Dysfonction sexuelle après chirurgie laparoscopique ou endoprothèse pour anévrysme de l’aorte abdominale chez l’homme

25 février 2020

Auteurs : C. Dariane, I. Javerliat, S. Doizi, E. Fontaine, A. Mejean, R. Coscas, M. Coggia
Référence : Prog Urol, 2020, 2, 30, 105-113




 




Introduction


Endovascular aortic repair (EVAR), laparoscopic aortic surgery (LAS) and open repair (OR) are three well-established treatment methods of infrarenal abdominal aortic aneurysms (AAA). LAS and OR have been associated with a similar postoperative sexual dysfunction in 22-30% of male patients [1, 2, 3], due to autonomic nerve injury and pelvic blood flow changes, but sexual dysfunction in men can be caused by either disorder in arousal, orgasm, ejaculation or erectile dysfunction. Moreover, erectile dysfunction can also be a consequence of AAA itself, treatments and/or vascular risk factors [3]. The potential benefit on sexual functions from EVAR could result in the absence of nerve's dissection around the aorta. Indeed, some authors reported lower incidence of sexual dysfunction after EVAR based on retrospective studies [4]. But there is a general lack of studies in patients undergoing EVAR regarding sexual function and some authors reported a lack of information of patients before EVAR, although a significant impairment in quality of erection and ejaculation could be found postoperatively in this population [5]. Recently, EVAR has been compared to hand-assisted laparoscopic surgery (HALS] [6], providing similar results at 12 months in sexual function, but with lower incidence of retrograde ejaculation, due to the absence of dissection of the iliac bifurcation [7, 8, 9]. However, EVAR has never been compared to total laparoscopic repair.


In this 2-years, monocentric prospective observational and non-randomized study, with a 12-months follow up, we evaluated the incidence of sexual and erectile dysfunction and ejaculation troubles after 3 types of current treatment of AAA in men: LAS, OR and EVAR.


Methods


Study design and patient population


Between December 2013 and December 2015, 171 patients underwent AAA repair in our unit. Seventy-nine patients refused to take part in the study and 4 patients were excluded because of previous prostate surgery which could interfere with sexual function (Figure 1). The remaining 45 patients [LAS group (N =21), OR group (N =9) and EVAR group (N =15)] completed the preoperative International Index of Erectile Function (IIEF) questionnaire but only 21 accepted to complete the questionnaire at 3, 6 and 12 months and completed the study: 16 in the LAS group (group A), 5 in the EVAR group (group B) and no one in the OR group (Figure 1). Patients from the OR group were finally excluded from the study.


Figure 1
Figure 1. 

Flow chart depicting the study design and inclusion process.




The study was approved by the Ethical Committee and all patients gave informed written consent.


Preoperative assessment


Investigations in all patients included duplex scanning of the aorta, lower limbs and cervical arteries. In addition, a standard contrast-enhanced spiral computed tomography (CT) scan with images acquired at 3-mm intervals was performed.


The cardiopulmonary examination included stress echocardiography, functional respiratory evaluation and determination of arterial blood gas levels. Renal insufficiency was defined as an estimated CrCl level<30mL/min according to Cockroft and Gault [10].


The quality of sexual function was evaluated preoperatively and at 3, 6 and 12 months postoperatively using the IIEF, a 15-items, self-administered questionnaire, which includes 6 specific questions on erection (erection score/30 and final score/75) [11, 12, 13, 14, 15]. A score of 0-5 is awarded to each of the 15 questions that examine the 4 main domains of male sexual function, leading to a final score from 0 to 75. Based on the final score, the patients were divided into three classes: severe sexual dysfunction (class I, total score<11), moderate sexual dysfunction (class II, total score 11-21], and no sexual dysfunction (class III, total score>21), and erectile function' score (values from 0 to 30, score<6 meaning severe erectile dysfunction and score 25-30 meaning no erectile dysfunction) was also evaluated specifically.


Aspects relating to ejaculation troubles (retrograde ejaculation, anejaculation, hypospermia) were also evaluated by 5 specific supplementary questions (Appendix A).


Morbidity and mortality were evaluated for both groups at 1 month (perioperative) and at 12 months.


Outcomes


The primary outcome of the study was the variation in the IIEF score at 12 months. The secondary outcomes were the change in the erectile score and the percentage of trouble ejaculations at 12 months.


Choice of surgery


Since EVAR, LAS and OR are complementary established treatment methods of AAA, the choice of the technique was based on the surgical risk of the patient and the anatomic EVAR criteria of the French Health Authority, as previously described by our team [16]. Four groups of patients were thus established in our vascular unit: (1) good risk and favourable anatomy (GR-FA); (2) good risk and unfavourable anatomy (GR-UA); (3) high-risk and favourable anatomy (HR-FA); and (4) high-risk and unfavourable anatomy (HR-UA).


Among GR-FA patients, EVAR and LAS were discussed according to life expectancy and wishes of the patient [17]. In GR-UA patients, both LAS and OR were proposed. For HR-FA patients, EVAR remained the technique of choice. In the HR-UA patients, OR can be proposed because of the late complications of EVAR, but a broader use of fenestrated stent grafts or the chimney technique could be beneficial [16].


Operative procedures


Group A: total laparoscopic aortic surgery (LAS)


LAS technique to repair AAA has been already described [17, 18, 19, 20]. Two main principal transperitoneal approaches are currently used [19, 20]. Left retrorenal approach is preferred, outside any contraindications [17, 20]. The patient is placed in a dorsal decubitus position with a deflated pillow under the left part of the abdomen. There is a chopping block under knees to relax the left crural nerve during laparoscopic procedure. The pillow is inflated in addition to a right maximal rotation of the operating table, allowing a right lateral decubitus of 80° and a stable aortic exposure.


The abdominal aorta is thus controlled from left renal artery to aortic bifurcation. The proximal part of common iliac arteries is also controlled. The laparoscopy allows seeing well the sexual neural bundles running along the aorto-iliac bifurcation, allowing its preservation whenever possible.


In this series, transperitoneal retrorenal aortic approach was used in all patients in the group A.


Group B: endovascular aneurysm repair (EVAR)


The aortic endograft is put in a standardized way, just below the lower renal artery and above the iliac bifurcation whenever possible, in order to preserve hypograstric patency (in this series, in the EVAR group, only patients treated by standard EVAR were included) [21].


Statistical methods


Continuous variables are summarized as mean±standard deviation when normally distributed, and as median and interquartile range when asymmetrically distributed.


Categorical variables are presented as numbers and percentages. Differences between continuous variables were compared by two-tailed unpaired Student's t -test with Welch's correction. Categorical variables were compared by two-tailed Fisher's exact test.


A probability value<0.05 was considered statistically significant. Data were analysed using Prism 6, version 6.01 (©1992-2012 GraphPad Software, Inc.).


Results


Study population


On the 124 patients eligible in the study, only 45 patients completed the preoperative questionnaire. Seventy-nine refusals to complete questionnaire included patients with cognitive troubles, patients no more having sexual intercourse and patients not interested in sexual function. Overall, only 21 completed the questionnaire at 3, 6 and 12 months (16 in the group A, 5 in the group B and no one from the OR group) and were then included in the study (Figure 1).


Clinical preoperative characteristics


The baseline characteristics of the 21 patients enrolled in the study after completion of the postoperative IIEF are compared in Table 1.


Patients were significantly older in the EVAR group B and presented more cardiovascular issues than the patients from the laparoscopic group A.


Regarding the features of aortic disease, there was no significant difference in the diameter of the aorta in the two groups, neither in the presence of iliac aneurysm or iliac thrombus (Table 2). Six patients had unilateral thrombus in the primitive iliac artery including 3 patients with unilateral hypogastric thrombus. No patient presented de novo hypogastric arteries occlusion after laparoscopic repair. In the EVAR group, no patient had hypogastric covering since distal connection was on primitive iliac artery.


The perioperative mortality rate at 30 days was zero. No respiratory complications were noted in the two groups. No patient needed dialysis and no patient presented cardiac decompensation or myocardial infarction. One patient in the group A experienced a leg ischemia on postoperative day 2, successfully treated by iliac angioplasty and another patient from the group A experienced claudication after laparoscopic aortic tube graft with need of bilateral iliac kissing angioplasty at 17 months. No vascular complication was noted in the group B.


Global sexual preoperative assessment


From the 45 patients who completed the preoperative IIEF test, 17 patients (37.8%) and 8 patients (20%) had respectively preoperative severe or moderate sexual dysfunction, leading to 57.8% of patients having baseline sexual dysfunction. In these population of patients with severe and moderate sexual global dysfunction (N =25), all of them had severe erectile dysfunction (score≤6) (Figure 1).


Among these 45 patients, the EVAR group was mainly constituted by patients with moderate to severe sexual dysfunction (N =11/15, 73.3%) whereas in the laparoscopic group 52.4% of patients (N =11/21) had no sexual dysfunction (class III).


On the population finally included (N =21), 8 patients reported no sexual intercourse (6th question from the IIEF-15) during the 4-weeks preoperative period [N =5 (31.2%) from the laparoscopic group and N =3 (60%) from the EVAR group], leading to a rate of 61.9% of sexually active patients before surgery. Among them, the frequency of sexual intercourses was 2-3/month preoperatively in the laparoscopic group and 0-1/month in the EVAR group.


At baseline, the mean IIEF score and erectile score were significantly different in the 2 groups with baseline moderate to severe dysfunction in the EVAR group (respectively 39/75 and 16.3/30 in the laparoscopic group, and 21/75 and 8/30 in the EVAR group).


Laparoscopic group postoperative sexual assessment


In the laparoscopic group, no statistical difference was found in the erectile function at 12 months (P =0.83). We observed a slight but not significant global sexual function improvement compared to the baseline preoperative IIEF score (P =0.74) (Figure 2a and b).


Figure 2
Figure 2. 

a. Erection score in the laparoscopic group; b. IIEF score in the laparoscopic group.




No significant difference was detected between IIEF class at M12 and before surgery (P =0.93) (Figure 3). At baseline, erection score of 16.3 reveals mild to moderate erectile dysfunction, and of the 16 patients, 7 (43.8%) were taking medicine which can influence erectile function (benzodiazepines, antidepressant treatment or beta-blockers).


Figure 3
Figure 3. 

IIEF score in the laparoscopic group.




Regarding ejaculations troubles in the laparoscopic group, 3 patients had preoperative transient ejaculations troubles and reported persistence of their troubles at M12 (hypospermia, anejaculation or retrograde ejaculation). On the 13 patients with no preoperative troubles, 8 (61.5%) reported major ejaculation troubles (6 anejaculations and 2 retrograde ejaculations), appearing at 3 months and persistent at 12 months, with only one improvement. Three other patients (23%) reported the onset of minor troubles of ejaculations (hypospermia).


EVAR group postoperative sexual assessment


In the EVAR group, patients had moderate erectile dysfunction at baseline (mean score 8/30) and moderate global sexual dysfunction at baseline (mean score 21/75) with 2 patients (40%) taking medicine which can influence erectile function (benzodiazepines, antidepressant treatment or beta-blockers).


Erectile function and global sexual function were not different at 12 months compared to baseline (respectively p =0.29 and 0.26). One patient reported transient ejaculation troubles starting in the preoperative period with persistent anejaculation appearing at 3 months. No other patient from this EVAR group described ejaculation troubles or they did not have erection strong enough to reach and evaluate ejaculation.


Discussion


We conducted a monocentric prospective study on sexual function and ejaculation after AAA repair. Our unit is the only one to offer regularly all the techniques currently available to treat AAA (OR, laparoscopic repair and EVAR). It seemed interesting to us to evaluate sexual dysfunctions of such techniques. There is a paucity of data on sexual results whereas preservation of hypogastric permeability is a high subject of discussion in vascular surgery, especially since the endovascular era [21, 22].


Despite the prospective design of the study, two-third of patients eligible refused to participate, mainly because of no baseline sexual interest or baseline sexual impairment. Moreover, to limit inclusion bias, we excluded patients with history of prostatic surgery, since radical prostatectomy for cancer induces anejaculation and can set off erectile dysfunction, and since transurethral resection of the prostate for hyperplasia can induce retrograde ejaculation.


Among the patients included, almost two-third presented baseline sexual dysfunction. At 12 months, erectile function and global sexual function were slightly improved in the LAS group and most patients had onset of ejaculation troubles compared to EVAR group. In EVAR group, patients were older with more cardio-vascular issues due to our algorithm of choice based on the surgical risk and the anatomic EVAR criteria, leading to high baseline sexual dysfunction and without significant improvement at 12 months. This difference in age and comorbidities is similar to results reported in literature between OR and EVAR [1].


Sexual function results in LAS group


Alteration in sexual function in men is well documented following OR for AAA during the first postoperative year with a prevalence of 7.4 to 79% of postoperative erectile dysfunction [22, 23, 24, 25]. The reasons for this may be the interference with the autonomic plexus located in front of the aortic bifurcation as well as with the internal iliac circulation. Aorto-iliac surgery can lead to sexual dysfunction by different mechanisms such as bilateral hypogastric ligation or hypogastric embolization, neurogenic injuries and aortic cross-clamping. Indeed, dissection along the anterior surface of the aorta and over the left iliac artery can injure the neural bundles running from the spinal cord (superior hypogastric plexus and inferior mesenteric plexus).


No reports addressing the impact of LAS on sexual function have been published. In laparoscopy-assisted studies, Alimi et al. found 13% of sexual troubles including retrograde ejaculation and dyserection in this population [8]. Recently, Veroux et al. reported the results of sexual dysfunction after EVAR or hand-assisted LAS, with similar results in both groups regarding sexual function and onset of retrograde ejaculation in only 6% of hand-assisted LAS patients [6].


In our prospective study, the baseline mean erection score of patients from the LAS group revealed a mild to moderate erectile dysfunction with a slight improvement at 12 months with no significant difference. These results are similar to previous studies reporting a preoperative rate of erectile dysfunction from 10.3% to 66% in patients undergoing OR for AAA [22]. In our study, no patient reported the onset of de novo dyserection after surgery (evaluated from 20% to 83% in literature, [22]) even in the sub-group of patients with unilateral iliac and hypogastric thrombus. Of note, in literature, unilateral hypogastric artery occlusion can result in new sexual dysfunction in approximately 10% of patients [22], and this increases significantly with bilateral hypogastric occlusion [8, 26].


We pointed out a high rate of ejaculation troubles in the LAS group with 46.1% patients reporting anejaculation, which is higher than the incidence described in literature for hand-assisted laparoscopy [6], maybe due to the prospective design of our study and the high number of specific questions on ejaculation troubles.


These results suggest that even if nerves can be individualized during LAS, the anatomy of the AAA does not always allow preserving autonomic nerves responsible for ejaculation. Even in preserving autonomic nerves, some patients may develop ejaculation troubles which can be explained by postoperative fibrosis or hematoma around the sexual nervous bundles, leading to their inflammation. Moreover, we may wonder if the use of devices using hybrid energy technology, such as Thunderbeat - ultrasonar and bipolar energy - (Olympus®), increases the risk of nerve damage by close contact.


Impairment of sexual function in EVAR group


EVAR does not involve dissection around the aorta and thus may not interfere with the autonomic supply as reported by some authors [6] and with results showing no sexual deterioration in comparison to OR in studies using retrospective approach [1, 11]. However, after each EVAR repair, there can be many inflammatory changes due to aneurismal sac thrombosis [2]. This phenomenon also may explain sexual troubles observed after EVAR: although it doesn't involve nerve dissection, aortic endoprosthesis induces an inflammatory reaction around the aorta, which can involve pre-aortic nerves secondarily.


Some authors reported that after EVAR, patients recovered to preoperative sexual levels faster than after OR [9]. On the other hand, other authors reported significant impairment on overall satisfaction and sexual intercourse after EVAR [5, 27] as in our study, maybe due to the belonging of these patients to a high-risk group of patients with a poor baseline sexual function.


A prospective study comparing the sexual function after EVAR and OR demonstrated a decrease of sexual activity in both groups but only a significant impairment in quality of erection in patients sexually active of the EVAR group [5]. In this study, the patients from the EVAR group presented significantly less coronary artery disease, compared to our study (80% of patients in the EVAR group). In another prospective study, EVAR was compared to hand-assisted LAS and total score evaluation of the IIEF test showed no statistical difference between groups [6], and similarly only 16% from their EVAR group presented history of coronary artery disease. In patients with coronary artery disease, the prevalence of erectile dysfunction has been estimated in literature between 47% and 75% [22]. It is noteworthy that erectile dysfunction has been identified as an independent risk factor for death following AAA repair, leading to the conclusion that pre-operative erectile function would be of interest as a prognostic factor in patients undergoing AAA surgical repair [28].


Baseline status in EVAR group


In our study, the main result was the baseline sexual dysfunction which prevailed in the EVAR group and which can explain the high rate or refusal of inclusion in the study (52% of refusal arises from the EVAR group, N =41). These results are almost comparable to those reported by other authors [1, 5, 22, 25].


Moreover, in this group, most patients who filled the survey before surgery presented severe baseline sexual dysfunction. Most of them did not answered the questionnaire at 3, 6 and 12 months and were then excluded from the study. These observations are correlated with the profile of older patients undergoing EVAR with patients presenting more cardio-vascular issues in our population and more often pre-operative sexual dysfunction.


Overall, preoperative sexual dysfunction may lead to a decrease in sexual interest. On the other hand, it is difficult to know whether the patients who lacked interest had a change in the physical ability to achieve erection and orgasm. Finally, some patients could state that the vascular surgery itself is most worrying that the sexual function, which could be considered as unimportant and it would be interesting to investigate the potential impact of stress and anxiety in patients undergoing AAA surgical repair.


Limitations


Our study is monocentric and the rate of inclusion is low. Indeed, despite a prospective consecutive design, we included only 17% of patients from the eligible population which is a low response rate comparing to other studies [5, 6]. However, 76.2% of the laparoscopic patients did answer to the postoperative questionnaire, due to their belonging to a good risk group of patients, with less comorbidities than EVAR patients. These results can also be explained by low sexual interest before surgery in vascular patients and in the first postoperative year. Indeed, some authors reported up to 40% of patients undergoing operation for AAA who felt some anxiety of having sex before surgery [5]. And these results decreased to 7% after one year, leading to repeat answering of the questionnaires after one year to raise sexual interest in patients.


In our study, the IIEF-15 questionnaire is based on patients self-reported experiences of their sexual function and not on any specific physiological measurements and thus does not indicate which type of injury is implicated (distal collateral iliac embolization, crucial nerves damage, use of medications or change in their mental status).


Finally, we decided to exclude women in our study since the number of women in our cohort was insufficient. But it seems important, in a later study, to further focus also on the effects of LAS and EVAR on women's sexual functions, since the prevalence of AAA in women may increase [29] and since there is small amount of published data [5, 29, 30].


Conclusion


Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction. For patients developing sexual troubles after laparoscopic AAA repair, it is important to note that we observed a global sexual improvement at 12 months after surgery. Ejaculations troubles are frequent and persistent after laparoscopic repair. This study suggests that baseline sexual dysfunction is frequent in patients undergoing repair of AAA, particularly in patients undergoing EVAR who present with more comorbidities. Most patients eligible for EVAR had severe erectile and sexual dysfunction at baseline and showed no improvement at 1 year, with no onset of ejaculations troubles.


Disclosure of interest


The authors declare that they have no competing interest.



Appendix A. Appendix 1


Ejaculation questions.

1. Over the past 4 weeks before surgery, did you experiment ejaculation troubles like an absence of sperm emission?

2. Since surgery, did you experiment ejaculation troubles?

3. If you experimented ejaculation troubles since surgery, was it an absence of sperm emission?

4. If you experimented ejaculation troubles since surgery, was it a modification in the volume of sperm?

5. Since surgery, did you experiment modification of the consistence of urines?




Table 1 - General features of the study group.
Variables  Laparoscopic group A (N =16)  EVAR group B (N =5)  P -value 
Age (years)   65±5.6  77±10.6  0.003  
ASA score        
Score 1  NS  
Score 2  10 (62.5)  3 (60)  1  
Score 3  6 (37.5)  2 (40)  1  
Medications with interaction with sexuality [N (%)]   7 (43.8)  2 (40)  1  
Cardiovascular risk factors [N (%)]        
Diabetes  3 (18.8)  0 (0)  0.06  
Hypertension  9 (56.3)  2 (40)  0.63  
Dyslipidaemia  12 (75)  3 (60)  0.6  
Smoke  15 (93.8)  4 (80)  0.43  
Obesity  5 (31.3)  1 (20)  1  
Co-morbidity [N (%)]        
COPD  4 (25)  3 (60)  0.28  
Coronary Artery Disease  4 (25)  4 (80)  0.048  
Acute Myocardial Infarction  1 (6.3)  4 (80)  0.004  
Stroke  1 (6.3)  0 (0)  1  
Preoperative medications with interactions with erection  7 (43.8)  2 (40)  1  
Perioperative data        
Surgery duration (min)  276.3±52  85±7.1  0.0001  
Length of hospital stay (days)  5.8±0.9  5.6±3.2  0.86  



Légende :
ASA: American Society of Anesthesiologists; COPD: chronic obstructive pulmonary disease. Continuous variables are given as the sample mean±standard deviation and categorical variables as proportions with number of patients (percentage). Characters in italic: preoperative.



Table 2 - Operative and perioperative aortic features.
Variables  Laparoscopic group A (N =16)  EVAR group B (N =5)  P -value 
Features of aortic disease        
Diameter of the aneurysm (mm)  52.4±3.06  51.8±1.93  0.91  
Iliac aneurysm [N (%)]  2 (12.5)  0 (0)  1  
Iliac thrombus [N (%)]  6 (37.5)  0 (0)  0.27  
Massive calcifications [N (%)]  1 (6.3)  2 (40)  0.13  
Type of laparoscopic repair [N (%)]       NA  
Aorto-aortic tubes  6 (37.5)     
Bitubular aortic prosthesis  5 (31.3)     
Aortic bi-iliac bypass  5 (31.3)     
Common or external iliac stenting  2 (12.5)     
EVAR distal landing zone [N (%)]   NA    NA  
Primitive iliac artery    5 (100)   
External iliac artery     
Preoperative hypogastric arteries occlusion [N (%)]   3 (18.8)  NA  



Légende :
Continuous variables are given as the sample mean±standard deviation and categorical variables as proportions with number of patients (percentage). Characters in italic: preoperative.


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