4:04 Retrograde ejaculation after anterior lumbar interbody fusion: transperitoneal versus retroperitoneal

Abstract

Purpose of study: One of the most devastating complications of anterior lumbar interbody fusion (ALIF) in the young male patient is retrograde ejaculation. The purpose of this study is to compare the incidence of retrograde ejaculation in a group of patients undergoing ALIF through either a transperitoneal or retroperitoneal approach.Methods used: A total of 279 patients were entered into a randomized, prospective US Food and Drug Administration investigational device exemption (IDE) study evaluating recombinant human bone morphogenic protein (rhBMP)-2 in a tapered titanium cylindrical cage placed through an open anterior approach for treatment of symptomatic degenerative disc disease. Choice of retroperitoneal or transperitoneal approach was at the surgeon's discretion. All procedures were at the L4–L5 or L5–S1 level. The investigation group received rhBMP-2 and the control group autograft iliac crest bone in the cage. Of the 143 patients in the rhBMP-2 group, 78 were male. A retroperitoneal approach was performed on 61 and transperitoneal on 17. In the control group, 68 of 136 patients were male. Fifty-five had a retroperitoneal approach, and 13 had a transperitoneal approach. There is no reported influence of type of bone graft on retrograde ejaculation, so the groups were combined for evaluation. A total of 146 male patients were included in this study with 116 undergoing a retroperitoneal approach and 30 a transperitoneal approach. All male patients were advised preoperatively of the risk of retrograde ejaculation. Patients were questioned postoperatively about adverse events. If a patient reported retrograde ejaculation had occurred postoperatively, they were questioned at each subsequent visit to determine if it was a transient or permanent condition.of findings: Six of 146 male patients reported retrograde ejaculation. Two occurred in the retroperitoneal group (2 of 116) for a 1.7% rate. Four occurred in the transperitoneal group (4 of 30) for a 13.3% rate. This was statistically significant using the Fisher's exact test (p=.017). One patient who developed retrograde ejaculation had an L4–L5 fusion using a retroperitoneal approach and five had an L5–S1 fusion, four with a transperitoneal approach and one with a retroperitoneal approach. Two patients had resolution of their condition at the 1-year postoperative interval, one from the retroperitoneal group and one from the transperitoneal approach. One patient with transient symptoms had an L4–L5 fusion through the retroperitoneal approach, and one patient had an L5–S1 fusion through a transperitoneal approach. At the 2-year postoperative evaluation, four patients had persistent retrograde ejaculation. One was in the retroperitoneal group (1 of 116) for a rate of 0.86% and three in the transperitoneal group (3 of 30) for a rate of 10%. The difference in the rate of permanent retrograde ejaculation is statistically significant between the retroperitoneal and transperitoneal groups using the Fisher's exact test (p=.027)Relationship between findings and existing knowledge: The first reports of retrograde ejaculation after ALIF were made in the 1960s. Although a rare complication, concern arose in the 1990s when a higher rate was noted with laparoscopic procedures. The results of this study show a statistically significant higher rate of permanent retrograde ejaculation in men undergoing a transperitoneal compared with a retroperitoneal approach (10% vs. 0.86%).Overall significance of findings: Transperitoneal approaches to the lumbar spine at L4–L5 and L5–S1 have a 10 times higher chance of retrograde ejaculation compared with retroperitoneal approaches in male patients.Disclosures: No disclosures.Conflict of interest: Rick Sasso, MD, grant research support; Rick Sasso, MD, consultant; Kenneth Burkus, MD, grant research support; Kenneth Burkus, MD, consultant; Jean Charles LeHuec, MD, grant research support; Jean Charles LeHuec, MD, consultant.