Ejaculation-sparing enucleation of benign prostate hyperplasia: is it almost feasible?

Abstract

Introduction. Patients often request maintenance of antegrade ejaculation, and try to find the clinic, surgeon, and treatment to store it. Despite an established technique, the long-term results of ejaculation-sparing operations at a large prostate volume remain unstable. This is not allowed to give patients a guarantee in maintaining this component in their sexual life.Objective. To evaluate the frequency of ejaculation maintenance after laser ejaculatory-sparing prostate enucleation.Materials & methods. Since 2017 ejaculation-sparing laser enucleations have been performed in prostate volume (V pr > 80 cc) in 84 patients. Fifty-four patients (64%) had three lobes benign prostate hyperplasia (BPH) and two lobes — 30 patients (36%). Preoperative voiding parameters were IPSS score — 21.0 ± 2.7, QoL — 4.8 ± 0.6, residual urine volume (V res) — 139 ± 43 mL, Q max — 8.1 ± 2.0 mL. We estimate the result as positive if antegrade ejaculation remained after intervention. If ejaculation volume decreased, then as partially positive and negative — ejaculation was absent postoperatively. We conducted questionnaire and follow-up examination 3 – 6 months after intervention.Results. Thulium-fiber laser enucleations have been performed in all cases without any serious complications. Followup 3 – 6 months after operation showed V pr — 29 ± 4 cc, V res — 19 ± 17 mL, Q max — 19.1 ± 3.1 mL/sec. IPSS score — 8.1 ± 1.9 and QoL — 2.6 ± 0.7. There are the following technical remarks: 1) tissue-sparing in the verumontanum; 2) no or minor mechanical tissue tension during enucleation; 3) avoid additional resection in the bladder neck; 4) refuse total coagulation; 5) no urethral catheter tension after operation; 6) catheter balloon inflow only in the bladder, not in the fossa. Antegrade ejaculation has stored at 17 (20%) patients, partial ejaculation — at 34 (40%) patients, so overall efficacy is 60%. The presence of a median lobe is shown to be negative prognostic factor due to the absence of full antegrade ejaculation in all cases. A partial ejaculation was achieved at 21 patients. Based on the obtained results we have optimized the three-lobe prostate enucleation technique. Four from our initial 7 patients had full storage of ejaculation and 3 — partial.Conclusion. The possibility of BPH laser surgery to store ejaculation function at the request of the patients is modest. The presence of the median lobe makes the full ejaculation-sparing impossible. In cases of two lobes BPH full storage of the ejaculation was at 57% and partial at 43%, respectively. The following evaluation of the described technique is mandatory.