- Email: [email protected]
The impact of transrectal prostate biopsy on erectile function
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ARTICLE IN PRESS
Actas Urol Esp. 2016;xxx(xx):xxx---xxx
Actas Urol´ ogicas Espa˜ nolas www.elsevier.es/actasuro
ORIGINAL ARTICLE
The impact of transrectal prostate biopsy on erectile function夽 E. Linden-Castro a , M. Pelayo-Nieto a,∗ , D. Espinosa-Perezgrovas a , E.D. Rubio-Arellano b , G. Catalán-Quinto a , F. Guzmán-Hernández a , J.A. Morales-Covarrubias a , R. Cortez-Betancourt a a
Departamento de Urología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, Mexico Laboratorio de Investigación y Desarrollo Farmacéutico, Departamento de Farmacobiología, Centro Universitario de Ciencias Exactas e Ingenierías, Universidad de Guadalajara, Jalisco, Mexico
b
Received 14 September 2015; accepted 21 February 2016
KEYWORDS Erectile dysfunction; Prostate biopsy
Abstract Objective: To assess erectile function at different periods of time in patients who undergo transrectal prostate biopsy (TRPB). Material and methods: A total of 364 patients underwent TRPB. All of the patients were assessed using the International Index of Erectile Function-5 (IIEF-5). All patients with a positive result for cancer or with previous erectile dysfunction in the initial assessment were excluded. Ninety-three patients were included and were assessed before the biopsy and at 4, 12 and 24 weeks after the TRPB, using the IIEF-5 and assessing erectile function across these time periods. Results: We assessed 93 patients. During the first prebiopsy assessment, 100% of the patients scored ≥22 points. In the first postbiopsy evaluation at 4 weeks, 66.6% scored ≥22 points, and 33.3% had erectile dysfunction, thereby indicating a statistically significant reduction in the IIEF-5 score (p = .001). In the second postbiopsy evaluation, only 9.1% patients still had mild to moderate erectile dysfunction (p = .04). By the end, 92.48% of the patients scored ≥22 points, and 7.52% still had mild erectile dysfunction, without presenting a significant difference (p = .1). Conclusions: After a TRPB, the drop in IIEF-5 scores and the presence of erectile dysfunction are temporary and transient, with greater impairment during the first month following the procedure and improvement starting after the first month, with almost total recovery at 6 months. © 2016 AEU. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
夽 Please cite this article as: Linden-Castro E, Pelayo-Nieto M, Espinosa-Perezgrovas D, Rubio-Arellano ED, Catalán-Quinto G, GuzmánHernández F, et al. Impacto de la biopsia transrectal de próstata en la función eréctil. Actas Urol Esp. 2016. http://dx.doi.org/10.1016/ j.acuro.2016.02.006 ∗ Corresponding author. E-mail addresses: [email protected], [email protected] (M. Pelayo-Nieto).
2173-5786/© 2016 AEU. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
ACUROE-857; No. of Pages 4
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PALABRAS CLAVE Disfunción eréctil; Biopsia de próstata
Impacto de la biopsia transrectal de próstata en la función eréctil Resumen Objetivo: Evaluar la función eréctil en distintos periodos de tiempo en pacientes que se someten a biopsia transrectal de próstata. Material y métodos: Trescientos sesenta y cuatro pacientes se sometieron a BTRP. Todos los pacientes se evaluaron utilizando el Índice Internacional de Función Eréctil (IIEF-5); se excluyó a todos los pacientes con resultado positivo para cáncer y con disfunción eréctil o previa en la evaluación inicial. Se incluyó a 93 pacientes, los cuales se evaluaron antes de la biopsia y a las 4, 12 y 24 semanas posteriores a la BTRP, utilizando el IIEF-5 y evaluando la función eréctil a través de estos periodos. Resultados: Se evaluó a 93 pacientes; durante la primera evaluación prebiopsia el 100% presentó ≥ 22 y en la primera evaluación posbiopsia a las 4 semanas el 66,6% tuvo ≥ 22 puntos y el 33.3% presentó disfunción eréctil, identificando una reducción estadísticamente significativa en las puntuaciones del IIEF-5 (p = 0,001). En la segunda evaluación posbiopsia solo el 9,1% de los pacientes persistió con disfunción eréctil, leve y moderada (p = 0,04); al finalizar, el 92,48% de los pacientes tenían ≥ 22 puntos y el 7,52% persistió con disfunción eréctil leve sin presentar una diferencia significativa. (p = 0,1). Conclusiones: Después de la BTRP, la disminución en las puntuaciones de IIEF-5 y la presencia de disfunción eréctil son temporales y transitorias, con una mayor afectación durante el primer mes posterior al procedimiento, mostrando una mejoría a partir del primer mes, y una recuperación casi total a 6 meses. © 2016 AEU. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction
Material and methods
Prostate biopsy guided by ultrasound (TRUS biopsy) has become the gold standard in diagnosing carcinoma of the prostate since the method’s introduction in 1989 by Hodge et al.1 Millions of men throughout the world undergo a TRPB, with nearly a million biopsy procedures being done yearly in the United States.2,3 Amongst the men who undergo a TRPB, almost 50% of them will be diagnosed with carcinoma of the prostate (CaP).4 TRUS biopsy is not a complication-free procedure since 1.0---6.9% of men who undergo the procedure can present adverse effects such as haematuria, hematospermia, dysuria, fever, and septicemia in 0.5---5% of cases.5,6 Regardless, it is still considered a relatively safe procedure. As a complication of biopsy, erectile dysfunction (ED) has been observed and has been described since the year 2001.7 The repercussion of TRPB over erectile function is not described as one of the main side effects; however, few studies have demonstrated the relationship that exists between ED and TRPB. This has lead to several theories and hypotheses being made on ED’s origin, but the exact mechanism is still unknown. The majority of studies carried out on the subject are in small-scale, retrospective, and show heterogeneous results. It is because of this that in our present study we decided to evaluate the erectile function of men before and after a TRPB was done, all of whom did not previously suffer from erectile dysfunction.
After institution approval was granted, 364 patients underwent a TRUS biopsy done by different urologists trained on how to do the procedure. There was identification of 93 men that met the inclusion criteria: presence of specific prostate antigen >3 ng/mL, abnormal rectal exam, knowing how to read and write, having enough comprehension to fill out the IIEF-5 questionnaire, and a negative PCa result in the TRUS biopsy. All men with a previous ED and/or PCa diagnosis, a previous TRUS biopsy, or a second neoplasm were excluded, as well as patients with: bone pains, disease opposing TRPB, history of cardiovascular disease (acute myocardial infarction, stroke, chronic obstructive pulmonary disease), terminal chronic kidney disease, major depression disorder, intake of antidepressants within the last three months, and intake of phosphodiesterase inhibitors (tadalafil, vardenafil, sildenafil). The patients who met the criteria underwent the biopsy. The main point of evaluation was erectile function, studied with the International Index of Erectile Function (IIEF-5). The IIEF’s score range is from 5 to 25 points. We grouped the patients into four categories according to the severity of ED: severe (5---7 points), moderate (8---16 points), mild (17---21 points), and no ED (22---25 points). The questionnaire (IIEF-5) was answered before the procedure (biopsy) and later on three different occasions at 4 weeks, 12 weeks, and 6 months after the biopsy. The questionnaires were answered during the follow-ups of the patients. All patients who had a positive PCa diagnosis post-biopsy were excluded. The biopsy was conducted in a systematic manner in all patients. All patients had rectal preparation one day prior to the procedure and the administration of antibiotics was done according to the AUA’s Best Practice Statement 2014. The ultrasound equipment used was an Aloka® ␣ 6
Objective To evaluate erectile function across different time periods in male patients who undergo a transrectal prostate biopsy.
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ARTICLE IN PRESS
The impact of transrectal prostate biopsy on erectile function Prosound, along with a 5---10 MHz intracavity probe and an 18 Ga 20 cm BARD® Biopsy Needle to obtain samples measuring 22 mm. Local anesthesia with simple xylocaine at 2% was applied on the right and left periprostatic venous plexus and on the left and right apex, 2.5cc in each region with a Echotip Skinny Needle, Chibe Tip® 22 Ga/20 cm. 12 cylinders specimens were obtained in all cases and patients who underwent a saturation biopsy were excluded. The prostatic volume was calculated with the following equation: volume (mL) = 0.524 × (length × height × width). Descriptive statistics were used for the patients’ characteristics, as well as a Student’s t-test to compare the base scores against the follow-up patient scores on the first, second, and third evaluations, all at different time periods. The statistical analysis was done using IBM SPSS Statistics 19® .
Results Mean age was 59 years old (range: 45---73 years old), with a mean prostate-specific antigen of 5.7 ng/mL and the average prostatic volume being 59 mL. During the patient evaluations prior to the procedure, 100% of them had an IIEF-5 score >21 points. At the evaluation 4 weeks post-biopsy, 66.6% of the patients maintained a score above 22 points, indicating no ED, and the resting 33.3% presented certain degree of ED with 26.8% being classified as mild ED, 4.30% having mild-moderate ED, 2.15% with moderate ED, and none of the patients with severe ED. Nearly a third of the patients during this first evaluation presented a certain degree of ED in comparison to the base evaluation (p = 0.001). At the second evaluation post-biopsy done after 12 weeks, 9.1% of patients persisted with ED, from these 3.41% being mild cases and 5.68% being mild-moderate ones. During this second evaluation, just as in the first, no severe cases of ED were observed, representing a statistical difference (p = 0.04). On the third evaluation done 6 months post-biopsy, none of the patients were classified as mild-moderate, and just 7.52% of patients persisted as cases of mild ED, this time the statistical difference was not significant. During the 6-month period of evaluation, none of the patients suffered severe ED and the majority of patients that showed ED were classified as mild according to the IIEF-5. The changes in scores of the IIEF-5 were not correlated to age of the patient or to the specific prostate antigen levels.
Discussion Prostate biopsy is one of the most common urology procedures, with more than 1 million procedures made each year in the United States and Europe.8 The biopsy is typically well-tolerated with low risks of major complications, nonetheless minor complications are frequent. In our study we evaluated the presence of erectile dysfunction in patients that underwent a transrectal prostate biopsy.9 Studies show that erectile dysfunction is not more frequent in males with carcinoma of the prostate.5 However, the data related to transrectal prostate biopsy and erectile dysfunction is scarce, heterogeneous,10 and the majority of studies include patients who had an extended prostate biopsy or
3 it was done by saturation; they include both patients with positive and negative PCa results11 as well as samples of patients who already have ED from mild to severe or other few studies have studied patients with negative PCa result. Up to this date, this is the first study that evaluates patients with no ED prior to the biopsy and who have a negative PCa result. This was done in order to avoid anxiety and slant that could be due to receiving diagnosis of cancer and that could also lead to or worsen ED.12 In our series, we identified that 100% of patients were potent at the beginning of the study before the procedure was done, at 4 weeks 33% suffered from ED, and at 12 weeks only 9.12% persisted with ED. In general, and as shown in other studies, erectile dysfunction presents usually during the first month post-biopsy. We also saw a recovery in the potency of our patients that had shown a degree of ED, it is to say that the majority of patients return to their baseline in the long term. Klein et al. identified that the use of periprostatic nerve block produces higher rates of erectile dysfunction.13 In our study, however, 100% were applied the periprostatic nerve block, which is currently considered as a standard, and we believe it is not a factor that increases the ED rate, at least not in our case. Fujita et al. found a positive correlation between erectile dysfunction and a larger amount of cylinder specimens,14 but this association was not able to be valued since in all of our patients only 12 specimens were taken. Chrisofos et al. pointed at ED in 8.9% of patients after the prostate biopsy with a full recovery after three months of follow-up.15 Zisman et al. identified ED in 9.7% of his sample, but both of these studies included patients with a positive PCa result,16 which is an important anxiety factor.17 In our environment, we omitted that factor but greater levels of ED were still presented (33.3%). This can be justified since the first evaluation was done 4 weeks later and none of the patients in the study already had ED. We identified recovery as time passed by during the evaluations done 12 weeks and 24 weeks later, showing during the last evaluation only 7.52% of patients persisting with a degree of ED, all classified by the IIE-5 as mild. Erectile dysfunction does affect patients who undergo a transrectal prostate biopsy, it being more evident during the first four weeks, point from which a recovery of potency is observed. Only a small percentage persists with ED, but it could possibly be that a matter of time and follow-ups beyond 6 months should be considered to prove whether or not the ED persists. The cause of erectile dysfunction following a transrectal prostate biopsy is unknown but it could be tied to certain factors such as the temporary inflammatory tissue process, inflammation or damage to the neurovascular plexus, the presence of hematomas or edema. Other causes could be attributed to the presence of pelvic pain, prostatitis or anxiety.18,19 Therefore, the impact of transrectal prostate biopsy upon erectile function appears to be minimum and usually transient.
Conclusions The effects of prostate biopsy upon erectile function have been underestimated. After biopsy, the lowering of IIEF-5 scores and the presence of ED is temporary and transient. It
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is important to warn patients that undergo a prostate biopsy of the transitory repercussion on the erectile function. 10.
Conflict of interest The authors declare that they have no conflict of interest.
11.
References
12.
1. Hodge K, McNeal J, Terris M, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol. 1989;142:71---5. 2. Hodge K, McNeal J, Terris M, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of the prostate. J Urol. 1989;142:71. 3. Hodge K, McNeal J, Stamey T. Ultrasound guided transrectal core biopsies of the palpably guided transrectal core biopsies of the palpably abnormal prostate. J Urol. 1989;142:66. 4. Welch HG, Fisher ES, Gottlieb DJ, Barry MJ. Detection of prostate cancer via biopsy in the Medicare-SEER population during the PSA era. J Natl Cancer Inst. 2007;99:1395---400. 5. Loeb S, Carter HB, Berndt SI, Ricker W, Schaeffer EM. Complications after prostate biopsy: data from SEER Medicare. J Urol. 2011;186:1830---4. 6. Nam RK, Saskin R, Lee Y, Liu Y, Law C, Klotz LH, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol. 2010;183:963---9. 7. Gómez-Gómez E, Ramírez M, Gómez-Ferrer A, Rubio-Briones J, Iborra I, Carrasco-Valiente J, et al. Evaluación del dolor y factores asociados en pacientes sometidos a biopsia de próstata transrectal. Actas Urol Esp. 2015;39:414---9. 8. Zisman A, Leibovici D, Kleinmann J, Siegel YI, Lindner A. The impact of prostate biopsy on patient well-being: a prospective study of pain, anxiety and erectile dysfunction. J Urol. 2001;165:445---54. 9. Rosario DJ, Lane JA, Metcalfe C, Donovan JL, Doble A, Goodwin L, et al. Short term outcomes of prostate biopsy in men tested
13.
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for cancer by prostate specific antigen: prospective evaluation within ProtecT study. BMJ. 2012;344:d7894. Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R. Impact of postejaculatory pain in men with category III chronic prostatitis/chronic pelvic pain syndrome. J Urol. 2004;172:542---7. Sairam K, Kulinskaya E, Boustead GB, Hanbury DC, McNicholas TA. Prevalence of undiagnosed prostate cancer in men with erectile dysfunction. BJU Int. 2002;89:261. Helfand BT, Glaser AP, Rimar K, Zargaroff S, Hedges J, McGuire BB. Prostate cancer diagnosis is associated with an increased risk of erectile dysfunction after prostate biopsy. BJU Int. 2013;111:38---43. Linden-Castro E, Pelayo-Nieto M, Alias-Melgar A, RamírezGalindo I, Espinosa-Perez-Grovas D, Ordaz-Macias D, et al. The psychological impact of prostate biopsy: anxiety and depression associated with a positive biopsy result. Urol Pract. 2016;3:32---5. Naccarato AM, Reis LO, Zani EL, Cartapatti M, Denardi F. Psicoterapia: una pieza que falta en el puzle de la rehabilitación de la disfunción eréctil tras prostatectomía radical. Actas Urol Esp. 2014;38:385---90. Klein T, Palir RJ, Holz A, Brock M, Noldus J, Hinkel A. The impact of prostate biopsy and periprostatic nerve block on erectile and voiding function: a prospective study. J Urol. 2010;184:1447---52. Fujita K, Landis P, McNeil BK, Pavlovich CP. Serial prostate biopsies are associated with an increased risk of erectile dysfunction in men with prostate cancer on active surveillance. J Urol. 2009;182:2664---9. Chrisofos M, Papatsoris AG, Dellis A, Varkarakis IM, Skolarikos A, Deliveliotis C. Can prostate biopsies affect erectile function? Andrologia. 2006;38:79---83. Korfage IJ, Essink-Bot ML, Janssens AC, Schroder FH, de Koning HJ. Anxiety and depression after prostate cáncer diagnosis and treatment: 5-year follow-up. Br J Cancer. 2006;94: 1093---8. Glaser AP, Novakovic K, Helfand BT. The impact of prostate biopsy on urinary symptoms, erectile function, and anxiety. Curr Urol Rep. 2012;13:447---54.
ARTICLE IN PRESS
Actas Urol Esp. 2016;xxx(xx):xxx---xxx
Actas Urol´ ogicas Espa˜ nolas www.elsevier.es/actasuro
ORIGINAL ARTICLE
The impact of transrectal prostate biopsy on erectile function夽 E. Linden-Castro a , M. Pelayo-Nieto a,∗ , D. Espinosa-Perezgrovas a , E.D. Rubio-Arellano b , G. Catalán-Quinto a , F. Guzmán-Hernández a , J.A. Morales-Covarrubias a , R. Cortez-Betancourt a a
Departamento de Urología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, Mexico Laboratorio de Investigación y Desarrollo Farmacéutico, Departamento de Farmacobiología, Centro Universitario de Ciencias Exactas e Ingenierías, Universidad de Guadalajara, Jalisco, Mexico
b
Received 14 September 2015; accepted 21 February 2016
KEYWORDS Erectile dysfunction; Prostate biopsy
Abstract Objective: To assess erectile function at different periods of time in patients who undergo transrectal prostate biopsy (TRPB). Material and methods: A total of 364 patients underwent TRPB. All of the patients were assessed using the International Index of Erectile Function-5 (IIEF-5). All patients with a positive result for cancer or with previous erectile dysfunction in the initial assessment were excluded. Ninety-three patients were included and were assessed before the biopsy and at 4, 12 and 24 weeks after the TRPB, using the IIEF-5 and assessing erectile function across these time periods. Results: We assessed 93 patients. During the first prebiopsy assessment, 100% of the patients scored ≥22 points. In the first postbiopsy evaluation at 4 weeks, 66.6% scored ≥22 points, and 33.3% had erectile dysfunction, thereby indicating a statistically significant reduction in the IIEF-5 score (p = .001). In the second postbiopsy evaluation, only 9.1% patients still had mild to moderate erectile dysfunction (p = .04). By the end, 92.48% of the patients scored ≥22 points, and 7.52% still had mild erectile dysfunction, without presenting a significant difference (p = .1). Conclusions: After a TRPB, the drop in IIEF-5 scores and the presence of erectile dysfunction are temporary and transient, with greater impairment during the first month following the procedure and improvement starting after the first month, with almost total recovery at 6 months. © 2016 AEU. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
夽 Please cite this article as: Linden-Castro E, Pelayo-Nieto M, Espinosa-Perezgrovas D, Rubio-Arellano ED, Catalán-Quinto G, GuzmánHernández F, et al. Impacto de la biopsia transrectal de próstata en la función eréctil. Actas Urol Esp. 2016. http://dx.doi.org/10.1016/ j.acuro.2016.02.006 ∗ Corresponding author. E-mail addresses: [email protected], [email protected] (M. Pelayo-Nieto).
2173-5786/© 2016 AEU. Published by Elsevier Espa˜ na, S.L.U. All rights reserved.
ACUROE-857; No. of Pages 4
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ARTICLE IN PRESS
2
E. Linden-Castro et al.
PALABRAS CLAVE Disfunción eréctil; Biopsia de próstata
Impacto de la biopsia transrectal de próstata en la función eréctil Resumen Objetivo: Evaluar la función eréctil en distintos periodos de tiempo en pacientes que se someten a biopsia transrectal de próstata. Material y métodos: Trescientos sesenta y cuatro pacientes se sometieron a BTRP. Todos los pacientes se evaluaron utilizando el Índice Internacional de Función Eréctil (IIEF-5); se excluyó a todos los pacientes con resultado positivo para cáncer y con disfunción eréctil o previa en la evaluación inicial. Se incluyó a 93 pacientes, los cuales se evaluaron antes de la biopsia y a las 4, 12 y 24 semanas posteriores a la BTRP, utilizando el IIEF-5 y evaluando la función eréctil a través de estos periodos. Resultados: Se evaluó a 93 pacientes; durante la primera evaluación prebiopsia el 100% presentó ≥ 22 y en la primera evaluación posbiopsia a las 4 semanas el 66,6% tuvo ≥ 22 puntos y el 33.3% presentó disfunción eréctil, identificando una reducción estadísticamente significativa en las puntuaciones del IIEF-5 (p = 0,001). En la segunda evaluación posbiopsia solo el 9,1% de los pacientes persistió con disfunción eréctil, leve y moderada (p = 0,04); al finalizar, el 92,48% de los pacientes tenían ≥ 22 puntos y el 7,52% persistió con disfunción eréctil leve sin presentar una diferencia significativa. (p = 0,1). Conclusiones: Después de la BTRP, la disminución en las puntuaciones de IIEF-5 y la presencia de disfunción eréctil son temporales y transitorias, con una mayor afectación durante el primer mes posterior al procedimiento, mostrando una mejoría a partir del primer mes, y una recuperación casi total a 6 meses. © 2016 AEU. Publicado por Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction
Material and methods
Prostate biopsy guided by ultrasound (TRUS biopsy) has become the gold standard in diagnosing carcinoma of the prostate since the method’s introduction in 1989 by Hodge et al.1 Millions of men throughout the world undergo a TRPB, with nearly a million biopsy procedures being done yearly in the United States.2,3 Amongst the men who undergo a TRPB, almost 50% of them will be diagnosed with carcinoma of the prostate (CaP).4 TRUS biopsy is not a complication-free procedure since 1.0---6.9% of men who undergo the procedure can present adverse effects such as haematuria, hematospermia, dysuria, fever, and septicemia in 0.5---5% of cases.5,6 Regardless, it is still considered a relatively safe procedure. As a complication of biopsy, erectile dysfunction (ED) has been observed and has been described since the year 2001.7 The repercussion of TRPB over erectile function is not described as one of the main side effects; however, few studies have demonstrated the relationship that exists between ED and TRPB. This has lead to several theories and hypotheses being made on ED’s origin, but the exact mechanism is still unknown. The majority of studies carried out on the subject are in small-scale, retrospective, and show heterogeneous results. It is because of this that in our present study we decided to evaluate the erectile function of men before and after a TRPB was done, all of whom did not previously suffer from erectile dysfunction.
After institution approval was granted, 364 patients underwent a TRUS biopsy done by different urologists trained on how to do the procedure. There was identification of 93 men that met the inclusion criteria: presence of specific prostate antigen >3 ng/mL, abnormal rectal exam, knowing how to read and write, having enough comprehension to fill out the IIEF-5 questionnaire, and a negative PCa result in the TRUS biopsy. All men with a previous ED and/or PCa diagnosis, a previous TRUS biopsy, or a second neoplasm were excluded, as well as patients with: bone pains, disease opposing TRPB, history of cardiovascular disease (acute myocardial infarction, stroke, chronic obstructive pulmonary disease), terminal chronic kidney disease, major depression disorder, intake of antidepressants within the last three months, and intake of phosphodiesterase inhibitors (tadalafil, vardenafil, sildenafil). The patients who met the criteria underwent the biopsy. The main point of evaluation was erectile function, studied with the International Index of Erectile Function (IIEF-5). The IIEF’s score range is from 5 to 25 points. We grouped the patients into four categories according to the severity of ED: severe (5---7 points), moderate (8---16 points), mild (17---21 points), and no ED (22---25 points). The questionnaire (IIEF-5) was answered before the procedure (biopsy) and later on three different occasions at 4 weeks, 12 weeks, and 6 months after the biopsy. The questionnaires were answered during the follow-ups of the patients. All patients who had a positive PCa diagnosis post-biopsy were excluded. The biopsy was conducted in a systematic manner in all patients. All patients had rectal preparation one day prior to the procedure and the administration of antibiotics was done according to the AUA’s Best Practice Statement 2014. The ultrasound equipment used was an Aloka® ␣ 6
Objective To evaluate erectile function across different time periods in male patients who undergo a transrectal prostate biopsy.
+Model
ARTICLE IN PRESS
The impact of transrectal prostate biopsy on erectile function Prosound, along with a 5---10 MHz intracavity probe and an 18 Ga 20 cm BARD® Biopsy Needle to obtain samples measuring 22 mm. Local anesthesia with simple xylocaine at 2% was applied on the right and left periprostatic venous plexus and on the left and right apex, 2.5cc in each region with a Echotip Skinny Needle, Chibe Tip® 22 Ga/20 cm. 12 cylinders specimens were obtained in all cases and patients who underwent a saturation biopsy were excluded. The prostatic volume was calculated with the following equation: volume (mL) = 0.524 × (length × height × width). Descriptive statistics were used for the patients’ characteristics, as well as a Student’s t-test to compare the base scores against the follow-up patient scores on the first, second, and third evaluations, all at different time periods. The statistical analysis was done using IBM SPSS Statistics 19® .
Results Mean age was 59 years old (range: 45---73 years old), with a mean prostate-specific antigen of 5.7 ng/mL and the average prostatic volume being 59 mL. During the patient evaluations prior to the procedure, 100% of them had an IIEF-5 score >21 points. At the evaluation 4 weeks post-biopsy, 66.6% of the patients maintained a score above 22 points, indicating no ED, and the resting 33.3% presented certain degree of ED with 26.8% being classified as mild ED, 4.30% having mild-moderate ED, 2.15% with moderate ED, and none of the patients with severe ED. Nearly a third of the patients during this first evaluation presented a certain degree of ED in comparison to the base evaluation (p = 0.001). At the second evaluation post-biopsy done after 12 weeks, 9.1% of patients persisted with ED, from these 3.41% being mild cases and 5.68% being mild-moderate ones. During this second evaluation, just as in the first, no severe cases of ED were observed, representing a statistical difference (p = 0.04). On the third evaluation done 6 months post-biopsy, none of the patients were classified as mild-moderate, and just 7.52% of patients persisted as cases of mild ED, this time the statistical difference was not significant. During the 6-month period of evaluation, none of the patients suffered severe ED and the majority of patients that showed ED were classified as mild according to the IIEF-5. The changes in scores of the IIEF-5 were not correlated to age of the patient or to the specific prostate antigen levels.
Discussion Prostate biopsy is one of the most common urology procedures, with more than 1 million procedures made each year in the United States and Europe.8 The biopsy is typically well-tolerated with low risks of major complications, nonetheless minor complications are frequent. In our study we evaluated the presence of erectile dysfunction in patients that underwent a transrectal prostate biopsy.9 Studies show that erectile dysfunction is not more frequent in males with carcinoma of the prostate.5 However, the data related to transrectal prostate biopsy and erectile dysfunction is scarce, heterogeneous,10 and the majority of studies include patients who had an extended prostate biopsy or
3 it was done by saturation; they include both patients with positive and negative PCa results11 as well as samples of patients who already have ED from mild to severe or other few studies have studied patients with negative PCa result. Up to this date, this is the first study that evaluates patients with no ED prior to the biopsy and who have a negative PCa result. This was done in order to avoid anxiety and slant that could be due to receiving diagnosis of cancer and that could also lead to or worsen ED.12 In our series, we identified that 100% of patients were potent at the beginning of the study before the procedure was done, at 4 weeks 33% suffered from ED, and at 12 weeks only 9.12% persisted with ED. In general, and as shown in other studies, erectile dysfunction presents usually during the first month post-biopsy. We also saw a recovery in the potency of our patients that had shown a degree of ED, it is to say that the majority of patients return to their baseline in the long term. Klein et al. identified that the use of periprostatic nerve block produces higher rates of erectile dysfunction.13 In our study, however, 100% were applied the periprostatic nerve block, which is currently considered as a standard, and we believe it is not a factor that increases the ED rate, at least not in our case. Fujita et al. found a positive correlation between erectile dysfunction and a larger amount of cylinder specimens,14 but this association was not able to be valued since in all of our patients only 12 specimens were taken. Chrisofos et al. pointed at ED in 8.9% of patients after the prostate biopsy with a full recovery after three months of follow-up.15 Zisman et al. identified ED in 9.7% of his sample, but both of these studies included patients with a positive PCa result,16 which is an important anxiety factor.17 In our environment, we omitted that factor but greater levels of ED were still presented (33.3%). This can be justified since the first evaluation was done 4 weeks later and none of the patients in the study already had ED. We identified recovery as time passed by during the evaluations done 12 weeks and 24 weeks later, showing during the last evaluation only 7.52% of patients persisting with a degree of ED, all classified by the IIE-5 as mild. Erectile dysfunction does affect patients who undergo a transrectal prostate biopsy, it being more evident during the first four weeks, point from which a recovery of potency is observed. Only a small percentage persists with ED, but it could possibly be that a matter of time and follow-ups beyond 6 months should be considered to prove whether or not the ED persists. The cause of erectile dysfunction following a transrectal prostate biopsy is unknown but it could be tied to certain factors such as the temporary inflammatory tissue process, inflammation or damage to the neurovascular plexus, the presence of hematomas or edema. Other causes could be attributed to the presence of pelvic pain, prostatitis or anxiety.18,19 Therefore, the impact of transrectal prostate biopsy upon erectile function appears to be minimum and usually transient.
Conclusions The effects of prostate biopsy upon erectile function have been underestimated. After biopsy, the lowering of IIEF-5 scores and the presence of ED is temporary and transient. It
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is important to warn patients that undergo a prostate biopsy of the transitory repercussion on the erectile function. 10.
Conflict of interest The authors declare that they have no conflict of interest.
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