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Minerva Urologica e Nefrologica 2001 March;53(1):19-28

Copyright © 2001 EDIZIONI MINERVA MEDICA

language: English, Italian

Iatrogenic ejaculation disorders and their prevention

Terrone C., Castelli E., Aveta P., Cugudda A., Rocca Rossetti S.

From the Università degli Studi - Torino Clinica Urologica

Ejaculation is me­di­at­ed by sym­pa­thet­ic fi­bers orig­i­nat­ing ­from the D10-L2 me­dul­lar cen­ter. These ­nerves ­rise ­from the lum­bar gan­glia of the par­a­ver­te­bral sym­pa­thet­ic ­trunk and trav­el pos­te­ri­or­ly to the ve­na ca­va and ­then to the inter­aor­toc­a­val ­space, on the ­right ­side, and lat­er­al­ly to the aor­ta, on the ­left ­side. They are the prin­ci­pal con­stit­u­ents of the super­i­or hy­po­gas­tric plex­us. Many sur­gi­cal op­er­a­tions can ­cause an ejac­u­la­tion dis­or­der, but the ­most im­por­tant is ret­ro­per­i­to­neal lym­phad­e­nec­to­my (RL) for tes­tis can­cer, be­cause it in­volves ­young pa­tients and it has ­been the sub­ject of im­por­tant re­search­es in or­der to per­form ­lymph ­node dis­sec­tion with­out ejac­u­la­tion ­loss (uni­lat­er­al lym­phad­e­nec­to­my and ­nerve spar­ing lym­phad­e­nec­to­my). Our ex­pe­ri­ence con­cerns 41 pa­tients who under­went RL for tes­tis can­cer ­from 1983 to 1998. Survival ­rate was 95.2% (­mean fol­low up 64 ­months). RL was per­formed bi­lat­er­al­ly in 14 pa­tients. Two of ­them ­died of me­tas­ta­ses with­in 2 ­years af­ter the op­er­a­tion. Ejaculation was main­tained in on­ly 4 of the 12 sur­viv­ing pa­tients (33%). All the 17 pa­tients (100%) under­went ­right mono­lat­er­al RL and 7 of the 10 (70%) under­went ­left mono­lat­er­al RL pre­served ejac­u­la­tion. The an­a­tom­o­sur­gi­cal con­cepts of the RL spar­ing the ejac­u­la­tion can be adopt­ed in oth­er ret­ro­per­i­to­neal sur­gi­cal op­er­a­tions ­that can pro­duce ejac­u­la­tion dis­or­ders, ­such as ­wide lym­phad­e­nec­to­my for re­nal ­cell car­ci­no­ma or tu­mors of the ­upper uri­nary ­tract, ex­er­e­sis of pre- aor­tic tu­mors, ex­er­e­sis or dis­junc­tion of horse­shoe kid­ney and aor­to-­iliac re­vas­cu­lar­iza­tion. Surgical ther­a­py of be­nign pros­tat­ic hy­per­pla­sia (BPH) (­open sur­gery or trans­ureth­ral pros­tat­ic re­sec­tion) is as­so­ciat­ed ­with ret­ro­grade ejac­u­la­tion in near­ly 100% of cas­es. The mech­a­nism of the dys­func­tion is ­clear, if fol­low­ing the pro­ce­dure the blad­der ­neck re­mains ­opened. Loss of ejac­u­la­tion is re­port­ed in var­i­able per­cent­age af­ter the new­er en­do­scop­ic tech­niques for the treat­ment of BPH. Transurethral nee­dle ab­la­tion (TU­NA) ­seems to ­have the low­er ­risk of ret­ro­grade ejac­u­la­tion. Retrograde ejac­u­la­tion can al­so be re­lat­ed to a trau­mat­ic in­ju­ry of the pos­te­ri­or ure­thra, be­cause of the trau­ma it­self or the ther­a­py. Finally, the ejac­u­la­tion dis­or­der can be pro­duced by sev­er­al ­drugs ­that ­block, as a ­main or sec­on­dary ef­fect, the al­pha-ad­re­nor­e­cep­tors or act at the cen­tral lev­el. This ­side ef­fect has to be ­kept in ­mind ­when ­these ­drugs are ­used in ­young or sex­u­al­ly ac­tive pa­tients.