|Year : 2021 | Volume
| Issue : 4 | Page : 355-359
Sexual dysfunction following aortoiliac surgery: Does endovascular repair preserve erectile function??
Souad Benallal1, Mourad Raiah2, Karima Chenni2
1 Department of Vascular Surgery, EHS of Organs and Tissues Transplantation, Blida, Algeria
2 Department of Epidemiology and Biostatistics, Faculty of Medicine, Oran, Algeria
|Date of Submission||04-Jan-2021|
|Date of Acceptance||03-May-2021|
|Date of Web Publication||9-Dec-2021|
Department of Vascular Surgery, EHS of Organs and Tissues Transplantation, Blida
Source of Support: None, Conflict of Interest: None
Objective: The purpose is to determine the incidence of erectile dysfunction (ED) in patients with aortoiliac occlusive disease and compare the change of ED after open surgery and endovascular repair. Materials and Methods: A prospective and comparative study in a single center from January 2013 to October 2015, 103 male patients admitted for extensive aortoiliac occlusive lesions. The erectile function (EF) was evaluated using a questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after 1 year. Results: This study enrolled two groups: 48 patients underwent endovascular treatment and 55 patients underwent open surgery (aortofemoral or aorto-iliac bypasses). Preoperatively, 45.8% of patients were functionally impotent; there was no difference EF depending on the stage of peripheral arterial disease or the severity of obstructive aortoiliac lesions. Postoperative impotence was twice as common in those with minor dysfunction preoperatively, deterioration of EF occurred in 16.2% in the surgical group, and 2.1% in the endovascular group, with a very significant difference (P = 0.0001). In multivariate analysis, adjusted to preoperative EF was significantly more impaired postoperatively after median laparotomy (heart rate: 24.80 confidence interval = 95% [3.17–51.80], P < 0.0001). Conclusion: Sexual dysfunction is a frequent and often missed comorbidity in vascular surgery patients, especially after aortoiliac surgery. Hence, it must be diagnosed and evaluated in preoperatively in the choice of the therapeutic approach. For that endovascular treatment offers a less invasive alternative to open surgery and allows patients to maintain its sexual function intact and improve the quality of life.
Keywords: Aortoiliac occlusive disease, endovascular repair, erectile dysfunction; Impotence, sexual dysfunction
|How to cite this article:|
Benallal S, Raiah M, Chenni K. Sexual dysfunction following aortoiliac surgery: Does endovascular repair preserve erectile function??. Indian J Vasc Endovasc Surg 2021;8:355-9
|How to cite this URL:|
Benallal S, Raiah M, Chenni K. Sexual dysfunction following aortoiliac surgery: Does endovascular repair preserve erectile function??. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 25];8:355-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/355/332046
| Introduction|| |
Sexual function is an important quality of life (QoL) criterion. Male sexual dysfunction after aortoiliac operations can be a distressing complication. The true incidence of this complication has been difficult to ascertain. Conventional dissection techniques increased the risk of sexual dysfunction. Postoperative impotence is twice as common in patients with minor dysfunction preoperatively.
The sexual dysfunction or disorder is the inability to achieve a satisfactory sexual intercourse or activity; it has three aspects: erectile dysfunction (ED) (develop and maintain an erection), ejaculation disorders: Absent or delayed ejaculation despite adequate sexual stimulation (retarded ejaculation) or inability to control the timing of ejaculation (early or premature ejaculation), and desire disorders.
The purpose is to determine the incidence of ED in patients with aortoiliac occlusive disease and compare the change of ED after open surgery and endovascular repair.
Anatomy and physiology
It is very important to know the anatomy and physiology of erection in order to prevent secondary complications of aortoiliac surgery.
The neuroanatomy of male sexual response encompasses a wide variety of anatomical structures in the brain, spinal cord, and peripheral nervous system including autonomic, somatic, sensory, and motor neuronal structures.
The innervation of the intarpelvic organ is derived from sympathic and parasympathic chain. The main efferent sympathetic innervation is derived from the superior hypogastric plexus, also called preaortic plexus; within the pelvis, the mainly parasympathetic sacral splanchnic nerves, also called pelvic splanchnic nerves, join the hypogastric nerve forming the bilateral inferior hypogastric plexus.
The neurological pathways affected by genitosexual control belong to the somatic system (conscious) and the vegetative system (autonomic).
Male sexual response is a complex multidisciplinary biologic process involving central pathways and peripheral neural mechanisms controlling libido, arousability, penile erection and rigidity, orgasm, and ejaculation. Neurologic disorders that can compromise central pathways and peripheral neuronal mechanisms would disrupt physiological sexual response during sexual stimulation.,,
Sexual function has three phases:
- The erection which depends on the splanchnic plexus. Penile erection includes arterial dilation, trabecular smooth muscle relaxation, and activation of the corporeal veno-occlusive mechanism. Rhythmic contraction of pudendal nerve innervated perineal muscles (ischio-cavernosus muscles) achieves such pressures. This ability is gradually lost by age, neuropathy, and surgery
- Emission dependent on lumbar and sacral splanchnic nerves (sympathic)
- Ejaculation: Dorsal Nerves transmit sensation to spinal cord (sensory stimuli from the glans ascend along the pudendal to the hypogastric plexus and to sympathetic ganglia T10-L2. From there, they rise to the central nervous system).
The development of an erection is a complex event involving integration of psychologic, neurologic, endocrine, vascular, and local anatomic systems.
Direct damage to the erector nerves, the shameful nerve, or the pelvic or peri-aortic nerve pathways can also determine a ruptured neural connection causing impotence. It can be due to trauma or iatrogenic after proximity surgery.
Cardiovascular diseases, including atherosclerosis, hypertension, heart disease, and stroke, are widely considered as multiple risk and predictive factors for standard deviation.
| Materials and Methods|| |
Single-center prospective comparative study including 190 males patients, treated consecutively by open surgery and endovascular repair for extensive aortoiliac occlusive lesions TASC C/D, from November 2013 to October 2015.
However, our sample was carried out only on 103 patients because 87 patients had preoperative sexual dysfunction (Disorders secondary to vascular lesions or other pathologies).
(N.B: patients with preoperative sexual dysfunction were excluded from our study).
For each patient, in addition to the clinical, demographics, risk factors, and biological characteristics, the preoperative and postoperative erectile function (EF) was measured by the international questionnaire index of EF, as well as the sexual QoL.
The study of sexual function included 4 criteria: quality of erections, presence of anterograde ejaculation, overall satisfaction, and frequency of intercourse. An evaluation was carried out by a self-questionnaire derived from the IIEF, completed by the patient before, 3 months, and 1 year after the intervention. The results were compared with the two surgical techniques by statistical analysis.
Statistical analysis was performed with software from IBM SPSS Statistics 20 (IBM SPSS Inc., Chicago, IL, USA) and MEDCALC12.
Variables were compared with the use of Chi-square tests, log rank correlation tests, and the Student test. P < 0.05 was considered to indicate statistical significance.
Longitudinal mixed-effects models, adjusted for baseline values, were used to compare the two groups with respect to quality-of-life measure.
| Results|| |
This study enrolled two groups: 48 patients underwent endovascular treatment and 55 patients underwent open surgery (aortofemoral or aortoiliac bypasses).
Our patients are young with a mean age of 56.37 years, with extremes ranging from 40 to 78 years old. Among co morbidities, all patients were chronic smokers (100%), 85.4% had hypercholesterolemia, 38.8% were hypertensive, and 25.2% were diabetics.
The baseline characteristics are shown in [Figure 1].
Preoperatively, 45.8% of patients were functionally impotent; there was no difference EF depending on the stage of peripheral arterial disease (PAD) or the severity of obstructive aortoiliac lesions.
Postoperative follow-up is done on 103 patients; on this sample, 20 patients (19, 41%) had a postoperative sexual dysfunction.
The postoperative evolution in the both groups is illustrated in the form of a histogram confirming the greater postoperative deterioration for patients in the laparotomy group [Figure 2].
|Figure 2: Postoperative Sexual Function; on this sample 20 patients (19, 41%) had a postoperative sexual dysfunction|
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There was a significantly greater increase in the postoperative prevalence of sexual dysfunction in the surgical group with 34%, of which 16.8% had a severe dysfunction (impotence), a highly significant difference with P < 0.0001 and heart rate (HR) =24 at a 95% confidence interval (CI) [Figure 3].
|Figure 3: Postoperatively erectile dysfunction is more marked in the surgical group with 34% of which 16.8% had a severe dysfunction (impotence), a highly significant difference with P < 0.0001 and HR = 24 at 95% confidence interval|
Click here to view
The sexual QoL was worsened postoperatively after open surgery compared to the endovascular group.
The evaluation of retrograde ejaculation at 3 months was made only by questioning, we found five retrograde ejaculations, or 4.85% of the total study population. All of these patients had open surgery with aortobi-iliac bypass.
Linear regression models with downstream selection were used to study associations between EF score and possible risk factors. The offending factors are age, cardiac complications, and type of surgery, and open surgery has been shown to be a risk factor for worsening ED.
According logistic regression, our model presents a good calibration (test Hosmer and Lemshow test = 4.307 with a P = 0.828) [Figure 4].
|Figure 4: According logistic regression, our model presents a good calibration (test Hosmer and Lemshow test = 4.307 with a P = 0.828). Linear regression models with downstream selection were used to study associations between erectile function score and possible risk factors. The offending factors are age, cardiac complications and type of surgery, the latter influences enormously the occurrence of erectile dysfunction|
Click here to view
In multivariate analysis, adjusted to preoperative EF was significantly more impaired postoperatively after median laparotomy and defined open surgery as the only risk factor for ED (HR: 24.80. CI = 95% [3.17–51.80], P < 0, 0001).
| Discussion|| |
Sexual dysfunction affects physical and psychosocial health and has a significant impact on the QoL of sufferers and their partners and families as proven by the fact that some men are ready to choose a shorter survival to remain potent.
The risk of deterioration of EF following surgical or interventional procedures, especially in the distal aortic and iliac regions, is well known.
The different series of the literature report rates of postoperative ED of aortoiliac surgery ranging from 10% to 98.5%.
A large number of patients with PAD suffer from ED secondary to atherosclerosis which compromises the penile vascularization.
Dissection of the proximal segment of the common iliac arteries should be avoided because it is the privileged passage zone for the superior hypogastric plexus, the main crossroads of pelvic sympathetic nerve pathways. This would be the cause of ED but also retrograde ejaculations linked to the absence of closure of the bladder neck during the expulsion phase, the contractions of the smooth muscle fibers of the bladder neck being under the control of the sympathetic adrenergic system.
Mehta et al. found severe ED in 13% of cases when there was no vascularization of at least one internal iliac artery postoperatively. Another hypothesis that may also participate in the degradation of EF is that developed by Queral et al., who described that clamping and aortic dissection would be at the origin of microemboli and contribute to exacerbate sexual disorders.
Flanigan et al. reported that a permeable internal iliac artery was not always necessary for satisfactory sexual function.
Our study showed the benefit of endovascular surgery for the preservation of sexual function. Laparotomy appeared to be a major risk factor for ED with an odds ratio of 35.5.
A preoperative evaluation of EF before aortoiliac surgery appears necessary. The preservation of sexual function and its impact on QoL must be criteria to be taken into account in the treatment proposed.
In our series, the rate of preoperative ED was high at 45.8%. Concerning the evolution of EF after treatment, it was 16.2% in the surgical group and 2.8% in the endovascular group, with a very significant difference (P = 0.002).
In Jimenez's meta-analysis, the incidence of postoperative ED ranges from 20.5% to 83% for surgery and 9%–50% for endovascular. Koo and Lederle have shown that open surgery results in significantly more ED than endovascular. Other series show smaller figures such as Nevelsteen et al., who found 8% ejaculatory disorders after aortic bypass surgery.
These differences are probably explained by the surgical techniques of dissection of the retroperitoneum because in the absence of sacrifice of the hypogastric artery, the degradation of the EF in the surgery would be due mainly to the trauma of the pelvic sympathetic nerve fibers or after denervation of the aortic crossroads.
In our series, there was no difference in EF according to the stage of PAD or the severity of the aortoiliac obstructive lesions.
The treatment of aortoiliac occlusive lesions is evolving rapidly in vascular medicine and surgery. Multiple approaches must be considered, ranging from medical management to endovascular and open surgical procedures. The introduction of percutaneous endovascular techniques has significantly changed the landscape forever. We will compare and weigh different treatment strategies and review the available literature to allow for evidence-based clinical decisions for the surgical and endovascular treatment of aortoiliac occlusive injury.
According to Sabri, if the superior hypogastric plexus is preserved, sexual function can be maintained 90% of the time. In Machleder's series, 83% of patients who lost their ejaculation had a dissection extending to the primary iliac arteries. Our series adds that dissection of the left primary iliac artery alone is associated with both erection and ejaculation loss. It corresponds well to the passage of the superior hypogastric plexus.
The experience drawn from clinical and anatomical studies, in particular, by Van Schaik, De Palma, Creech, and Machleder, has enabled the authors to propose dissection techniques aimed at sparing these sympathetic nerve pathways (“nerve sparing dissections”).
In young patients with unilateral iliac occlusion, in order to avoid access to the aorta, it may be preferable to perform a femorofemoral cross bypass rather than aortofemoral. In this case, femorofemoral bypass has been reported to improve EF in these patients when they are impotent.
Similarly, percutaneous angioplasty of the iliac arteries rather than aortofemoral bypass may be a solution of choice for preserving EF. Karkos, in his series of aortoiliac occlusive disease, found in patients with normal preoperative function, 28% postoperative ED in the surgery group against 0% in the angioplasty group (P = 0.003).
At the end: Help the patient to better assimilate the information provided during the consultation, the course of the intervention and also the risks and complications. A multidisciplinary urology-vascular surgery collaboration could improve the overall therapeutic management of the patient.
| Conclusion|| |
Sexual dysfunctions are a frequent complication of open aortoiliac surgery, and they must therefore be understood both diagnostic and therapeutic, in order to improve the QoL of our patients.
Open surgery is at risk for sexual dysfunction (trauma to the peri-aortic sympathetic nerve pathways during dissection). Endovascular treatment does not cause any change in sexual function. These data must be taken into consideration for the choice of technique in a patient with sexual activity or with a desire for paternity.
We are grateful to Bouayed Mohamed Nadjib for reviewing the article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Giuliano F, Rampin O. Neural control of erection. Physiol Behav 2004;83:189-201.
Correia JA, De-Ary-Pires B, Pires-Neto MA, De Ary-Pires R. The developmental anatomy of the human superior hypogastric plexus: A morphometrical investigation with clinical and surgical correlations. Clin Anat 2010;23:962-70.
Allard J, Edmunds NJ. Reflex penile erection in anesthetized mice: An exploratory study. Neuroscience 2008;155:283-90.
Karabakan M, Bozkurt A, Akdemir S, Gunay M, Keskin E. Significance of serum endothelial cell specific molecule-1 (Endocan) level in patients with erectile dysfunction: A pilot study. Int J Impot Res 2017;29:175-8.
Tuiten JJ, Bloemers JM. Use of testosterone and a 5-HT1A agonist in the treatment of sexual dysfunction. US Patent 2017:USO09597335B2.
Coutinho P. Metabolic syndrome and erectile dysfunction: Assessing the clinical and hemodynamic parameters. Rev Int Androl 2013;11:60-5.
Goldstein I. Male sexual circuitry. Working group for the study of central mechanisms in erectile dysfunction. Sci Am 2000;283:70-5.
Tomza-Marciniak A, Stępkowska P, Kuba J, Pilarczyk B. Effect of bisphenol A on reproductive processes: A review of in vitro, in vivo
and epidemiological studies. J Appl Toxicol 2018;38:51-80.
Salonia A, Castagna G, Saccà A, Ferrari M, Capitanio U, Castiglione F, et al.
Is erectile dysfunction a reliable proxy of general male health status? The case for the international index of erectile function-erectile function domain. J Sex Med 2012;9:2708-15.
Buvat J, Glasser D, Neves RC, Duarte FG, Gingell C, Moreira ED Jr., et al.
Sexual problems and associated help-seeking behavior patterns: Results of a population-based survey in France. Int J Urol 2009;16:632-8.
Nevelsteen A, Beyens G, Duchateau J, Suy R. Aorto-femoral reconstruction and sexual function: A prospective study. Eur J Vasc Surg 1990;4:247-51.
Chena L, Shib GR, Huangc D, Lid Y, Mae C, Shia M, et al
. Male sexual dysfunction: A review of literature on its pathological mechanisms, potential risk factors, and herbal drug intervention. Biomed Pharmacother 2019;112:108585.
Mehta M, Veith FJ, Darling RC, Roddy SP, Ohki T, Lipsitz EC, et al.
Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair. J Vasc Surg 2004;40:698-702.
Queral LA, Whitehouse WM Jr., Flinn WR, Zarins CK, Bergan JJ, Yao JS. Pelvic hemodynamics after aortoiliac reconstruction. Surgery 1979;86:799-809.
Flanigan DP, Schuler JJ, Keifer T, Schwartz JA, Lim LT. Elimination of iatrogenic impotence and improvement of sexual function after aortoiliac revascularization. Arch Surg 1982;117:544-50.
Jimenez JC, Smith MM, Wilson SE. Sexual dysfunction in men after open or endovascular repair of abdominal aortic aneurysms. Vascular 2004;12:186-91.
Koo V, Lau L, McKinley A, Blair P, Hood J. Pilot study of sexual dysfunction following abdominal aortic aneurysm surgery. J Sex Med 2007;4:1147-52.
Ligush J Jr., Criado E, Burnham SJ, Johnson G Jr., Keagy BA. Management and outcome of chronic atherosclerotic infrarenal aortic occlusion. J Vasc Surg 1996;24:394-404.
Ruggiero NJ 2nd
, Jaff MR. The current management of aortic, common iliac, and external iliac artery disease: Basic data underlying clinical decision making. Ann Vasc Surg 2011;25:990-1003.
Sabri S, Cotton LT. Sexual function following aortoiliac reconstruction. Lancet 1971;2:1218-9.
Machleder HI, Weinstein M. Sexual dysfunction following surgical therapy for aorto-iliac disease. Vasc Surg 1975;9:283-7.
van Schaik J, van Baalen JM, Visser MJ, DeRuiter MC. Nerve-preserving aortoiliac reconstruction surgery: Anatomical study and surgical approach. J Vasc Surg 2001;33:983-9.
Karkos CD, Wood A, Bruce IA, Karkos PD, Baguneid MS, Lambert ME. Erectile dysfunction after open versus angioplasty aortoiliac procedures: A questionnaire survey. Vasc Endovascular Surg 2004;38:157-65.
Burnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, et al.
Erectile dysfunction: AUA guideline. J Urol 2018;200:633-41.
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