Postoperative Impotence Research Articles

Transurethral ultrasound-guided laser-induced prostatectomy: a critical evaluation.

We evaluated 38 patients with a follow-up of 30 months after transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia. The mean symptom score decreased by 54%, and peak urinary flow increased by 112%. For the entire series, 43.6% of the patients had an improved symptom score and 41% better urinary flow, but only 28.2% had improvement in both. Six patients (16%) required reoperation, two underwent a radical prostatectomy, and one patient presented total urinary incontinence. Also, 19% presented postoperative impotence, and 47% presented retrograde ejaculation. Although one third of the patients are improved with the TULIP procedure, the rate of complications is significantly higher than for TURP, which remains the most effective treatment of obstructive BPH.

Beyond the nerve-sparing radical prostatectomy.

Radical prostatectomy remains the most effective long-term treatment for patients with localized adenocarcinoma of the prostate. In the past it did not gain widespread popularity because many urologists believed the operation was technically difficult and was associated with significant intraoperative hemorrhage and postoperative impotence and incontinence. Over the past 15 years, an anatomical approach to radical retropubic prostatectomy has been developed that has greatly reduced the morbidity and mortality of the procedure. Delineation of the anatomy of the dorsal vein complex in 1979 by Reiner and Walsh enabled the procedure to be performed in a relatively bloodless field [1]. In 1982, Walsh and Donker described the anatomic course of the pelvic nerve plexus that provides innervation to the corpora cavernosa [2] and determined that impotence after radical prostatectomy was caused by injury to this plexus during dissection of the prostate. With the knowledge of the anatomy of the neurovascular bundles to the prostate and corpora carvernosa of the penis, the urologic surgeon may either spare the bundles or excise them when a wider margin is required to remove all of the tumor. Increased emphasis on the preservation of the striated urethral sphincter with an accurate sutured vesicourethral anastamosis that includes mucosal coaptation has led to a reduction in postoperative incontinence and bladder neck contracture [3]. This anatomic approach to radical prostatectomy has led to decreased blood loss and incontinence and has allowed many men to regain erectile potency. Thus, radical prostatectomy has become more acceptable to both patients and physicians.KeywordsProstate CancerRadical ProstatectomyGleason ScoreLocalize Prostate CancerPositive Surgical MarginThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

A Modified Winter's Procedure for Priapism Treatment with a New Trocar

A modified Winter's procedure with trocar which was used for 7 patients with priapism is presented. Complete detumescence was resumed in 5 of 7 patients. Cavernosaphenous shunt was used for only 2 patients. Two patients had postoperative impotence.

Effects of prostatectomy onsexual function

We evaluated the effects of prostatectomy on sexual function in 210 patients, 49.6 percent of whom underwent transurethral resection of the prostate (TURP), and the remainder had suprapubic transvesical prostatectomy (SPP). Pre- and postoperative interviews with detailed questionnaires were utilized. Postoperative sexual dysfunction was reported by 18 of 152 patients (11.8%) who were functioning normally prior to surgery. The incidence of postoperative impotence was evenly distributed between the TURP and SPP groups and was age-related; it was highest among older patients. We further observed a strong correlation between the presence of a permanent sexual partner and the preservation of potency. We conclude that the risk of postoperative impotence is dependent on both the patient's age and the presence of a partner, and should be discussed with the patient preoperatively.

Sexual Function following Radical Prostatectomy: Influence of Preservation of Neurovascular Bundles

The influence of preservation or excision of the neurovascular bundles on return of sexual function is analyzed. Between 1982 and 1988, 600 men 34 to 72 years old underwent radical retropubic prostatectomy for prostate cancer. Of the 503 patients who were potent preoperatively and followed for a minimum of 18 months 342 (68%) are potent postoperatively. Three factors were identified that correlated with the return of sexual function: 1) age, 2) clinical and pathological stage, and 3) surgical technique (preservation or excision of the neurovascular bundle). In men less than 50 years old potency was similar in patients who had both neurovascular bundles preserved (90%) and patients who had 1 neurovascular bundle widely excised (91%). With advancing age of more than 50 years sexual function was better in patients in whom both neurovascular bundles were preserved than in patients in whom 1 neurovascular bundle was excised (p <0.05). When the relative risk of postoperative impotence was adjusted for age the risk of postoperative impotence was 2-fold greater if there was capsular penetration or seminal vesicle invasion, or if 1 neurovascular bundle was excised (p <0.05).These data indicate that the return of sexual function postoperatively in men more than 50 years old is quantitatively related to preservation of autonomic innervation. In these men when it is necessary to excise the neurovascular bundle on 1 side, consideration in the future should be given to approaches that may restore autonomic function through nerve regeneration, for example partial excision of the bundle or cavernous nerve grafts.

Radical prostatectomy in cases of prostatic carcinoma: the problem concerning erectile impotence.

It has become fashionable to perform radical prostatovesiculectomy for carcinoma of the prostate using the nerve-sparing method. In cases with a not too large prostate and a locally limited tumor, it is possible to preserve erectile potency. Our anatomic and radiologic preparation proved that postoperative impotence is not only due to lesions of the nerves but, almost as frequently, the consequence of obliterations of the vessels or a combination of both. If the lesion is purely arterial, revascularization surgery guarantees normal erections.

Papaverine Testing of Impotent Patients Following Nerve-Sparing Radical Prostatectomy

To investigate the etiology of impotence following nerve-sparing radical retropubic prostatectomy we performed papaverine testing on 23 patients who did not regain erections sufficient for vaginal penetration. Intervals from surgery to testing ranged from 3 to 30 months, with an average of 9 months. All patients achieved some degree of tumescence. In response to intracavernous papaverine injection only 1 patient (5 per cent) obtained an erection equivalent to the preoperative state. Of 18 patients who were fully potent preoperatively 8 (44 per cent) achieved an erection less than normal but judged to be sufficient for intercourse by the examining physician. Twelve patients, including 2 who were not fully potent preoperatively, had erections of poor quality insufficient for vaginal penetration. The results suggest that in most of these patients postoperative erectile dysfunction is predominantly vasculogenic in origin. Thus, factors other than injury to the neurovascular bundles may be responsible for postoperative impotence.

Division of the External Urethral Sphincter and Potency in Spinal Cord Injury Patients

Endoscopic biopsy of the external urethral sphincter (internal membranous urethrotomy) was used first in England in 1956. A total of 258 patients underwent this operation for relief of outflow obstruction in the neuropathic bladder between 1956 and 1975. Recently, reports of postoperative impotence had appeared in the literature. A prospective study of 160 men undergoing division of the external urethral sphincter between 1975 and 1981 was done to determine if there was any effect on sexual function and to reassess the long-term results of the operation. Impotence has not been documented in any of these 418 patients. This study confirms previous reports on the reliability and simplicity of the operation.

Erectile function before and after reconstructive arterial surgery in men with occlusive arterial leg disease.

Erectile impotence is a well-known complication of vascular surgery in the aorto-iliac area. So far the pathogenesis has not quite been understood, but peroperative damage to the autonomous nerves has been suggested. Ninety-eight men with arterial insufficiency in their legs underwent an additional sexual evaluation including penile blood pressure measurement and cystometric examination. The arterial insufficiency necessitated arterial reconstruction involving aorta or the common iliac arteries in 28 patients. When possible, improvement of the penile blood supply was aimed at during the operation, but no nerve-sparing techniques were employed. The seven potent patients remained potent, while nine patients became potent after the operation. The cases remaining impotent after the operation could all be explained considering the arteriography, the operation and the changes in penile blood pressure. The erectile function is related to the condition of the penile blood supply and it may be possible to reduce the rate of postoperative impotence by considering the penile blood supply when planning the operative strategy.

The long term results of transurethral division of the external urethral sphincter in the neuropathic urethra with reference to potency.

The operation of endoscopic biopsy of the external urethral (internal membranous urethrotomy) was first used in England in 1957. Currently the total of 322 patients had this operation for relief of outflow tract obstruction in the neuropathic bladder. In recent years reports of post-operative impotence had appeared in the literature. This is a prospective study of 143 men undergoing division of the external urethral sphincter to determine if there was any effect on sexual function as well as assessing again the long term results of the operation. There has been no case of impotence in this prospective study of 143 patients, nor has it been documented in any of the 322 cases treated from 1956 to 1980. This brief study confirms previous reports on the reliability and simplicity of the operation.

Aortoiliac operations and sexual dysfunction.

Male sexual dysfunction after aortoiliac operations can be a distressing complication. Since previous studies dealing with this problem have not excluded other causes of sexual dysfunction, the true incidence of this complication has been difficult to ascertain. We assessed preoperative and postoperative sexual function in a group of patients with no identifiable organic or functional etiology of sexual dysfunction other than aortoiliac operations or arterial occlusive disease. Seventy-six male patients had no evidence of sexual dysfunction of ambiguous etiology before or after operation. Preoperatively, 33% of patients with abdominal aortic aneurysm and 22% of those with aortoiliac occlusive disease were functionally impotent. Conventional dissection techniques rendered an additional 30% of each group functionally impotent. Postoperative impotence was twice as common in those with minor dysfunction preoperatively.

Impotence Following Radical Prostatectomy: Insight Into Etiology and Prevention

This study was undertaken to identify the cause of impotence in men undergoing radical prostatectomy, with the hope that this information may provide insight into the possible prevention of this complication. The autonomic innervation of the corpora cavernosa in the male fetus and newborn was traced to determine the topographical relationship between the pelvic nerve plexus, and the prostate, urethra and urogenital diaphragm. We have demonstrated that the branches of the pelvic plexus that innervate the corpora cavernosa are situated between the rectum and urethra, and penetrate the urogenital diaphragm near or in the muscular wall of the urethra. Injuries to the pelvic plexus can occur in 2 ways: 1) during division of the lateral pedicle and 2) at the time of apical dissection with transection of the urethra. Thirty-one men who underwent radical retropubic prostatectomy were evaluated to determine risk factors that correlated with postoperative impotence: 5 (16 per cent) were fully potent, 7 (23 per cent) had partial erections that were inadequate for sexual intercourse and 19 (61 per cent) had total erectile impotence. The 2 factors that had a favorable influence on postoperative potency were age and pathologic stage of the lesion: 31 per cent of the patients less than 60 years old were potent versus only 6 per cent of the patients more than 60 years, while 33 per cent of the patients with tumor microscopically confined to the prostatic capsule were potent versus only 5 per cent of those with capsular penetration. When the factors of age and capsular penetration were combined 60 per cent of the men less than 60 years old who had an intact prostatic capsule were potent. Arterial insufficiency and psychogenic factors were excluded as major contributing factors by the finding of normal penile blood flow and absence of nocturnal penile tumescence in the impotent patients. We conclude that impotence after radical prostatectomy results from injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa. Further studies will be necessary to determine whether refinements in surgical technique, especially during ligation of the lateral pedicle and apical dissection, can prevent this complication.

External Sphincterotomy at the 12 O’Clock Position

Transurethral resection of the external sphincter was done at the 12 o’clock position 61 times in 60 men. There was a 2.8 per cent incidence of postoperative impotence and a 75 per cent cure of vesicoureteral reflux but there was only a 65 per cent success rate of decreasing post-voiding residual urine after 6 months. The techniques and applications of the procedure are discussed.

Transurethral Sphincterotomy: Relationship of Site of Incision to Postoperative Potency and Delayed Hemorrhage

A series of 33 cases of transurethral sphincterotomy is reviewed, comparing the incidence of postoperative complications between incisions at the 3 and 9 o’clock and those at the 1 and 11 o’clock positions. Postoperative impotence and delayed hemorrhage were more frequently encountered following incisions at the 3 and 9 o’clock positions. It is recommended that patients be warned of the possibility of loss of erections following sphincterotomy and that the 1 and 11 o’clock positions be adopted routinely for this procedure.

Postoperative Impotence

Postoperative Impotence