Impact of Prostate Surgery for LUTS on Patients' QOL With Emphasis on Sexual- and Ejaculatory Function

Benign prostatic hyperplasia (BPH) is a common condition in aging men, which may lead to lower urinary tract symptoms (LUTS) and sexual dysfunction, negatively impacting the patients' quality of life. Despite allowing relief from LUTS, classical medical and surgical treatments for BPH have always been burdened by important consequences on the patients' sexual and ejaculatory function. Over the past three decades, research has focused on the development of new surgical strategies to reduce morbidity and complications of surgical procedures, however, in most cases overlooking the impact on the patients' quality of life aspects.

Despite the well-documented advantages of Laser techniques over transurethral resection of prostate (TURP) and open prostatectomy (OP), they have not been able to overcome postoperative ejaculatory dysfunction (EjD). It is well known that loss of ejaculation after endoscopic surgery was and is still attributed by many to compromising the ejaculatory mechanism, causing retrograde ejaculation. The ejaculatory mechanism has long been misunderstood and misinterpreted. However, recent evidence on ejaculation physiology has demonstrated the importance of the tissues surrounding the verumontanum, rather than the bladder neck, for outward ejaculation . Dynamic transrectal ultrasonography (TRUS) has shown how, just before ejaculation, the verumontanum undergoes a caudal shift, contacting the anterior wall of the urethra, allowing the antegrade progression of semen, which is emitted into the inframontanal urethra and expelled, almost simultaneously, through the external sphincter. No accumulation of semen inside the prostatic urethra, and therefore, generation of a high-pressure area was demonstrated. A fundamental role in this process is played by the musculus ejaculatorious, a longitudinal strain of muscle fibers, which originate from around the ejaculatory ducts and extend caudally in the urethral crest, inserting below the urethral sphincter. Contraction of the musculus ejaculatorious could be responsible not only for the emission of semen from the ejaculatory ducts into the prostatic urethra, but also for the correct movement of the veru montanum during ejaculation. Based on these findings, supramontanal and paracollicular tissue-sparing surgical techniques have been developed. Ejaculation preserving (EP) techniques have been applied to TURP, Photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HOLEP) with encouraging results.

EP technique will be performed as:

During BPH open and endoscopic surgery, all prostatic tissue except adjacent to the verumontanum is removed. Ejaculation preserving endoscopic prostatectomy is a new technique, where all apical prostatic tissue is removed by resecting tissue up to 1 cm above the verumontanum laterally and proximally, to preserve antegrade ejaculation.

Operating physicians will report the type or surgery technique in terms of preservation or not of the ejaculation as: "no", "probably no", "probably yes" or "yes"