Preserving Sexual Function after Urologic Surgery Men SUPM Ase ve Recent changes in urological DAVE A. OMAH-MAHARAJH, MD) treatment, such as early RAMON PEREZ-MARRERO, MD, FRCSC orchiopexy and adolescent variococelectomy, can help to preserve fertility and reduce the risk of testicular Nerve-sparing malignancy. RESERVATION OF SEXUAL FUNC- do not cause immediate problems but may operations have been developed for cancer of the D tion has become an important pose a future threat to fertility. The trend prostate, bladder, and testicle consideration for our patients is to be more aggressive in diagnosing such to prevent or reduce their when contemplating thera- conditions. sequelae of impotence and peutic altematives to their retrograde ejaculation. These medical conditions and, in particular, surgical Undescended testicle. Undescended new advances must be intervention. This concern has prompted the testicles (cryptorchism) occurs commonly in embraced with caution so as development of new surgical techniques and male neonates but often resolves during the not to compromise patients' the modification of some old ones. first 6 months oflife. Testicles that have not chances for curative In men we are interested specifically in descended by the time the patient is 9 treatment. preserving fertility, erectile function, and ejac- months of age are unlikely to do so. ulation. We can preserve these functions by These testicles have an increased inci- Des changements recents timely corrective surgery, by modifying surgi- dence ofinfertility later in life, as well as an apportes aux traitements cal techniques to avoid unwanted sequelae, or increased incidence of testicular malignan- urologiques, comme by substituting surgery for some other form cy. Cancer of the testicle can, in turn, im- l'orchidopexie precoce et la of therapy less likely to produce unwanted pair fertility, not only by the loss of one varicocelectomie chez This article reviews the gonad but also by the therapy that may be I'adolescent, contribuent a complications. preserver la fertilite et a changes that have occurred in urology that al- required afterward. Chemotherapy inhibits reduire le risque de malignite low us to offer our male patients better preser- spermatogenesis for a prolonged time and testiculaire. On a reussi a vation of their sexual function. occasionally permanently. Retroperitoneal mettre au point des Table I lists urologic procedures that node dissection can interfere with emission. techniques chirurgicales qui may be used to protect sexual function or Timely surgery to position the testicles in epargnent l'innervation lors that have the potential to interfere with sex- the scrotum (orchiopexy) can significantly des interventions pour cancer ual function. These procedures span the reduce the incidence of both these condi- de la prostate, de la vessie et entire life of a male patient. tions. du testicule, ce qui previent ou reduit les sequelles Furthermore, there is growing evidence d'impuissance et d'ejaculation Innate threats to fiunction that the use of gonadotropic stimulating retrograde. 11 est important Some boys and men have conditions that hormone (GnRH) instead ofor in conjunc- de s'abstenir de prendre des * 0 - - - 0 0 - .0 - 0 0 - - 0 0 - - - - 0 - - - - 0 - - v v 0 - 0 0 0 0 - 0 0 tion with orchiopexy can further improve risques significatifs quant aux Dr Maharajh is a senior resident in Urology, and fertility in these boys.2 We recommend that chances du patient d'obtenir Dr Perez-Marrero is Associate Professor of the testicles be brought down to the scro- un traitement curatif. Urology and Pediatrics, both at QueenI University, tum during the first 2 years oflife. Although Con Fm Fyskn 1991;37:953-956. Kingston, Ont. this will not completely eliminate the risk Canadian Family Physician VOL 37: April 1991 953 ofmalignancy, it will make the testicles more vent future impairment of sexual function. amenable to examination and could provide Much urologic surgery also has the potential for early detection of any abnormality. to interfere with sexual function. New devel- opments in surgical techniques are designed Table 1. GENITOURINARY SURGICAL PROCEDURES primarily to prevent such complications. Transurethral prostatectomy. More * Orchiopexy than 400 000 transurethral prostatectomies . Varicocelectomy are performed in the United States. This is a safe and effective procedure but is asso- . Prostatectomy ciated with an almost 90% incidence of ret- rograde ejaculation and about 0.5% - Open prostatectomy chance of impotence. Open prostatectomy - Transurethral resection for benign disease has a similar incidence - Balloon dilation of the prostate ofthese complications. Impotence seems to - Radical prostatectomy occur more commonly in older patients and can have a psychosexual rather than . Cystoprostatectomy an organic cause.'& . Retroperitoneal lymph node dissection In an effort to reduce many of the com- plications of prostatic surgery, several new techniques have been devised. Orandi7 has Varicoceles. Varicocele is the abnormal popularized a transurethral incision of the distention of scrotal veins (pampiniform prostate, cutting the prostatic tissue from plexus) owing to the congenital absence of bladder neck to veru montanum without venous valves, which permits the retro- resecting any tissue. Although this proce- grade flow of venous blood to the testicle dure reduces the incidence ofsome compli- and slowly dilates these veins. Varicocele cations, it does not eliminate retrograde occurs in more than 10% of normal men ejaculation. Balloon dilation of the prostate and in probably the same percentage of is a new technique that uses coaxial high- adolescents. pressure balloons to dilate the prostatic ure- Only in a few of these subjects is it asso- thra to 75F to 90F. Scveral balloons and ciated with subfertility.3 Young adolescents modes of placement have been described. normally present with a visible scrotal mass, We have experience with an endoscopically which can be symptomatic. There is growing placed 75F balloon manufactured by the evidence that the adolescent varicocele af- Advanced Surgical Intervention Company fects future fertility in some instances. Kass4 of San Clemente, Calif. This device pro- has proposed that adolescents with a varico- duces satisfactory relief of symptoms and, cele and ipsilateral smaller than normal in more than 2000 dilatations, there has testes, as well as those with bilateral varico- been no incidence of impotence or retro- celes or abnormal results of semen analysis, grade ejaculation." This technique is most should be offered repair to preserve their fer- suited to male subjects with moderately tility potential. An abnormal response to an sized prostates- the patients most con- infusion of GnRH has been found in some cerned about the possibility of these com- infertile men with varicoceles.5 Kass4 and plications (Figure 1). others believe that such a test could help us decide which teenagers with varicoceles are Radical prostatectomy. Prostatic can- at risk offuture subfertility and should be re- cer is one of the most common malignan- paired. Ongoing studies are continuing to cies in male subjects and the second leading define the role of varicocelectomy in the cause of cancer death. Radical prostatecto- young adult and child, but it seems that early my for disease localized to the prostate of- varicocelectomy in selected cases can pre- fers the patient a significant potential for serve fertility. cure. Unfortunately it has traditionally been associated with a very high incidence Surgery that threatens function of incontinence and impotence. Many pa- Until now we have discussed surgery to pre- tients have rejected this option for treat- 954 Canadian Family Physician VOI. 37: April 1991 jj:'..:.'di:':ei... -- :.1 :o,a: Figure 1. BALLOON DIIATION OF PROSTATE: A new technique dilates the prostatic urethra to 75F to 90F . ment primarily because of these unaccept- too recent to comment on long-term seque- able sequelae. lac and local tumor control.'2 Recently Walsh' and associates have modified the technique ofradical prostatcc- Retroperitoneal lymph node dissec- tomy in order to preserve the nervi cri- tion. Testicular cancer is perhaps the most gentes and maintain erectile potential. This common solid tumor in youing malc pa- has proven to be a more anatomically tienits. Its effect on fertility is devastating. sound way of removing the prostate and There is evidence that patients with testicu- has not only improved the preservation of lar malignancy have decreased fertility potency to about 60("/o but also has virtually from birth, many having had cryptorchid climinated postoperative incontinence." testicles in infancy. Retrospective analysis of these paticnts in- The occurrence of a testicular malig- dicates that it is feasibile to spare the nerve nancy necessitates a unilateral orchiectomy without compromising tumor excision."' for diagnosis and treatment and, in many This new technique is encouraging more instances, a retroperitoneal lymph node patients to take advantage of this curative dissection. This procedure is quite effective treatment. in staging and treating testicular tumor with retroperitoneal node invasion and is Surgeryfor bladder cancer. Radical cys- often necessary before or after chemothera- tectomy and urinary diversion is one of the py for residual disease. This dissection often options for treatmcnt of localized, invasive injures the sympathetic nerves that traverse transitional cell