Ejaculatory disorders after prostatic artery embolization: a reassessment of two prospective clinical trials

Abstract

Purpose: This study aims to specify and explain the previous findings of unexpectedly high rates of ejaculatory disorders, i.e. 56%, found after prostatic artery embolization (PAE) in a randomized controlled trial comparing safety and efficacy of PAE and transurethral resection of the prostate (TURP).

Patients and methods: Case report forms of the randomized controlled trial were analyzed to specify the grade of postoperative ejaculatory dysfunction 3 months postoperatively. In addition, study participants with assessable ejaculation were asked to complete the four-item Male Sexual Health Questionnaire-Ejaculation Dysfunction Short Form (MSHQ-EjD) referring to their ejaculatory function at present, as well as before treatment and 3 months after. Potential explanations for ejaculatory disorders after PAE were derived from histological examination of five radical prostatectomy specimens of patients that underwent PAE 6 weeks before radical prostatectomy within a proof-of-concept trial at the study site, St. Gallen Cantonal Hospital. An experienced uropathologist systematically examined the whole-gland embedded tissue with focus on structures that are involved into ejaculation.

Results: While patients after TURP predominantly suffered from anejaculation (52%), diminished ejaculation was found more often after PAE (40%). Significantly higher MSHQ-EjD scores were found 3 months after PAE and at a median follow-up of 31 months. Histological examination showed marked changes of structures involved into ejaculation (e.g., prostatic glands, seminal vesicles, ejaculatory ducts) after PAE.

Conclusion: Although anejaculation occurs less frequently after PAE (16%) compared to TURP (52%), patients have to be informed about the relevant risk of ejaculatory disorders, especially diminished ejaculation.

Keywords: Anejaculation; Benign prostatic hyperplasia; Diminished ejaculation; Ejaculatory disorders; Prostatic artery embolization; Retrograde ejaculation.

Conflict of interest statement

Boston Scientific (Natick, MA, USA) provided Embozene microspheres for the patients in the proof-of-concept study assessing PAE in localized prostate cancer free of charge. The company did not influence design, conduct, and analysis of the study. DA: Research support (institutional): Olympus, Boston Scientific, Advisory role (institutional): Janssen, Travel support (institutional): Janssen, Debiopharm. GM: Travel support: Debiopharm.

Figures

Fig. 1

Postoperative ejaculatory disorders assessed according to CTCAE [5] (a), Male Sexual Health Questionnaire-Ejaculation Dysfunction Short Form (MSHQ-EjD) ejaculatory function total score (questions 1–3, possible range 0–15) (b) and MSHQ-EjD ejaculatory bother item (question 4, possible range 0–5) (c) [bars show means and 95% CI, numbers are means, and p values from Wilcoxon rank sum tests indicate the significance of differences between PAE and TURP. Asterisk: ejaculation was considered as not assessable in patients with complete erectile dysfunction and in patients reporting to have no sexual stimulation at all; note that MSHQ-EjD was completed retrospectively by the patients for baseline and 3 month follow-up. Latest follow-up was median 31 months (17—58)]

Fig. 2

Histological findings in patients undergoing radical prostatectomy 6 weeks after prostatic artery embolization. Selected pictures (HE staining) show extensive necrosis next to embolization particles in the central prostatic gland (a, × 50), extensive fibrosis around the verumontanum (b, × 25) and mucosal necrosis and atrophy of the seminal vesicles (c, × 50) and ejaculatory duct (d, × 50)