Recent advances in scientific and technological progress have significantly altered the traditional approach to the treatment of many urological diseases, including those leading to infarctional obstruction, among which the most common is benign prostatic hyperplasia (BPH).
Despite the fact that transurethral endoscopic interventions have long become traditional for most urological clinics and their proportion compared with open surgical interventions on the lower urinary tract is much larger, the constant introduction into clinical practice of new equipment and instruments necessitates studying the possible side effects of their use.
One such effect is erectile dysfunction. It has been proven that patients who have undergone transurethral resection (TUR) of the prostate due to its hyperplasia develop erectile disorders of varying severity in 4-40% of cases (Bruskenitz, Larsen, Madsen, 1986; Hargreve et al., 1987). In the works of M.L. Gorilovsky (1997), L. Edwards et al. (1985), P. Soonawalla et al. (1992), A. Le Duc et al. (1993), Internet, National Library of Medicine, USA (1997) provides an exhaustive analysis of complications after TUR. The frequency of erectile function disorders in the postoperative period was noted in 3.3-34.8% of patients.
S. Madersbacher and M. Marberger (1999) in their study, including an analysis of the results of a survey of 3032 patients suffering from BPH, who later underwent a TOUR using the standard method and electroportionation of the prostate, noted the occurrence of erectile dysfunction in 19% of cases in patients who underwent a TOUR and in 21% in the group of patients after vaporization. In a similar study, M.Y. Hammadeh et al. (2000), which includes two groups of patients who underwent TUR and electrovaporization (52 people each), in the postoperative period, the appearance of erectile dysfunction was observed in 11% and 17% of cases, respectively.
Due to the increased quality of life requirements and the recognition of satisfactory sexual activity as one of the most important criteria for its assessment, the problem of treating erectile disorders currently has virtually no age limit. Since many older men, who make up the majority of patients undergoing transurethral endoscopic interventions, invest in the concept of improving quality of life not only improving urination quality, but also quality of sex life, such a high percentage of postoperative erectile dysfunction requires close attention of doctors and researchers to this problem.
Transurethral resection of the prostate compared with transvesicular adenomectomy and especially with radical prostatectomy is accompanied by significantly less traumatization of the prostate, seminal vesicles, seminal tubercle, urethra, but often leads to aggravation of copulative dysfunction, which occurred before the operation due to age changes in the organism, but the aggravation of copulative dysfunction, which occurred before the operation due to age changes in the organism, often aggravated the copulative dysfunction that occurred before the operation due to age changes in the organism, but the aggravation of copulative dysfunction that occurred before the operation due to age changes in the organism, often exacerbated the copulative dysfunction that occurred before the surgery due to age changes in the body, but the aggravation of copulative dysfunction, which occurred before the operation due to age changes in the organism, often exacerbated the copulative dysfunction, which occurred before the surgery due to age changes in the organism. Attee S., Sultana S., Hodgson G. et al., 2000).
Madorsky et al. (1997) first put forward a hypothesis about the role of thermal damage to the structures of the cavernous nerves when performing TURP of the prostate in the projection of the 5 and 7 o'clock conditional dial.
Damage to the nerve fibers of the pelvic plexus is the main cause of erectile dysfunction after surgery on the pelvic organs. Therefore, the pelvic plexus and its efferent fibers innervating the cavernous bodies (cavernous nerves) have recently been the subject of extensive research. Walsh and Donker (1982) traced the topography of the innervation of the cavernous bodies on stillbirths and fruits. The passage of the important branches of the pelvic plexus between the rectum and the urethra was revealed: they penetrate the urogenital diaphragm near the urethra or through its muscular wall. The authors concluded that after operations on the prostate gland (radical retropubic prostatectomy, transpersonal adenomectomy, transurethral resection of the prostate), erectile dysfunction can occur as a result of damage to these branches at two points: when the lateral pedicle is divided, or during the apical dissection during mechanical and at the time of the apical dissection, and after mechanical and injuries of these branches; on the wall of the urethra. A common cause of the development of erectile insufficiency after transurethral interventions is also the defeat of the cavernous nerves and vessels of the penis, located in the paraprostatic zone during the perforation of the surgical capsule of the prostate (Walsh et al., 1983; Vigg et al., 1990 Vegeter et al., 1990).
Despite the progress made in recent years in the diagnosis and treatment of erectile dysfunction, questions regarding the characteristics of etiopathogenesis, the nature of the course, prognostic criteria, treatment and prevention of this condition after endoscopic surgical interventions have not been completely studied. All of the above determines the scientific and practical relevance of solving this problem.
This study was conducted in the period from 1997 to 2004 on the basis of the Research Institute of Urology of the Ministry of Health of the Russian Federation and the City Clinical Urological Hospital No. 47 of the city of Moscow.
Patients with a diagnosed BPH who underwent transurethral resection or electroportionation of the prostate were identified as the study population.
Characteristics of patient groups
Of all patients (412 people) with benign prostatic hyperplasia, who planned transurethral resection, 68.9% of patients were not interested in maintaining adequate erectile function in the postoperative period. More than half of the patients, having a potential sexual partner (wife), nevertheless came to terms with the resulting dysrhythmia of sexual life (up to her complete absence) against the background of a progressive increase in the symptoms of urinary disorders. At the same time, in many cases skepticism of patients towards the doctor's argument that after normalization of urination, sex life is quite possible is noted. A lonely lifestyle, the difficulties of finding a new partner, psychological trauma after the loss of a spouse - these are only the main reasons for refusal or abstention of the majority of the elderly male population from sexual activity.
The main group of patients studied, for whom the preservation, as well as the possible improvement of erectile function seemed to be an urgent task, consisted of 128 men aged from 48 to 80 years (mean age 65.2 years). More than half of all patients were first or remarried. The duration of the disease in these patients ranged from one to five years, and among widowers or divorced mainly five years or more. In 67.2% of the patients in the study group, intercurrent pathological changes were revealed, primarily represented by cardiovascular and degenerative-destructive diseases. At the same time, 60.2% received concomitant therapy, including drugs that in themselves worsen the quality of erection (antihypertensive drugs, b-blockers, diuretics, H2-receptor blockers, etc.).
Evaluation of erectile function was carried out before and after the operation by means of a physical examination, patient filling of assessment scales (International Index of Erectile Function, scale of quantitative assessment of male copulative function (O.L. Loran, A.S. Segal, 1998), hospital anxiety and depression scale), RigiScan monitoring, pharmacodopplerography, electromyography, hormonal status studies, as well as cavernosography according to indications.
Preoperative examination results
All 128 patients of the study group before the operation had clinical manifestations of benign prostatic hyperplasia. In 53.1% of cases, patients complained of symptoms characteristic of menopause. Attention is drawn to the fact that almost all clinical manifestations of andropause (increased nervousness, weakening of memory and attention, fatigue, etc.) adversely affect not only erectile, but also sexual function in general. There was a tendency to a decrease in the number of "climacteric" complaints in patients over 60-65 years old with the progression of associated diseases.
The overwhelming majority of patients interested in preserving, and possibly improving their erectile function (90.6%), had sex life; 81% had a permanent sexual partner. 75% had a varying severity of the complaint of the sexual sphere, of which erectile insufficiency was detected in 58.3% of cases, a decrease in libido - 78.1%, difficulty or accelerated ejaculation - 47.9%, a decrease in the severity of orgasm - 86.5 % Many patients presented several complaints. Despite this severity of symptoms, only 12.5% ??of them used episodic means to improve the quality of erection before the operation (phosphodiesterase inhibitors of type 5, biologically active food additives, as well as alternative or traditional medicine methods).
Despite widespread media coverage of the prevention and treatment of BPH, when talking to a doctor, 64.9% of patients were confident that the operation would lead to a total loss of erectile function, and 39.9% expressed uncertainty about the effectiveness of treatment in terms of quality improvement self urination.
In the study of sexual activity of patients depending on the degree of age difference between the spouses, it was found that mostly (62%) sporadic manifestations of sexual activity are observed (with a frequency of excesses less than 1 time per week), 26.6% of patients had a regular sex life (1 2 times a week) and only 7.4% reported increased sexual activity (more than 2 times a week). At the same time, there was a general tendency to increase the level of sexual activity in all patients with an increase in the difference between their age and the age of their wives.
The sexual temperament of the average level was found in 46.1% of patients, strong - in 18%, weak - in 35.9%. At the same time, a decrease in sexual activity was noted with age, especially in patients with a weak sexual temperament.
Of the total number of patients in the study group, 16 patients took finasteride before surgery. The effectiveness of treatment was assessed by improving the parameters of independent urination and reached 56.3%. In 25% of cases, a decrease in libido was registered, in 18.8% of patients - difficulty of ejaculation, in 37.5% - manifestations of erectile dysfunction. Common to all patients was an increase in the duration of sexual intercourse, which is undesirable, since it requires much more energy to a man or both partners. In our opinion, all patients treated with finasteride should be warned about the possible development of erectile dysfunction.
A survey showed that the majority of patients in the study group had even worsened erectile quality before surgical treatment, 73.4% of patients showed signs of anxiety-depressive syndrome. We have found a pattern according to which for patients aged 48-60 years, the presence of alarming symptoms is more characteristic, and in older patients, depression symptoms come in first place.
At the preoperative stage, hypotestosteronemia was detected in 42.2% of patients, with a tendency to a greater decrease in testosterone levels in the older age groups. In 91.2% of patients, the dependence of the manifestations of the climacteric syndrome on the level of plasma testosterone was revealed. However, the frequency of complaints of a decrease in the quality of erections in patients with hypotestosteronemia was not significantly different from that in the general group. Meanwhile, a decrease in libido and sexual arousal were the main complaints in the group with low testosterone levels.
Before surgery, hyperestrogenemia was observed in 12.5% ??of cases, with elevated plasma estradiol levels, on average, moderately increased in older age groups.
Hyperprolactinemia was detected in 8 cases (6.25%). No significant correlation between age and these clinical cases has been identified.
According to transrectal ultrasound, there was a tendency to an increase in the volume of the prostate gland with the age of patients due to an increase in the volume of hyperplasia nodes. The ultrasound data correlated with the uroflowmetry data, and the signs of infravesical obstruction were detected in 100% of cases.
RigiScan monitoring of night penile tumescences revealed violations in 75.8% of patients. The frequency of observed violations of nighttime penic tumescences increased in the older age groups. In most cases, there was a partially insufficient erection (53.6%), insufficient rigidity was determined in 29.9% of cases, its absence - in 16.5%. Considering the presence of sleep disorders in many patients at the preoperative stage, as well as sustained activation of the sympathetic nervous system due to depressive mood, the results of the RigiScan test can be false-negative, therefore, to objectify them, a comprehensive comprehensive assessment of physical, laboratory and instrumental examination data is necessary. When comparing the data of pharmacodo-plerography with the data of RigiScan monitoring, vasculogenic disturbances correlated with disorders of night penile tumescence in 76.3% of cases (p <0.05), which may indicate the influence of the above factors on the nature of night erections.
A Doppler study with pharmacological stress revealed vascular disorders in 90 patients, while the following changes in hemodynamics prevailed: arterial insufficiency (31.3%), arterio-venous (25%), venous (14.1%). Only in 5.4% of cases, the absence of pathological changes during laboratory examination, recording of parameters of penile hemodynamics and RigiScan monitoring in the presence of typical complaints about a decrease in the quality of adequate erections was regarded as cases of psychogenic erectile dysfunction with inhibition of libido.
An important diagnostic method for assessing autonomous penile innervation is electromyography, according to which only in 14.8% of cases signs of irregularities were expressed, resulting in a change in the peaks of electrical activity, their amplitude and regularity. In 2.3% of patients, a complete absence of electrical activity was recorded. In our opinion, this may be due to dystrophic changes in the vegetative fibers that make up the nerve trunks nn. erigentes with compression of their increasing in the volume of the prostate gland due to benign hyperplasia of the latter with the development of compression ischemia and degeneration of nerve fibers. It is possible that individual anatomical features of the pelvic organs innervation play a significant role in the appearance of neurovegetative disorders in these patients.
In this study, 22 patients underwent pharmaco-cavernosography using a spiral computed tomography, which allows visualizing the pathological venous outflow from the cavernous bodies through a deep penile and deep dorsal vein of the penis in the mode of volumetric computer reconstruction. This method, in our opinion, creates optimal conditions for the visualization of not only venous collectors, but also other structures of the penis in all planes and from any angle.
In the study group, venous insufficiency due to discharge through the system of deep penile veins was confirmed in 18 cases.
When analyzing the results of instrumental diagnostics of venous insufficiency of the penis, the diagnostic role of a preliminary pharmacodo-pleurographic study was revealed. When a pathological venous shedding was detected, the correlation of the results of pharmacodo-pleurography and pharmacovernagraphy in this study is close to 100%. The role of RigiScan monitoring in the diagnosis of venous insufficiency seems to be approximate.
The results of postoperative examination
In the present study, 122 patients (95.3%) underwent transurethral resection of the prostate using standard Barnes and Nesbit techniques. In 6 cases (4.7%), the prostate was electrovaporized.
Only in 2 patients (1.6%), during the transurethral resection, the surgical capsule of the prostate gland was perforated against the background of its spontaneous contraction during electrostimulation in the process of implementation. In this regard, we believe that the final stage of prostate resection should be carried out using standard electrodes and only when using conventional energy modes (150-200 W).
In 18.75% of cases, contact cystolithotripsy was performed; 32 patients underwent double-sided vasoresection.
Surgical operations have the ability to inhibit the function of the endocrine glands, and the degree of inhibition is directly proportional to the morbidity of the performed intervention. When comparing plasma testosterone levels in patients after transurethral electroresection and electroportioning in the immediate postoperative period, a significant decrease was observed on the first day with a tendency to reverse growth by the end of the first week. At the same time, in patients who have undergone electrovaporization, the decrease in the concentration of this hormone is much more pronounced. This may indicate that the degree of traumatic physical impact on the prostate gland and its surrounding tissues is greater during electrovaporization. Based on the data obtained, it can be concluded that testicular tissue is highly sensitive, its function being inhibited in response to injury of the prostate during surgery for BPH.
After three months of observation, the results of the survey (international index of erectile function, the scale of quantitative assessment of male copulative function) showed a slight decrease in the average maximum score, which indicates that, on average, the surgical intervention did not represent a serious depotentiating effect. At the same time, there was a decrease in overall satisfaction with sexual intercourse, the state of copulative function in general, as well as individual components of the copulatory cycle: libido, erectile function, and especially the ejaculatory component as a result of the appearance of retrograde ejaculation symptoms in the postoperative period. At the same time, the greatest severity of copulatory disorders was observed in patients with weak sexual constitution, complications arising during the implementation of surgery, significant hormonal imbalances, as well as severe concomitant diseases.
Data analysis of the Hospital Anxiety and Depression Scale (HSHTD) revealed a decrease in the manifestations of anxiety-depressive syndrome 3 months after surgery. The explanation of this fact, in our opinion, is a noticeable improvement in the quality of self-urination, especially for men of socially active age. Thus, the very conduct of surgical treatment significantly reduces the severity of anxiety-depressive symptoms for the vast majority of patients.
In 86% of patients, surgical treatment did not impair the quality of erectile function, however, 29.7% of patients required additional correction of erectile disorders, signs of which were identified before surgery. In the presence of dominant complaints of dysuria, painful urgency, intermittent difficulty urinating the appointment of a-blockers leads to an improvement in erectile function in this background in 40% of patients. In patients with severe manifestations of menopausal syndrome in combination with hypotestosteronemia and / or hyperestrogenemia, the use of hormone replacement therapy with androgens is effective in 50% of cases. For those whose leading complaints were manifestations of anxiety-depressive syndrome, treatment with modern homeopathic anxiolytics gave a positive effect in 60% of patients. In patients whose manifestations of erectile dysfunction could be explained by elevated plasma levels of prolactin without significant changes in the blood supply to the penis, dopamine receptor agonist therapy (bromocriptine) is effective in about 75% of cases.
Of the total group of patients examined, 14% noted a deterioration in erectile function after endoscopic surgery. Attention is drawn to the fact that all these patients had certain signs of erectile dysfunction before the operation, even though they had a sexual life. The average prescription of manifestations of benign prostatic hyperplasia is 4.9 years. Of all patients in this group, 66.7% were unmarried. Overweight, as a risk factor for erection disorders, was found in 55.6% of cases. Intercurrent diseases were detected in all 18 patients, in connection with which 72.2% received concomitant therapy.
Complaints in patients were characteristic of erectile dysfunction, the main of which were difficulties with achieving a full erection (83.3%), episodes of detumescence without ejaculation (88.9%). In 77.8% of cases, retrograde ejaculation was detected in the postoperative period, in 22.2% - partially antegrade with a decrease in the amount of secreted sperm. At the same time, 50% of patients attributed the resulting deterioration of erectile function to ejaculation disorders, being sure that retrograde ejaculation imposes a significant negative imprint on the quality of erection. Hyposthesia of the head of the penis during sexual intercourse was noted in 61.6% of cases, which may indirectly indicate a partial de-innervation of the organ. Patients after performing bilateral vasoresection (33.3%) at the peak of sexual arousal noted pain and discomfort in the groin, perineum and scrotum. Although according to the world literature there is no direct relationship between vasorection and deterioration in the quality of erection, however, according to our observations, in these patients, the occurrence of the above complaints may adversely affect the quality of sexual intercourse.
In terms of severity, moderately pronounced disorders prevailed (44.4%); Mild cases were detected in 38.9% of patients, expressed in 16.7%. No cases of severe disorders in this study have been identified. It was noted that the weak sexual constitution in patients dominated (72.2%), ahead of the average (16.7%) and weak (11.1%) in terms of occurrence. Changes in the body, characteristic of the menopausal period, to a certain extent can adversely affect the quality of sex life, indirectly affecting erectile function. Similar complaints were recorded in 55.6% of patients. In 100% of cases (18 patients) signs of anxiety-depressive syndrome were identified. This indicates the significant role of the psychological state of patients at risk of developing erectile dysfunction, the quality of erection.
In 72% of patients who noted deterioration of erectile function after surgery, hypothestosteronemia was detected even at the hospital stage. No significant correlation between the level of testosterone after surgery and the age of the patients was found. Hyperestrogenia (33.3%) was detected along with a decrease in testosterone concentration. Only in 4 cases (22.2%) an increase in plasma estradiol could be associated with the operation. There was a tendency to an increase in the frequency of increase in the concentration of estrogen in patients of older age groups. An increase in prolactin above the norm due to surgery was not recorded in any of the cases.
In the postoperative period, the survey data (urethrocystography, transrectal ultrasonography) indicated a significant radicalism in the operation. The relationship between the occurrence of erectile dysfunction and the amount of prostate tissue removed is established. In patients 51-60 years old, the most common cases of erectile dysfunction with a small volume of the gland (less than the average values ??in the general group), for older people (61-74 years), with a total prostate volume exceeding the average values ??in the general group. endoscopic erectile dysfunction
There is no significant correlation between the volume flow rate of urination and the occurrence of erectile dysfunction in the postoperative period.
According to the monitoring of night penile tumescences (RigiScan), the unsatisfactory rigidity of the penis was noted in 55.6% of cases, outperforming in terms of the incidence partially satisfactory - 27.7%, the complete absence of rigidity - 16.7%.
A pharmacodopplerographic study of this group of patients revealed a fact of deterioration of the arterial blood supply to the penis in only 33.3% of the subjects. In 11.1% of patients, signs of venous insufficiency were detected, which were determined before the operation. Conducting a combined pharmacodo-plerography and pharmacosaurography did not allow us to register a significant change in the nature of venous insufficiency after transurethral surgery in these patients.
When performing electromyography of the penis, signs of abnormal autonomic innervation were detected in all 18 patients (100%). At the same time, in patients with pronounced changes recorded during electromyography, the clinical signs of penile denervation by hypostezia in the region of the glans penis are of varying severity during sexual intercourse.
All 18 patients who have a deterioration of erectile function in the postoperative period, depending on the nature of the violations identified, are assigned to pathogenetically justified conservative combination therapy. In our study, we did not set the task of studying the comparative efficacy of combination therapy due to the small number of patient groups and the lack of conditions for a clear randomization of the study. The task was to assess the effectiveness of the method of prescribing a combination therapy, taking into account all the identified pathological changes.
Analysis of the results of the treatment made it possible to note a positive effect in all 18 patients of the study group. In terms of observation up to 3 years on the background of the therapy, sexual adaptation occurred in 12 patients. In 6 patients at the time of observation of 3 years, there were still complaints about manifestations of erectile dysfunction, however, during the treatment, these patients continued to have sex with a number of excesses from 1 to 4 per month, which, in turn, is an indicator of partial sexual adaptation and allows you to avoid the operational methods of correction of erectile disorders.
The dynamics of the indicators of sexological testing against the background of the treatment revealed a gradual (from 6 months to 3 years) improvement not only of erectile function, but also of such parameters as satisfaction with sex life, improvement of libido, orgasm. The most significant positive changes were recorded in younger groups of patients (from 51 to 60 years old). The fact of the absence of any influence of the therapy on the ejaculatory component of the copulatory cycle was noted.
As mentioned above, 13 patients with hypotestosteronemia for periods up to 3 years received hormone replacement therapy with oral medications with the obligatory preliminary determination of the level of prostate-specific antigen in blood plasma. In this case, not a single case of an increase in the concentration of prostate-specific antigen above the norm during the treatment was detected. The general tendency to an increase in the level of blood testosterone on the background of hormone therapy, is especially noticeable in younger age groups (51-60 years).
Considering the reciprocal relationship between estradiol and testosterone in the body of a man, it has been established that the administration of androgenic drugs during follow-up periods of up to 3 years can reduce the concentration of estradiol. No significant correlation between the level of estradiol reduction and the age of the patients was obtained.
In all 4 patients taking bromocriptine as an antihyperprolactinemic agent, normalization of the concentration of this pituitary hormone was noted. No significant dependence of the effectiveness of the applied treatment on the age of the patients is received.
According to the data of RigiScan monitoring of nightly penile tumescences, all 18 examined showed positive changes, manifested in the appearance of recorded penile rigidity in most of them, as well as in improving the quality of rigidity.
Analysis of the data obtained in pharmacodo-plerography of the vessels of the penis revealed a decrease in the pathological venous discharge in 2 cases. Also, in 2 patients with signs of arterial insufficiency, the arterial blood supply to the penis improved during erection. A significant lack of improvement against the background of the treatment was observed in 4 patients with arteriogenic erectile dysfunction with severe signs of atherosclerosis.
All 18 patients with deterioration of erection quality in the postoperative period during electromyographic studies from 6 months to 1 year showed an improvement in vegetative innervation rates (most cavernous tissue appeared in most of them, disappeared signs of penile innervation), approaching normal values This picture can be explained by the reinnervation of the tissues of the penis after surgery, which is consistent with the principles of pathological physiology.
The resulting complications associated with the development of pharmacological priapism (4%) were stopped without surgery; the frequency of their occurrence did not exceed that in the wide population of the examined patients.
According to our observations, the most common cause of erectile failure development during transurethral endoscopic operations is thermal or mechanical damage to the cavernous nerves and penile vessels located in the paraprostatic zone, when the surgical capsule of the prostate is perforated in combination with a complex of negative psycho-emotional effects received by the patient, uncertainty in the outcome of the operation, as well as the patient's ignorance of the nature and sexual consequences of the work ennoy his operations concern the existing reduced potency against the backdrop of andropause symptoms. The prevailing role of the neurogenic component in the development of erectile disorders has been established. Vascular disorders detected in this group of patients, most often are secondary.
The drug of choice for treating ED in patients undergoing transurethral endoscopic interventions is type 5 phosphodiesterase inhibitors. In cases where there are absolute or relative contraindications to their admission or to the operational correction of erectile disorders, the appointment of a combined pathogenetically substantiated therapy allows you to achieve certain positive results.