Abstract
Background/Aim: Sexual function in patients with benign prostatic hyperplasia (BPH) could be affected by surgical intervention, such as holmium laser enucleation of the prostate (HoLEP). The objective of the present study was to investigate whether changes in erectile function (EF) after HoLEP affect postoperative outcomes in patients with BPH. Patients and Methods: We retrospectively reviewed 54 consecutive Japanese patients with BPH undergoing HoLEP at our institution between August 2017 and December 2020, and analyzed data obtained before and 6 months after HoLEP, including the Erection Hardness Score (EHS), International Prostate Symptom Score (IPSS), IPSS-Quality of Life (IPSS-QOL), Overactive Bladder Symptom Score (OABSS), and the Medical Outcomes Study 8-Item Short-Form Health Survey consisting of a mental health component summary (MCS) and physical health component summary (PCS). Results: Although no significant differences were observed between preoperative and postoperative EHS, postoperative EHS deteriorated in 19 out of 54 patients. Total IPSS, IPSS-QOL, and OABSS significantly improved after HoLEP, irrespective of the deterioration of EHS; however, despite the lack of significant changes in MCS and PCS in 19 patients with deteriorated EHS, significant improvements in MCS, but not PCS, were postoperatively observed in the remaining 35. A multivariable analysis of several factors identified a preoperative estimated prostate volume >100 cm3 as an independent risk factor associated with the postoperative deterioration of EHS. Conclusion: HoLEP had limited impact on postoperative EF in BPH patients; however, favorable QOL may be expected in patients without the postoperative deterioration of EF. Accordingly, it may be important to consider the prostate volume and its effect on postoperative EF when selecting indications for HoLEP.
- Erectile function
- sexual function
- holmium laser enucleation of the prostate
- benign prostatic hyperplasia
Benign prostatic hyperplasia (BPH) and its accompanying lower urinary tract symptoms (LUTS) are highly prevalent and regarded as comorbid conditions in middle-aged and elderly men (1). The outcomes of pharmacotherapy for LUTS due to BPH have improved; however, surgical treatment is still regarded as the ultimate reliable option for BPH patients, particularly those with refractory or severe BPH-related LUTS (2). Since its original description by Gilling et al. (3), holmium laser enucleation of the prostate (HoLEP) has become a promising alternative to classical surgical therapies, including transurethral resection of the prostate (TURP) and open prostatectomy, for patients with BPH. A number of studies have consistently showed that HoLEP achieves more favorable outcomes with respect to both efficacy and safety than other surgical treatments (4, 5).
Sexual function has been shown to play an important role in the daily lives of the majority of men, irrespective of age, and to have a significant effect on their quality of life (QOL) (6). However, limited information is currently available on the postoperative impact of HoLEP on outcomes associated with sexual health in BPH patients (7-11). Furthermore, the impact of HoLEP on erectile function (EF) in Japanese BPH patients remains unknown. Therefore, the present study retrospectively included 54 consecutive Japanese patients with BPH who received HoLEP and analyzed changes in EF and its effects on postoperative comprehensive findings.
Patients and Methods
The design of the present study was approved by the Research Ethics Committee at our institution (No.18-289). The need to obtain informed consent from patients was waived because of its retrospective design; however, an opportunity to opt out from this study was provided through the website of our institution.
After the exclusion of patients with neurogenic bladder, a previous history of prostatic surgery, urethral stricture, and/or prostate cancer, the present study retrospectively included 54 consecutive patients diagnosed with BPH and subsequently treated with HoLEP at our institution between August 2017 and December 2020. Indications for surgery were refractory urinary retention and severe LUTS due to BPH. Details on indications for HoLEP and surgical procedures in this series were described in our previous study (12).
Data on these 54 patients, including clinicopathological characteristics and perioperative findings, were obtained from their medical records. Several symptoms were evaluated using the following self-administered questionnaires before and 6 months after HoLEP: the Erection Hardness Score (EHS) (13, 14), International Prostate Symptom Score (IPSS), IPSS-QOL (15), Overactive Bladder Symptom Score (OABSS) (16), and the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) (17). As for SF-8, which was developed for a multipurpose survey to evaluate the physical and mental health status with 8 multi-items scales, physical component summary scores (PCS) and mental health component summary scores (MCS) were used as representative findings of this survey.
All statistical analyses were conducted using EZR software (Saitama Medical Center, Jichi Medical University, ver. 1.40), and p-values <0.05 were considered to be significant. Differences between the 2 groups were examined by the unpaired t-test or a repeated measures ANOVA with Dunnett’s multiple comparison procedure. Univariable and multivariable logistic regression analyses were used to identify factors associated with the postoperative deterioration of EHS.
Results
No significant differences were observed between preoperative and postoperative EHS (1.76±1.22 and 1.44±1.15, respectively, p=0.074) in 54 patients. However, postoperative EHS deteriorated in 19 patients (35.2%), while the remaining 35 (64.8%) had similar or superior postoperative EHS. Table I summarizes the major characteristics of patients with and without the deterioration of EHS after HoLEP. No significant differences were observed in several parameters between these 2 groups. Table II shows comparative findings between patient-reported outcomes before and 6 months after HoLEP. In the overall population, despite the lack of a significant change in the IPSS storage symptom score, significant improvements were observed in PCS and MCS, postoperative findings on total IPSS, the IPSS voiding symptom score, IPSS-QOL, and OABSS from preoperative values. Furthermore, changes in patient-reported outcomes (PROs) by 19 patients with the deterioration of postoperative EHS showed similar patterns to those in the overall population. In the 35 patients without the deterioration of postoperative EHS, postoperative MCS significantly improved, while postoperative changes in the remaining outcomes were similar to those in the overall population.
Characteristics of patients according to changes in Erection Hardness Score (EHS) 6 months after holmium laser enucleation of the prostate (HoLEP).
Comparison of findings of patient-reported outcomes before and 6 months after holmium laser enucleation of the prostate (HoLEP).
Several factors were evaluated by univariable and multivariable analyses to examine their effects on postoperative changes in EHS. As shown in Table III, the univariable analysis showed that the deterioration of postoperative EHS correlated with a preoperative prostate volume >100 cm3 and postoperative impaired total IPSS, of which only a preoperative prostate volume >100 cm3 was identified as an independent predictor of the deterioration of EHS after HoLEP.
Uni- and multi-variable analyses of factors associated with the deterioration of Erection Hardness Score (EHS).
Discussion
In recent years, various surgical techniques have been developed for the treatment of patients with BPH (3-5). Among these, HoLEP has been shown to provide superior efficacy as well as safety to other surgical approaches for relieving LUTS due to BPH (4, 5). To date, few studies have performed detailed assessments on the sexual health of BPH patients receiving HoLEP, and their findings have been inconsistent (7-11). Furthermore, to the best of our knowledge, the impact of HoLEP on the sexual health of Japanese BPH patients, whose sexual function and behavior differ from those in Western populations (18), remains unknown. Therefore, we herein analyzed postoperative changes in EF in 54 Japanese BPH patients treated with HoLEP, and comprehensively assessed their impact on postoperative PROs.
Previous studies reported markedly lower sexual activity in Japanese men than in their Western counterparts (18,19). Namiki et al. showed that Japanese men were more likely to have poor sexual function, including sexual desire, erection ability, erection quality, and intercourse, than American men (19). Therefore, in the present study, EF was evaluated with EHS because it may be more appropriate than other tools, such as the International Index of Erectile Function-5, for men with an inactive sexual health status, such as Japanese men, as previously reported (20). In this series, no significant differences were noted between EHS before and 6 months after HoLEP. To date, conflicting findings on the impact of HoLEP on postoperative EF have been reported; an impairment in EF after HoLEP was demonstrated in a few studies (7), whereas others showed no postoperative changes (8). Klett et al. evaluated long-term EF in 393 American men undergoing HoLEP and revealed a transient reduction in EF over the first month with a return to baseline within 1 year (9). Collectively, these findings suggest that HoLEP exerts limited adverse effects on overall sexual function; however, more detailed assessments, including a time-course evaluation of EF, are warranted to reach a definitive conclusion on this point.
Previous studies reported that postoperative EF deteriorated in 20 to 30% of patients undergoing HoLEP (7-11), which is consistent with the present results showing the deterioration of EF after HoLEP in 35.2% of patients. Although changes in IPSS, IPSS-QOL, and OABSS after HoLEP showed similar patterns, irrespective of the postoperative deterioration of EF, improvements in QOL, particularly those associated with mental health, were marked in patients without the deterioration of EF. Improvements in the status associated with voiding may be widely achieved in BPH patients by HoLEP; however, postoperative changes in QOL in these patients may be significantly affected by whether EF deteriorates after HoLEP.
Further studies are warranted to identify factors contributing to postoperative changes in EF in patients with BPH undergoing HoLEP. In the present study, univariable and multivariable analyses of several parameters identified a preoperative prostate volume >100 cm3 as an independent predictor of the deterioration of EHS after HoLEP. The most widely accepted theory to explain impaired EF after the surgical management of BPH is energy-induced thermal injury to the nerves mediating EF, which are distributed between the prostatic and levator ani fascias and concentrated around the prostatic apex (21). However, the involvement of other psychological factors in the postoperative deterioration of EF has been suggested (7-11). Inconsistent factors were previously shown to be associated with the impairment of EF after surgical therapy for BPH among different studies, such as active preoperative EF, an advanced age, and a high ratio of laser energy to the prostate volume (7, 8).
Several limitations need to be addressed. This was a retrospective study with a small sample size; therefore, it is necessary to confirm the present outcomes in a prospective study including a larger number of patients. Furthermore, this study assessed postoperative data 6 months after HoLEP alone; therefore, further studies are needed to obtain long-term follow-up data and more reliable findings. In addition, there are a number of factors that were not examined in this study, which may have an impact on sexual function, such as medication, postoperative ejaculation disorders, and lifestyle.
In conclusion, despite the lack of a significant effect of HoLEP on postoperative EF, mental health-related QOL may be improved in patients without the deterioration of EF after HoLEP. In addition, a preoperative prostate volume >100 cm3 may predict deterioration of postoperative EF. Accordingly, it is important to consider prostate size and its impact on postoperative EF when evaluating indications for HoLEP, in Japanese BPH patients.
Footnotes
Authors’ Contributions
Research conception and design: Ryo Sato. Data acquisition: Ryo Sato, Asuka Sano and Kyohei Watanabe. Statistical analysis: Ryo Sato. Data analysis and interpretation: Yuto Matsushita, Hiromitsu Watanabe and Keita Tamura. Drafting of the manuscript: Ryo Sato. Critical revision of the manuscript: Hideaki Miyake. Supervision: Daisuke Motoyama, Takayuki Sugiyama, Atsushi Otsuka, Hideaki Miyake.
Conflicts of Interest
The Authors declare that they have no conflicts of interest.
- Received September 17, 2022.
- Revision received October 2, 2022.
- Accepted October 11, 2022.
- Copyright © 2022 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.