. Placer J, Salvador C, Planas J et al. Effects of Holmium Laser Enucleation of the Prostate on Sexual Function. J Endourol 2015; 29:332-9. 6. Meng F, Gao B, Fu Q et al. Change of sexual function in patients before and after Ho: YAG laser enucleation of the prostate. J Androl 2007;28:259-61. 7. Klett DE, Tyson MD 2nd, Mmeje CO, Nunez-Nateras R, Chang YH, Humphreys MR. Patient-reported sexual outcomes after holmium laser enucleation of the prostate: A 3-year follow-up study. Urology 2014;84:421-6. 8. Cappelleri JC, Siegel RL, Osterloh IH, Rosen RC. Relationship between patient self-assessment of erectile function and the erectile function domain of the international index of erectile function. Urology 2000;56:477-81. 9. Rynja S, Bosch R, Kok E, Wouters G, de Kort L. IIEF‐15: Unsuitable for Assessing Erectile Function of Young Men? J Sex Med 2010;7:2825-30.
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10. Rosen RC, Catania J, Pollack L, Althof S, O’Leary M, Seftel AD. Male Sexual Health Questionnaire (MSHQ): scale development and psychometric validation. Urology 2004;64:777-82. 11. Bae J, Choo M, Park JH, Oh JK, Paick JS, Oh SJ. Holmium laser enucleation of prostate for benign prostatic hyperplasia: seoul national university hospital experience. Int Neurourol J 2011;15:29-34. 12. Li S, Zeng XT, Ruan XL et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One 2014;9:e101615. doi:10.1371/journal.pone.0101615 13. Briganti A, Naspro R, Gallina A et al. Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2center, randomized trial. J Urol 2006;175:1817-21. 14. Jeong MS, Ha SB, Lee CJ, Cho MC, Kim SW, Paick JS. Serial Changes in Sexual Function Following Holmium Laser Enucleation of the Prostate: A Short-term Follow-up Study. Korean J Urol 2012;53:104-8. 15. Zong HT, Peng XX, Yang CC, Zhang Y. The Impact of Transurethral Procedures for Benign Prostate Hyperplasia on Male Sexual Function: A Meta‐Analysis. J Androl 2012;33:427-34. 16. Kim M, Song SH, Ku JH, Kim HJ, Paick JS. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate. Int J Impot Res 2015;27:20-4. 17. Jaidane M, Arfa N, Hmida W et al. Effect of transurethral resection of the prostate
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on erectile function: a prospective comparative study. Int J Impot Res 2010;22:14651. 18. Leonardi R. Preliminary results on selective light vaporization with the side-firing 980 nm diode laser in benign prostatic hyperplasia: an ejaculation sparing technique. Prostate cancer Prostatic Dis 2009;12:277-80. 19. Rosen RC, Cappelleri JC, Gendrano N 3rd. The International Index of Erectile Function (IIEF): a state-of-the-science review. Int J Impot Res 2002;14:226-44. 20. Rosen RC, Catania JA, Althof SE et al. Development and validation of four-item version of Male Sexual Health Questionnaire to assess ejaculatory dysfunction. Urology 2007;69:805-9. 21. Nakamura M, Fujimura T, Nagata M et al. Association between lower urinary tract symptoms and sexual dysfunction assessed using the core lower urinary tract symptom score and International Index of Erectile Function-5 questionnaires. Aging Male 2012;15:111-4. 22. Jung JH, Jae SU, Kam SC, Hyun JS. Correlation between Lower Urinary Tract Symptoms (LUTS) and sexual function in benign prostatic hyperplasia: impact of treatment of LUTS on sexual function. J Sex Med 2009;6:2299-304.
FIGURE LEGENDS Fig. 1. The proportion of answers for orgasmic intensity (Q5) and overall satisfaction (Q1) questionnaire in group A and group B patients among 87 patients who reported total loss or decreased ejaculatory volume after HoLEP. TABLES
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Table 1. Comparison of uroflowmetry parameters, IPSS, and IIEF-15 measures before and after HoLEP Pre-operative
Postop. 1mo
Postop. 3mos
Postop. 6mos
Postop. 12mos
11.0 ± 5.6
18.5 ± 8.6*
21.5 ± 10.4*
20.6 ± 9.3*
19.2 ± 8.8*
PVR volume (ml)
81.1±109.2
16.6 ± 17.9*
17.7 ± 26.0*
17.5 ± 49.8*
7.2 ± 16.7*
Total IPSS score
19.2 ± 7.1
11.7 ± 6.2*
7.2 ± 4.6*
7.1 ± 4.3*
7.1 ± 4.8*
Total score
39.2 ± 22.6
11.1 ± 17.3*
28.9 ± 22.3
32.5 ± 23.1
37.8 ± 21.2
Uroflowmetry Peak flow rate -1 (ms )
IIEF-15
* p < 0.01, Paired t-test IIEF: International Index of Erectile Function, IPSS: international prostate symptom score, PVR: postvoid residual
Table 2. Comparative analysis results according to the perception of decreased ejaculatory volume after HoLEP.
Age at surgery, years Prostate volume, mL Total volume, median (range) Transitional zone volume, median (range) Comorbidity, n (%) Hypertension Diabetes CVD BPH medication(s), n (%) alpha blocker 5-alpha reductase inhibitor both IPSS Score
Favorable perception Unfavorable perception (Group A, N=80) (Group B, N=7) Baseline characteristics 65.2 ± 5.2 66.6 ± 5.4
p-value 0.274
57.8 (28.6 – 140.0)
54.0 (32.5 – 94.5)
0.626
31.2 (10.0 – 92.0)
32.0 (13.0 – 61.2)
0.903
42 (52.5) 13 (16.3) 3 (3.8)
3 (42.9) 1 (14.3) 0 (0)
0.648 0.633 0.811
76 (95.0) 20 (25.0)
7 (100) 2 (28.6)
0.684 0.662
20 (25.0)
2 (28.6)
0.662
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Total score Emptying score Storage score QoL Score IIEF-15 score Uroflowmetry Maximal flow rate, mL/sec Post-voided residual urine, mL
19.1 ± 7.3 12.4 ± 6.4 6.9 ± 3.6 4.2 ± 0.8 36.4 ± 23.8
19.8 ± 5.7 12.8 ± 4.7 6.5 ± 2.5 3.9 ± 1.2 37.5 ± 22.4
0.822 0.655 0.642 0.630 0.928
11.0 ± 5.9
12.4 ± 3.2
0.472
84.4 ± 60.2
70.0 ± 27.7
0.232
Operative parameters 69.1 ± 23.1
Total operative time 56.3 ± 15.9 (min) Enucleation 51.3 ± 17.0 48.0 ± 16.1 Morcellation 13.2 ± 35.7 6.4 ± 2.0 Total energy used (KJ) 80.3 ± 30.7 80.1 ± 28.7 Total removed prostate 22.0 ± 13.7 26.4 ± 18.5 volume (g) Postoperative parameter changes at the time of survey Follow-up periods 23.7 ± 17.8 22.0 ± 17.3 (month) IPSS score change Total score change - 8.4 ± 6.1 - 8.7 ± 3.6 Emptying score change - 3.6 ± 4.7 - 4.5 ± 3.7 Storage score change - 4.8 ± 2.8 - 4.2 ± 2.5 QoL score change - 2.0 ± 1.5 - 2.3 ± 1.2 IIEF-15 score change - 3.6 ± 23.2 - 7.0 ± 13.2 Maximal flow rate 18.4 ± 9.0 27.8 ± 13.5 change, mL/sec Post-voided residual - 16.2 ± 47.1 - 10.2 ± 9.4 urine volume change, mL
0.195 0.676 0.674 0.990 0.507 0.762 0.961 0.805 0.611 0.526 0.677 0.111 0.234
BPH: benign prostatic hyperplasia, CVD: cardio-vascular disease, IIEF: International Index of Erectile Function, IPSS: international prostate symptom score, QoL: quality of life
Table 3. Comparative analysis results for non-validated general assessment questionnaires according to the perception of decreased ejaculatory volume after HoLEP.
(Q6) Favorable perception (Group A, N=80) (Q1) Overall satisfaction after surgery, n (%) Unsatisfied 9 (11.3)
Unfavorable perception (Group B, N=7)
p-value 0.007
5 (71.4)
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Satisfied (Q2) Voiding symptom change, n (%) Deteriorated No change or improved (Q5) Orgasmic intensity change on ejaculation, n (%) Decreased No change or improved
71 (88.8)
2 (28.6) 0.057
11 (13.8) 69 (86.3)
4 (57.1) 3 (42.9) 0.027
39 (48.8) 41 (51.3)
7 (100) 0 (0)
* Patients answered ‘(1) Yes’ in Q3, and ‘(1) total loss or (2-3) decreased ejaculatory volume’ in Q4 of our questionnaire were included in this table.
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