Evaluation of the Effects of Different Prostate Surgeries on Urinary and Sexual Function
Evaluation of the Effects of Different Prostate Surgeries on Urinary and Sexual Function
The impact of of different surgical treatment modalities of benign prostatic hyperplasia in
 men on their sexual function is not well studied.

 The investigators will investigate prospectively the effect of conventional monopolar
 transurethral resection of the prostate (TURP), bipolar TURP and Holmium laser enucleation on
 urinary and sexual functions.
Benign prostatic hyperplasia (BPH), one of the most common diseases of aging men, can be
 associated with bothersome lower urinary tract symptoms (LUTS) that affect quality of life.
 The prevalence of histopathologic BPH is age dependent, with initial development usually
 after 40 years of age. Similar to that of histologic evidence, the prevalence of bothersome
 symptoms also increases with age. Approximately half of all men who have a histologic
 diagnosis have moderate to severe LUTS.

 The other common disorder associated with BPH is sexual dysfunction based purely on age.
 Sexual dysfunction encompasses not only erectile dysfunction (ED), but also ejaculation
 abnormalities, difficulty in reaching orgasm, decreased libido and overall dissatisfaction.
 Many studies suggest that the presence of LUTS is a risk factor for sexual dysfunction.
 Increasing life expectancy has been associated with improvements in the health and quality of
 life of the elderly, and many studies examined the sexuality of these groups of subjects and
 reported that their interest in sex persist.

 By reviewing the literature, the effect of different modalities for treating BPH, including
 medical, open surgical, endourological procedures, on urinary function has been extensively
 discussed and to a less extent on sexual function. A significant problem which arises when
 discussing the sexual function with patients and partners, and when reviewing the literature,
 is to know which aspect of male sexual function is being referred to.

 Transurethral resection of the prostate (TURP) is still considered the gold standard in
 treating BPH. However, most authors accept that there will be some impairment of sexual
 function secondary to this procedure. The exact magnitude of this problem has been difficult
 to assess by reviewing the published literature. Most of the large series reported ED rates
 of 10 to 15%. (11&12) The etiology of ED secondary to TURP is poorly understood. Most likely
 it is secondary to electrical trauma to the cavernous nerves close to the prostate apex at 5
 and 7 o'clock positions. Furthermore, thrombosis of the cavernosal arteries may result from
 mechanical trauma or from thermal damage.

 Post TURP ejaculatory dysfunction was reported and documented to be in the form of retrograde
 ejaculation in between 25-99 %. The mechanism for that was destruction of the bladder neck
 mechanism which is responsible for sympathetic mediated occlusion of the bladder neck during
 ejaculation ending in forward expulsion of the ejaculate.

 Since introduction of TURP as an effective tool for treatment of BPH, many endo-urologic
 techniques were tried to overcome the limitations and drawbacks of this gold standard
 procedure mainly caused by perioperative bleeding requiring transfusion or re-intervention,
 irrigation fluid absorption (TUR syndrome) and need for hospital stay.

 Currently holmium laser enucleation of the prostate (HoLEP) seems to be an attractive
 alternative to standard TURP. The efficacy and safety of HoLEP have been demonstrated even in
 cases of large prostates that otherwise would usually require open prostatectomy. In several
 comparative randomized studies, HoLEP was found to be superior to TURP in term of catheter
 time, hospital stay, weight of removed tissue, blood loss but with longer operative time.

 However, its impact on male sexual function has not been well established. The successful
 outcome of relief of LUTs is postulated to favor improving the overall sexual function.
 However, other factors including laser heating effect, is hypothesized to contribute to
 postoperative erectile dysfunction.

 The safety of bipolar TURP is enhanced by the use of normal saline eliminating the incidence
 of the metabolite toxicities and dilutional hyponatremia and the physics of electrical
 current return theoretically reduce the thermal tissue damage at the site of surgery or at a
 distant site by faulty patient grounding ( patient return electrode pad ). Urologists have
 observed better intra-operative visibility during bipolar resection, which may also enhance
 resident education. The deep coagulation effect of bipolar resection is thought to contribute
 in the postoperative sexual dysfunction. However, sexual function after bipolar TURP is still
 not well established in the literature.

 To the best of the investigators' knowledge there is no any prospective study in the
 literature comparing these three widely available procedures monopolar TURP, bipolar TURP and
 HoLEP in term of their urinary, erectile and ejaculatory outcome.
Inclusion Criteria:

 1. Lower urinary symptoms (LUTS) secondary to bladder outlet obstruction from BPH.

 2. Failed medical treatment of BPH.

 3. International prostate symptom score (IPSS) >9.

 4. Peak urinary flow rate (Qmax) <10 ml/sec.

 5. Patients in retention secondary to BPH.

 6. Total prostate size not less than 30 gm by TRUS (transrectal ultrasound)

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 Exclusion Criteria:

 1. Patient who have a neurological disorder as neurogenic bladder, cerebrovascular stroke
 or Parkinson disease.

 2. Non BPH causes of LUTS as cystitis.

 3. Infravesical causes of LUTS other than BPH as urethral stricture.

 4. Presence of active bladder cancer (within the last 2 years).

 5. Known cancer prostate patients on the basis of digital rectal examination, prostate
 specific antigen level, and TRUS imaging followed by prostate biopsies if necessary.

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