Health and Prostate

Preservation of sexual function has become an important consideration for our patients when contemplating therapeutic alternatives to their medical conditions and, in particular, surgical intervention. This concern has prompted the development of new surgical techniques and the modification of some old ones.

In men we are interested specifically in preserving fertility, erectile function, and ejaculation. We can preserve these functions by timely corrective surgery, by modifying surgical techniques to avoid unwanted sequelae, or by substituting surgery for some other form of therapy less likely to produce unwanted complications. This article reviews the changes that have occurred in urology that allow us to offer our male patients better preservation of their sexual function.

Table 1 lists urologic procedures that may be used to protect sexual function or that have the potential to interfere with sexual function. These procedures span the entire life of a male patient.

Innate threats to function

Some boys and men have conditions that do not cause immediate problems but may pose a future threat to fertility. The trend is to be more aggressive in diagnosing such conditions.

Undescended testicle. Undescended testicles (cryptorchism) occurs commonly in male neonates but often resolves during the first 6 months of life. Testicles that have not descended by the time the patient is 9 months of age are unlikely to do so.

These testicles have an increased incidence of infertility later in life, as well as an increased incidence of testicular malignancy. Cancer of the testicle can, in turn, impair fertility, not only by the loss of one gonad but also by the therapy that may be required afterward. Chemotherapy inhibits spermatogenesis for a prolonged time and occasionally permanently. Retroperitoneal node dissection can interfere with emission. Timely surgery to position the testicles in the scrotum (orchiopexy) can significantly reduce the incidence of both these conditions.

Furthermore, there is growing evidence that the use of gonadotropic stimulating hormone (GnRH) instead of or in conjunction with orchiopexy can further improve fertility in these boys. We recommend that the testicles be brought down to the scrotum during the first 2 years of life. Although this will not completely eliminate the risk of malignancy, it will make the testicles more amenable to examination and could provide for early detection of any abnormality.

Varicoceles. Varicocele is the abnormal distention of scrotal veins (pampiniform plexus) owing to the congenital absence of venous valves, which permits the retrograde flow of venous blood to the testicle and slowly dilates these veins. Varicocele occurs in more than 10% of normal men and in probably the same percentage of adolescents.

Only in a few of these subjects is it associated with subfertility. Young adolescents normally present with a visible scrotal mass, which can be symptomatic. There is growing evidence that the adolescent varicocele affects future fertility in some instances. Kass has proposed that adolescents with a varicocele and ipsilateral smaller than normal testes, as well as those with bilateral varicoceles or abnormal results of semen analysis, should be offered repair to preserve their fertility potential. An abnormal response to an infusion of GnRH has been found in some infertile men with varicoceles. Kass and others believe that such a test could help us decide which teenagers with varicoceles are at risk of future subfertility and should be repaired. Ongoing studies are continuing to define the role of varicocelectomy in the young adult and child, but it seems that early varicocelectomy in selected cases can preserve fertility.

Surgery that threatens function

Until now we have discussed surgery to prevent future impairment of sexual function. Much urologic surgery also has the potential to interfere with sexual function. New developments in surgical techniques are designed primarily to prevent such complications.

Transurethral prostatectomy. More than 400 000 transurethral prostatectomies are performed in the United States. This is a safe and effective procedure but is associated with an almost 90% incidence of retrograde ejaculation and about 0.5% chance of impotence. Open prostatectomy for benign disease has a similar incidence of these complications. Impotence seems to occur more commonly in older patients and can have a psychosexual rather than an organic cause.

In an effort to reduce many of the complications of prostatic surgery, several new techniques have been devised. Orandi has popularized a transurethral incision of the prostate, cutting the prostatic tissue from bladder neck to veru montanum without resecting any tissue. Although this procedure reduces the incidence of some complications, it does not eliminate retrograde ejaculation. Balloon dilation of the prostate is a new technique that uses coaxial high-pressure balloons to dilate the prostatic urethra to 75F to 90F. Several balloons and modes of placement have been described. We have experience with an endoscopically placed 75F balloon manufactured by the Advanced Surgical Intervention Company of San Clemente, Calif. This device produces satisfactory relief of symptoms and, in more than 2000 dilatations, there has been no incidence of impotence or retrograde ejaculation. This technique is most suited to male subjects with moderately sized prostates – the patients most concerned about the possibility of these complications (Figure 1).

Figure 1. Balloon Dilation of Prostate: A new technique dilates the prostatic urethra to 75F to 90F

Radical prostatectomy. Prostatic cancer is one of the most common malignancies in male subjects and the second leading cause of cancer death. Radical prostatectomy for disease localized to the prostate offers the patient a significant potential for cure. Unfortunately it has traditionally been associated with a very high incidence of incontinence and impotence. Many patients have rejected this option for treatment primarily because of these unacceptable sequelae.

Recently Walsh and associates have modified the technique of radical prostatectomy in order to preserve the nervi erigentes and maintain erectile potential. This has proven to be a more anatomically sound way of removing the prostate and has not only improved the preservation of potency to about 60% but also has virtually eliminated postoperative incontinence. Retrospective analysis of these patients indicates that it is feasibile to spare the nerve without compromising tumor excision. This new technique is encouraging more patients to take advantage of this curative treatment.

Surgery for bladder cancer. Radical cystectomy and urinary diversion is one of the options for treatment of localized, invasive transitional cell cancer of the bladder. This necessitates the removal of the prostate and always results in impotence. It is possible to apply the nerve-sparing techniques used in radical prostatectomies to this surgery. Care must be taken to exclude those patients likely to have local extension of tumor outside the bladder and lymph node involvement.” Experience with this form of cystectomy is still too recent to comment on long-term sequelae and local tumor control.

Retroperitoneal lymph node dissection. Testicular cancer is perhaps the most common solid tumor in young male patients. Its effect on fertility is devastating. There is evidence that patients with testicular malignancy have decreased fertility from birth, many having had cryptorchid testicles in infancy.

The occurrence of a testicular malignancy necessitates a unilateral orchiectomy for diagnosis and treatment and, in many instances, a retroperitoneal lymph node dissection. This procedure is quite effective in staging and treating testicular tumor with retroperitoneal node invasion and is often necessary before or after chemotherapy for residual disease. This dissection often injures the sympathetic nerves that traverse the area, which initiate emission. Thus retrograde ejaculation is a common sequela of this surgery. Early attempts at reducing the incidence of this complication originally limited the fields of dissection, but were not uniformly successful. More recently a true nerve-sparing technique has been described that involves the specific dissection and recognition of these nerves and their preservations. Early results with selected patients are encouraging.

Restoration of sexual function

This discussion would be incomplete without mention of techniques to restore sexual function. New advances in fertility may soon make in vitro fertilization available to male subjects with significantly reduced sperm numbers. Electroejaculation, OC-adrenergic medication, and sperm retrieval from the bladder can be effective in some patients with retrograde ejaculation or lack of emission but not, unfortunately, when they are the result of bladder neck resection in prostatic surgery.

The treatment of organic impotence has provided us with many techniques applicable to postsurgical impotence. Among these are the injection of papaverine and prostaglandins into the corpus cavernosum penis, some oral pharmacologic agents, such as yohimbine, and many vacuum devices designed to increase blood entrapment in the penis. In addition, there are many rigid, semirigid, and inflatable prosthetic penile implants that can be used. Patients should be made aware of these alternatives when discussing these new surgical procedures.

Discussion

The desire to preserve sexual function has increasingly affected patients’ acceptance of treatment modalities. In response to this concern, techniques have been modified and new surgical procedures devised. We have moved to early orchiopexy; we are exploring the advisability of early varicocele repair; and we have moved to more limited nerve-sparing procedures for some of the genitourinary malignancies. These nerve-sparing procedures are meticulous and not indicated in all patients. Disease grade and stage, as well as local variations in anatomy, have to be taken into consideration before embarking on such procedures.

It is important to realize that long-term follow up of nerve-sparing surgery is not yet available. We still do not know whether the new techniques will measure up to previous techniques in terms of long-term local control and distant metastasis. Balloon dilation of the prostate is an attractive alternative for the young male patient with symptoms of prostatism. It is capable of providing at least temporary relief of symptoms, can be repeated several times, and does not preclude subsequent surgery.

Patients are demanding and should have more say in selecting therapeutic alternatives. We must make them aware that we are still unsure whether long-term cancer control is as good with new as with old surgical techniques, and also that there are many ways to restore affected sexual function. In this way, we can assist them in making a truly informed decision. ■