Impact on Sexual Function of Holmium Laser Enucleation Versus Transurethral Resection of the Prostate: Results of a Prospective, 2-Center, Randomized Trial.

Briganti A, Naspro R, et al:
J Urol; 2006; 175 (May): 1817-1821

Background: Mixed data exist in the literature on the effect of surgical intervention for benign prostatic hyperplasia (BPH) on sexual function. Design/Objective: This randomized, controlled trial compared the impact of holmium laser enucleation (HoLEP) and transurethral resection of the prostate (TURP) on sexual function. Participants/Methods: 120 patients with BPH and lower urinary tract symptoms were randomized to either HoLEP or TURP (60 patients in each group). The patients were followed up and completed the validated sexual function inventory in the International Index of Erectile Function (IIEF), as well as a series of global assessment questions at 12 and 24 months postoperatively. The patient groups were matched for International Prostatic Symptom Score (IPSS) and quality of life (QOL) scores at baseline (21 and 4.5, respectively). The HoLEP group had a larger prostate volume (73 g) than did the TURP group (58 g). The baseline erectile function scores were similar between the 2 groups (21.8 vs 22.1; >25 indicates no erectile dysfunction [ED]), with approximately 50% of patients in both groups having some degree of ED preoperatively. The pharmacological treatment profiles prior to surgery were similar for both groups. Results: At 12 and 24 months after intervention, there was a slight, but statistically insignificant, increase in IIEF erectile function domain score in both groups (approximately a 1.5-point increase), with no difference in scores or degree of improvement between either surgical group. Furthermore, there was no difference in the incidence of retrograde ejaculation between groups. Of note, orgasm function (as scored by the IIEF) was decreased in both groups to a similar extent. There was a strong positive correlation between postoperative IPSS and QOL scores and the erectile function improvement, suggesting that the improvement in urinary function may be integral to sexual function improvement. Conclusions: Surgical intervention for BPH in the forms of HoLEP and TURP had no significant negative effect on erectile function, and no difference was found between the 2 surgical modalities. Reviewer’s Comments: This excellently conducted study sheds significant light on the fact that surgical treatment of BPH likely has little impact on sexual function. Indeed, in some men, function may improve. The inclusion of a validated questionnaire is a major strength of this study. Of note, the reduced orgasm function domain scores are most probably indicative of the nature of orgasm assessment using the IIEF. The questionnaire has only 2 questions on orgasm, one of which pertains to ejaculation. Thus, after surgical management of BPH, the IIEF would not be considered an adequate assessment tool for orgasm. It is worth noting that 50% of men had ED at baseline; therefore, it is conceivable that, in a population of patients with full erectile function at baseline, these results might be different, perhaps even a greater postoperative improvement in erectile function. (Reviewer–John P. Mulhall, MD).