How can we Preserve Sexual Function after Ablative Surgery for Benign Prostatic Hyperplasia?
Authors: Mykoniatis Ioannis , Renterghem Koenraad Van , Sokolakis Ioannis 
Published: September 2020

Our aim is to provide a narrative review regarding the prevalence, the associated pathophysiologic pathways and
the potential management methods of sexual dysfunction related to ablative surgical techniques for Benign Prostatic Enlargement (BPE). Men suffering from BPE are at high risk of sexual dysfunction due to the disease itself, comorbidities, and
pharmacological/surgical treatments. Transurethral resection of the prostate, as the gold standard treatment option for BPE
has historically been associated with relatively high rates of postoperative sexual dysfunction problems, mainly retrograde
ejaculation but also erectile dysfunction. Ablative surgical techniques, including photoselective vaporization of the prostate
(PVP), transurethral needle ablation (TUNA), Transurethral Microwave Therapy (TUMT), Convective Water Vapor Energy
Ablation (Rezum®) and Aquablation® have been proposed as treatment methods able to reduce treatment-related complications for BPE patients, including adverse effects on erectile and ejaculatory function, without compromising the efficacy
rates for BPE. The neurovascular bundles can be damaged during TURP due to posterolateral capsular perforation. Ablative
techniques and especially PVP theoretically seems to skip this hazard as the distance created from the necrotic area to the
capsule is generally larger compared to the distance induced after TURP . However, indirect thermal injury of erectile
nerves, which could be induced also by the majority of available ablative techniques could potentially lead to ED. Two special technical characteristics (physiological saline use for tissue ablation and real time penetration depth control) of
Aquablation® could be proved beneficial with regard to the effect of the method on erectile function. In general ablative
techniques seems to have minor impact on sexual function. However, low methodological quality characterize the most of
the studies included in this review mainly due to the impossibility, in many cases, to perform a blind randomization. Also in
many studies did not have erectile and ejaculatory function as primary outcomes limiting that way their statistical power to
identify significant variations. Management of sexual dysfunction problems arising from ablative surgeries for BPE treatment could be divided in two levels. Firstly, intraoperatively the avoidance of manipulation of crucial structures regarding
ejaculatory (bladder neck or ejaculatory ducts) and erectile function (neurovascular bundles) could possibly decrease the
negative effect of these procedures on sexual function. Thus, in this direction, modifications of classic ablative techniques
have been proposed resulting in encouraging outcomes regarding postoperative sexual function. Secondly, if EjD and/or ED
are established the already known treatment choices should be chosen in order sexual function rehabilitation to be achieved.
Thus, regarding ED: PDE5i daily or on demand remain the gold standard first line treatment choice followed by intracaver-nosal alprostadil injections in cases of failure, while penile prosthesis implantation must be kept as final definitive solution
when all the other methods have failed. Regarding ejaculation disorders (retrograde ejaculation or anejaculation): medical
therapy with a-agonists (pseudoephedrine), sperm retrieval from the urine, bladder neck reconstruction, prostatic massage,
electroejaculation, penile vibratory stimulation and surgical sperm retrieval are the available treatment options. Further, high
quality studies are required to investigate potential side effects of BPE surgery on sexual function and efficient treatment
methods to manage them.