Sexual dysfunction after elective

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ORIGINAL ARTICLE

Sexual dysfunction after elective

laparoscopic or endovascular abdominal aortic aneurysm repair in men

Dysfonction sexuelle après chirurgie laparoscopique ou endoprothèse pour anévrysme de l’aorte abdominale chez l’homme

C. Dariane

^a^,^b^,^c

, I. Javerliat

^a^,^d^,∗

, S. Doizi

^e

,

E. Fontaine

^b

, A. Mejean

^b^,^c

, R. Coscas

^a^,^d

, M. Coggia

^a^,^d

aDepartmentofVascularsurgery,Ambroise-ParéHospital,AP—HP,Boulogne-Billancourt, France

bDepartmentofUrology,EuropeanGeorges-PompidouHospital,AP—HP,Paris,France

cMedicalUniversityParisDescartes,Paris,France

dUFRdessciencesdelasantéSimone-Veil,MedicalUniversityParis-IledeFrance-Ouest, UniversityVersaillesSaint-QuentinenYvelines,Montigny-le-Bretonneux,France

eDepartmentofUrology,TenonHospital,AP—HP,Paris,France

Received24September2019;accepted14December2019 Availableonline17January2020

KEYWORDS Abdominalaortic aneurysm(AAA);

Laparoscopicaortic repair;

Endovascularaortic repair(EVAR);

Sexualdysfunction;

Erectiledysfunction;

Ejaculationtroubles

Summary

Introduction.—Infrarenalabdominalaorticaneurysm(AAA)repaircanleadtoejaculationand erectiontroublesinmen.Therearefewstudiesonsexualdysfunctionafterendovascularrepair (EVAR)butthey suggestlessretrogradeejaculation thanafter openrepair. Weassessedthe sexualdysfunctionandejaculationtroublesafterelectivelaparoscopicrepairorEVAR.

Methods.—Weconducted amonocentricprospective studyon124 patientsundergoing AAA repairbetween2013and2015.SexualfunctionwasevaluatedusingtheIIEF-15questionnaire andquestionsonejaculation.

Results.—Only45patients(36.3%)acceptedtocompletetheIIEFpreoperativelywith20—37.8%

havingpreoperative sexualdysfunction.Among them,21 (46.7%)acceptedto completethe questionnaireat3,6and12months.Meanageatinclusionwas65±5.6yearsinthelaparoscopic group and77±10.5years inthe EVARgroup (P=0.003).Erectile andsexual function were slightlyimprovedat12monthsinthelaparoscopicgroup(+1.4forerectilescoreand+4.6for IIEFscore)withnosigniﬁcantdifference(P=0.83and0.74) whereas8patients (61.5%)had

∗Correspondingauthorat:DepartmentofVascularsurgery,Ambroise-ParéHospital,AP—HP,Boulogne-Billancourt,France.

E-mailaddress:ijaverliat@yahoo.fr(I.Javerliat).

https://doi.org/10.1016/j.purol.2019.12.003

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persistentejaculationtroublesat3months.IntheEVARgroup,patientshadmoderatesexual dysfunctionat baselinewithout improvementat 12 months,but only onepatient reported ejaculationtroubles.

Conclusions.—MostpatientseligibleforAAArepairpresentwithbaselineerectileandsexual dysfunction.LaparoscopicAAArepairprovidesnoonsetoferectileorsexualdysfunctionbuta globalimprovementaftersurgery.Ejaculationtroublesarefrequentandpersistentat1year.

However,EVARtreatment,doesn’tallowrecoveringofsexualfunctionat1year.

Levelofevidence.— 4.

MOTSCLÉS

Anévrysmedel’aorte abdominale(AAA); Chirurgie

laparoscopique; Endoprothèse aortique; Dysfonction sexuelle;

Dysfonctionérectile; Troublesde

l’éjaculation

Résumé

Introduction.—La chirurgie d’un anévrisme de l’aorte abdominale (AAA) infra-rénale peut entraînerdestroublesdel’éjaculationetdel’érectionchezl’homme.Lachirurgieparendopro- thèseseraitmoinspourvoyeused’éjaculationrétrogradequelachirurgieouverte.Nousavons évaluélafonctionsexuelleaprèschirurgielaparoscopiqueetaprèsendoprothèse.

Méthodes.—Nousavonsmenéuneétudeprospectivemonocentriquesur124patientsopérés d’unAAAentre2013et2015.LafonctionsexuelleétaitévaluéeparlequestionnaireIIEF-15et desquestionssurl’éjaculation.

Résultats.—Quarante-cinqpatients(36,3%)ontremplilequestionnaireIIEFenpréopératoire avec20—37,8%dedysfonctionsexuelle.Vingtetunpatients(46,7%)ontpoursuivil’étudeà 3,6et12mois.L’âgemoyen étaitde65±5,6ansdanslegroupelaparoscopieet77±10,5 ansdanslegroupeendoprothèse(p=0,003).Lafonctionsexuelleétaitlégèrementaméliorée à12moisdanslegroupelaparoscopie(+1,4pourlescoreérectileet+4,6pourl’IIEF-15)sans différencesigniﬁcative(p=0,83et0,74)mais8patients(61,5%)présentaientdestroublesde l’éjaculationpersistantsà3mois.Danslegroupeendoprothèse,lespatientsprésentaientune dysfonctionsexuellemodéréeinitialesansaméliorationà12mois,maisunseulrapportaitdes troublesdel’éjaculation.

Conclusions.—Lamajoritédespatientséligiblesàuntraitementchirurgicald’AAAprésentait unedysfonctionérectileetsexuelleinitiale.Lachirurgielaparoscopiquen’entraînepasdedys- fonctionérectileousexuelledenovoetilestnotéuneaméliorationglobalepostopératoire.Les troublesdel’éjaculationétaientfréquentsetpersistantsà1an.Lachirurgieparendoprothèse nepermettaitpasd’améliorationdelafonctionsexuelleà1an.

Niveaudepreuve.— 4.

Introduction

Endovascular aortic repair (EVAR), laparoscopic aortic surgery (LAS) and open repair (OR) are three well- established treatment methods of infrarenal abdominal aorticaneurysms(AAA).LASandORhave beenassociated witha similarpostoperative sexualdysfunctionin22—30%

ofmalepatients[1—3],duetoautonomicnerveinjuryand pelvicbloodﬂowchanges,butsexualdysfunctioninmencan becaused by either disorder in arousal, orgasm, ejacula- tionorerectiledysfunction.Moreover,erectiledysfunction canalsobeaconsequenceofAAAitself,treatmentsand/or vascular risk factors [3]. The potential beneﬁt on sexual functionsfromEVARcouldresultintheabsenceofnerve’s dissectionaroundtheaorta.Indeed,someauthorsreported lowerincidenceofsexualdysfunctionafterEVARbasedon

retrospective studies [4]. But there is a general lack of studiesinpatientsundergoingEVARregardingsexualfunc- tion and some authors reported a lack of information of patientsbeforeEVAR,althoughasigniﬁcantimpairmentin qualityoferectionandejaculationcouldbefoundpostop- eratively in this population [5]. Recently, EVAR has been comparedtohand-assistedlaparoscopicsurgery(HALS][6], providingsimilarresultsat12monthsinsexualfunction,but withlowerincidenceofretrogradeejaculation,duetothe absenceof dissection ofthe iliac bifurcation [7—9]. How- ever, EVARhasneverbeencomparedtototallaparoscopic repair.

In this 2-years, monocentric prospective observational andnon-randomizedstudy,witha12-monthsfollowup,we evaluatedtheincidenceofsexualanderectiledysfunction andejaculationtroublesafter3typesofcurrenttreatment ofAAAinmen:LAS,ORandEVAR.

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Methods

Study design and patient population

BetweenDecember2013andDecember2015,171patients underwent AAA repair in our unit. Seventy-nine patients refused to take part in the study and 4 patients were excludedbecauseofpreviousprostatesurgerywhichcould interfere with sexual function (Fig. 1). The remaining 45 patients[LASgroup(N=21),ORgroup(N=9)andEVARgroup (N=15)]completedthepreoperativeInternationalIndexof ErectileFunction(IIEF)questionnairebutonly21accepted tocomplete thequestionnaire at 3,6 and12months and completedthestudy:16intheLASgroup(groupA),5inthe EVARgroup(groupB)andnooneintheORgroup(Fig.1).

PatientsfromtheORgroupwereﬁnallyexcludedfromthe study.

The study wasapprovedbythe Ethical Committeeand allpatientsgaveinformedwrittenconsent.

Preoperative assessment

Investigationsinallpatientsincludedduplexscanningofthe aorta,lowerlimbsandcervicalarteries.Inaddition,astan- dard contrast-enhanced spiralcomputed tomography (CT) scanwithimagesacquiredat3-mmintervalswasperformed.

The cardiopulmonary examination included stress echocardiography, functional respiratory evaluation and determination of arterial blood gas levels. Renal insufﬁ- ciencywasdeﬁnedasan estimatedCrCl level<30mL/min accordingtoCockroftandGault[10].

The quality of sexual function wasevaluated preoper- atively and at 3, 6 and 12 months postoperatively using theIIEF,a15-items,self-administeredquestionnaire,which includes6specificquestionsonerection(erectionscore/30 andfinal score/75)[11—15].Ascoreof 0—5isawardedto eachofthe15questionsthatexaminethe4maindomainsof malesexualfunction,leadingtoafinalscorefrom0to75.

Basedontheﬁnalscore,thepatientsweredividedintothree

Figure1. Flowchartdepictingthestudydesignandinclusionprocess.

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classes:severesexualdysfunction(classI,totalscore<11), moderatesexual dysfunction(classII, totalscore11—21], andno sexual dysfunction(classIII, total score>21),and erectilefunction’score(valuesfrom0to30,score<6mean- ingsevereerectiledysfunctionandscore25—30meaningno erectiledysfunction)wasalsoevaluatedspeciﬁcally.

Aspectsrelatingtoejaculationtroubles(retrogradeejac- ulation,anejaculation,hypospermia)werealsoevaluatedby 5speciﬁcsupplementaryquestions(Appendix1).

Morbidityandmortalitywereevaluatedforbothgroups at1month(perioperative)andat12months.

Outcomes

Theprimaryoutcomeofthestudywasthevariationinthe IIEFscoreat12months.Thesecondaryoutcomeswerethe changeintheerectilescoreandthepercentageoftrouble ejaculationsat12months.

Choice of surgery

Since EVAR, LAS and OR are complementary established treatmentmethodsofAAA,thechoiceofthetechniquewas basedonthesurgical riskofthepatientandtheanatomic EVARcriteriaoftheFrenchHealthAuthority,aspreviously describedby ourteam[16]. Fourgroups of patientswere thus established in our vascular unit: (1) good risk and favourableanatomy(GR-FA);(2)goodriskandunfavourable anatomy(GR-UA);(3)high-riskandfavourableanatomy(HR- FA);and(4)high-riskandunfavourableanatomy(HR-UA).

Among GR-FA patients, EVAR and LAS were discussed accordingtolifeexpectancyandwishesofthepatient[17].

InGR-UApatients,bothLASandORwereproposed.ForHR- FApatients,EVARremainedthetechniqueofchoice.Inthe HR-UA patients, OR can be proposed becauseof the late complications of EVAR, but a broader use of fenestrated stentgraftsor the chimneytechnique couldbebeneﬁcial [16].

Operative procedures

Group A: total laparoscopic aortic surgery (LAS)

LAS technique to repair AAA has been already described [17—20].Twomainprincipaltransperitonealapproachesare currently used [19,20]. Left retrorenal approach is pre- ferred,outsideany contraindications[17,20]. The patient is placed in a dorsal decubitus position with a deﬂated pillowundertheleftpartoftheabdomen.Thereisachop- pingblockunderkneestorelaxtheleftcruralnerveduring laparoscopicprocedure.Thepillowisinﬂatedinadditionto arightmaximalrotationoftheoperatingtable,allowinga rightlateraldecubitusof80^◦andastableaorticexposure.

The abdominal aortais thus controlled fromleftrenal artery to aortic bifurcation. The proximal part of com- moniliacarteriesisalsocontrolled.Thelaparoscopyallows seeing well the sexual neural bundles running along the aorto-iliacbifurcation, allowingitspreservation whenever possible.

Inthisseries,transperitonealretrorenalaorticapproach wasusedinallpatientsinthegroupA.

Group B: endovascular aneurysm repair (EVAR)

Theaorticendograftisputinastandardizedway,justbelow thelowerrenalarteryandabovetheiliacbifurcationwhen- everpossible,inordertopreservehypograstricpatency(in thisseries,intheEVARgroup,onlypatientstreatedbystan- dardEVARwereincluded)[21].

Statistical methods

Continuous variables are summarized as mean±standard deviation when normally distributed, and as median and interquartilerangewhenasymmetricallydistributed.

Categoricalvariablesarepresentedasnumbersandper- centages. Differences between continuous variables were compared by two-tailed unpaired Student’s t-test with Welch’scorrection.Categoricalvariableswerecomparedby two-tailedFisher’sexacttest.

Results

Study population

On the124patients eligibleinthestudy,only45 patients completed the preoperative questionnaire. Seventy-nine refusals tocomplete questionnaireincluded patientswith cognitive troubles, patients no more having sexual intercourse and patients not interested in sexual function.

Overall,only21completedthequestionnaireat3,6and12 months(16inthegroupA,5inthegroupBandnoonefrom theORgroup)andwerethenincludedinthestudy(Fig.1).

Clinical preoperative characteristics

The baselinecharacteristicsof the21patients enrolledin the study after completion of the postoperative IIEF are comparedinTable1.

PatientsweresigniﬁcantlyolderintheEVARgroupBand presentedmorecardiovascularissuesthanthepatientsfrom thelaparoscopicgroupA.

Regardingthefeaturesofaorticdisease,therewasnosig- niﬁcantdifferenceinthediameteroftheaortainthetwo groups, neither in the presence of iliac aneurysmor iliac thrombus(Table2).Sixpatientshadunilateralthrombusin the primitiveiliac arteryincluding3 patients withunilat- eral hypogastric thrombus.No patientpresented denovo hypogastricarteriesocclusionafter laparoscopicrepair. In theEVAR group,nopatienthadhypogastriccoveringsince distalconnectionwasonprimitiveiliacartery.

The perioperative mortalityrate at 30 days was zero.

Norespiratorycomplicationswerenotedinthetwogroups.

No patientneeded dialysisand nopatient presented car- diacdecompensationormyocardialinfarction.Onepatient inthegroupAexperiencedalegischemiaonpostoperative day2,successfullytreatedbyiliacangioplastyandanother patient from the group A experienced claudication after laparoscopic aortic tube graft withneed of bilateral iliac

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Table1 Generalfeaturesofthestudygroup.

Variables LaparoscopicgroupA

(N=16)

EVARgroupB (N=5)

P-value

Age(years) 65±5.6 77±10.6 0.003

ASAscore

Score1 0 0 NS

Score2 10(62.5) 3(60) 1

Score3 6(37.5) 2(40) 1

Medicationswithinteractionwithsexuality[N(%)] 7(43.8) 2(40) 1 Cardiovascularriskfactors[N(%)]

Diabetes 3(18.8) 0(0) 0.06

Hypertension 9(56.3) 2(40) 0.63

Dyslipidaemia 12(75) 3(60) 0.6

Smoke 15(93.8) 4(80) 0.43

Obesity 5(31.3) 1(20) 1

Co-morbidity[N(%)]

COPD 4(25) 3(60) 0.28

CoronaryArteryDisease 4(25) 4(80) 0.048

AcuteMyocardialInfarction 1(6.3) 4(80) 0.004

Stroke 1(6.3) 0(0) 1

Preoperativemedicationswithinteractionswitherection 7(43.8) 2(40) 1 Perioperativedata

Surgeryduration(min) 276.3±52 85±7.1 0.0001

Lengthofhospitalstay(days) 5.8±0.9 5.6±3.2 0.86

ASA:AmericanSocietyofAnesthesiologists;COPD:chronicobstructivepulmonarydisease.Continuousvariablesaregivenasthesample mean±standard deviation and categorical variables as proportions with number of patients (percentage). Characters in italic:

preoperative.

Table2 Operativeandperioperativeaorticfeatures.

Variables LaparoscopicgroupA(N=16) EVARgroupB(N=5) P-value

Featuresofaorticdisease

Diameteroftheaneurysm(mm) 52.4±3.06 51.8±1.93 0.91

Iliacaneurysm[N(%)] 2(12.5) 0(0) 1

Iliacthrombus[N(%)] 6(37.5) 0(0) 0.27

Massivecalciﬁcations[N(%)] 1(6.3) 2(40) 0.13

Typeoflaparoscopicrepair[N(%)] NA

Aorto-aortictubes 6(37.5)

Bitubularaorticprosthesis 5(31.3)

Aorticbi-iliacbypass 5(31.3)

Commonorexternaliliacstenting 2(12.5)

EVARdistallandingzone[N(%)] NA NA

Primitiveiliacartery 5(100)

Externaliliacartery 0

Preoperativehypogastricarteriesocclusion[N(%)] 3(18.8) 0 NA

Continuous variables are given as the samplemean±standarddeviation and categoricalvariables as proportions with numberof patients(percentage).Charactersinitalic:preoperative.

kissingangioplastyat17months.Novascularcomplication wasnotedinthegroupB.

Global sexual preoperative assessment

From the 45 patients who completed the preoperative IIEF test, 17 patients (37.8%) and 8 patients (20%) had

respectively preoperative severe or moderate sexual dysfunction,leadingto57.8%ofpatientshavingbaselinesexual dysfunction.Inthesepopulationofpatientswithsevereand moderatesexualglobaldysfunction(N=25),allofthemhad severeerectiledysfunction(score≤6)(Fig.1).

Among these 45 patients, the EVAR group was mainly constituted by patients with moderate to severe sexual

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Figure2. a.Erectionscoreinthelaparoscopicgroup;b.IIEFscoreinthelaparoscopicgroup.

dysfunction(N=11/15,73.3%)whereasinthelaparoscopic group52.4%ofpatients(N=11/21)hadnosexualdysfunc- tion(classIII).

On the population ﬁnally included (N=21), 8 patients reportednosexualintercourse(6thquestionfromtheIIEF- 15)during the 4-weeks preoperative period[N=5 (31.2%) fromthelaparoscopicgroupandN=3(60%)fromtheEVAR group],leadingtoarateof61.9%ofsexuallyactivepatients beforesurgery.Amongthem,thefrequencyofsexualinter- courseswas2—3/monthpreoperativelyinthelaparoscopic groupand0—1/monthintheEVARgroup.

Atbaseline,themeanIIEFscoreanderectilescorewere signiﬁcantlydifferentinthe2groupswithbaselinemoderate toseveredysfunctionintheEVARgroup(respectively39/75 and16.3/30inthelaparoscopicgroup,and21/75and8/30 intheEVARgroup).

Laparoscopic group postoperative sexual assessment

In the laparoscopic group, no statistical difference was foundin theerectilefunction at12 months(P=0.83).We observedaslightbutnotsigniﬁcantglobalsexualfunction improvement compared to the baseline preoperative IIEF score(P=0.74)(Fig.2aandb).

NosigniﬁcantdifferencewasdetectedbetweenIIEFclass at M12andbeforesurgery (P=0.93)(Fig.3). At baseline, erection score of 16.3 reveals mild to moderate erectile dysfunction,andofthe16patients,7(43.8%)weretaking medicine which can inﬂuence erectile function (benzodiazepines,antidepressanttreatmentorbeta-blockers).

Regarding ejaculations troubles in the laparoscopic group, 3 patients had preoperative transient ejaculations troublesandreportedpersistenceoftheirtroublesat M12 (hypospermia,anejaculationorretrogradeejaculation).On the 13 patients with no preoperative troubles, 8 (61.5%) reportedmajorejaculation troubles(6anejaculationsand 2retrogradeejaculations),appearingat3monthsandper- sistent at 12 months, with only one improvement. Three otherpatients (23%)reported theonsetof minortroubles ofejaculations(hypospermia).

Figure3. IIEFscoreinthelaparoscopicgroup.

EVAR group postoperative sexual assessment

IntheEVARgroup,patientshadmoderateerectiledysfunc- tion at baseline (mean score 8/30) and moderate global sexual dysfunctionat baseline (meanscore 21/75) with2 patients (40%) taking medicine which can inﬂuence erectilefunction(benzodiazepines,antidepressanttreatmentor beta-blockers).

Erectile function and global sexual function were not differentat12monthscomparedtobaseline(respectively p=0.29 and 0.26). One patient reported transient ejaculation troubles starting in the preoperative period with persistent anejaculation appearingat 3months. Noother patientfromthisEVARgroupdescribedejaculationtroubles or theydidnothave erection strongenough toreachand evaluateejaculation.

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Discussion

We conducted amonocentric prospectivestudy on sexual function andejaculation afterAAA repair. Ourunit is the onlyonetoofferregularlyallthetechniquescurrentlyavail- able to treat AAA (OR, laparoscopic repair and EVAR). It seemedinterestingtoustoevaluatesexualdysfunctionsof suchtechniques.Thereisapaucityofdataonsexualresults whereaspreservationofhypogastricpermeabilityisahigh subjectofdiscussioninvascularsurgery,especiallysincethe endovascularera[21,22].

Despitetheprospectivedesignofthestudy,two-thirdof patientseligiblerefusedtoparticipate,mainlybecauseof nobaselinesexualinterestorbaselinesexualimpairment.

Moreover,tolimitinclusionbias,weexcludedpatientswith historyofprostaticsurgery,sinceradicalprostatectomyfor cancerinduces anejaculationandcan setofferectiledys- function,andsincetransurethralresectionoftheprostate forhyperplasiacaninduceretrogradeejaculation.

Amongthepatientsincluded,almosttwo-thirdpresented baselinesexualdysfunction.At12months,erectilefunction andglobalsexualfunctionwereslightlyimprovedintheLAS groupandmostpatientshadonsetofejaculationtroubles comparedtoEVARgroup.InEVARgroup,patientswereolder with more cardio-vascular issues due to our algorithm of choice based on the surgical risk and the anatomic EVAR criteria, leading to high baseline sexual dysfunction and withoutsigniﬁcantimprovementat12months.Thisdiffer- enceinageandcomorbiditiesissimilartoresultsreported inliteraturebetweenORandEVAR[1].

Sexual function results in LAS group

Alteration in sexual function in men is well documented following OR for AAA during the ﬁrst postoperative year witha prevalence of 7.4to79% of postoperative erectile dysfunction[22—25].Thereasonsforthismaybetheinter- ferencewiththeautonomicplexus locatedinfrontof the aorticbifurcationaswellaswiththeinternaliliaccircula- tion.Aorto-iliacsurgerycan leadtosexualdysfunctionby differentmechanismssuchasbilateralhypogastricligation orhypogastricembolization,neurogenicinjuriesandaortic cross-clamping. Indeed,dissection along the anterior sur- faceof theaorta andover theleftiliac arterycan injure theneural bundles running fromthe spinalcord (superior hypogastricplexusandinferiormesentericplexus).

NoreportsaddressingtheimpactofLASonsexualfunc- tionhave been published.Inlaparoscopy-assistedstudies, Alimi etal. found 13% of sexual troubles includingretro- grade ejaculation and dyserection in this population [8].

Recently,Verouxetal.reportedtheresults ofsexualdys- functionafterEVARorhand-assistedLAS,withsimilarresults inbothgroupsregardingsexualfunctionandonsetofretro- gradeejaculationinonly 6%ofhand-assistedLASpatients [6].

In our prospective study, the baseline mean erection score of patients from the LAS group revealed a mild to moderateerectiledysfunctionwithaslightimprovementat 12monthswithnosigniﬁcantdifference.Theseresultsare similartopreviousstudiesreportingapreoperativerateof erectile dysfunctionfrom10.3% to66%in patients under- going OR for AAA [22]. In our study, no patient reported

theonsetofdenovo dyserectionaftersurgery (evaluated from20%to83%in literature,[22])eveninthesub-group ofpatientswithunilateral iliacandhypogastricthrombus.

Ofnote,in literature,unilateral hypogastricarteryocclu- sioncanresultinnewsexualdysfunctioninapproximately 10% of patients [22], and this increases signiﬁcantly with bilateralhypogastricocclusion[8,26].

We pointed out a high rate of ejaculation troubles in theLASgroupwith46.1%patientsreportinganejaculation, whichishigherthantheincidencedescribedinliteraturefor hand-assistedlaparoscopy[6],maybeduetotheprospective designofourstudyandthehighnumberofspeciﬁcquestions onejaculationtroubles.

Theseresultssuggestthatevenifnervescanbeindivid- ualizedduringLAS,theanatomyoftheAAAdoesnotalways allowpreservingautonomicnervesresponsibleforejacula- tion.Even in preservingautonomic nerves, some patients maydevelop ejaculation troubles whichcan be explained by postoperative ﬁbrosis or hematoma around the sexual nervousbundles, leadingtotheir inﬂammation.Moreover, we maywonderif theuse of devicesusing hybrid energy technology,suchasThunderbeat —ultrasonar andbipolar energy—(Olympus^®),increasestheriskofnervedamageby closecontact.

Impairment of sexual function in EVAR group

EVARdoesnotinvolvedissectionaroundtheaortaandthus maynot interfere withthe autonomic supply as reported by some authors [6] and with results showing no sexual deterioration in comparison to OR in studies using retro- spectiveapproach[1,11].However,aftereachEVARrepair, therecan bemany inﬂammatorychanges due to aneuris- malsacthrombosis[2].Thisphenomenonalsomayexplain sexual troubles observed after EVAR: although it doesn’t involvenervedissection,aortic endoprosthesisinduces an inﬂammatoryreactionaroundtheaorta,whichcaninvolve pre-aorticnervessecondarily.

SomeauthorsreportedthatafterEVAR,patientsrecov- eredtopreoperativesexuallevelsfasterthanafterOR[9].

Ontheotherhand,otherauthorsreportedsigniﬁcantimpair- ment on overall satisfaction and sexual intercourse after EVAR[5,27]asinourstudy,maybeduetothebelongingof thesepatientstoahigh-riskgroupofpatients withapoor baselinesexualfunction.

Aprospectivestudycomparingthesexualfunctionafter EVAR and OR demonstrated a decrease of sexual activity in both groups but only a significant impairment in qual- ityoferectioninpatientssexuallyactiveoftheEVARgroup [5]. In this study, the patients from the EVAR group pre- sentedsignificantlylesscoronaryarterydisease,compared toourstudy(80%ofpatientsintheEVARgroup).Inanother prospectivestudy,EVARwascomparedtohand-assistedLAS andtotalscoreevaluation oftheIIEF testshowednosta- tistical difference between groups [6], and similarly only 16% from their EVAR group presented history of coronary arterydisease.Inpatientswithcoronaryarterydisease,the prevalence of erectile dysfunction has been estimated in literaturebetween47%and75%[22].Itisnoteworthythat erectiledysfunctionhasbeenidentifiedasan independent risk factor for deathfollowing AAA repair, leading tothe conclusionthatpre-operativeerectilefunctionwouldbeof

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interestasaprognosticfactor inpatients undergoingAAA surgicalrepair[28].

Baseline status in EVAR group

Inourstudy,themain resultwasthebaseline sexualdys- functionwhichprevailedintheEVARgroupandwhichcan explainthehighrateorrefusalofinclusioninthestudy(52%

ofrefusalarisesfromtheEVARgroup,N=41).Theseresults arealmostcomparabletothosereportedbyotherauthors [1,5,22,25].

Moreover, in this group, most patients who ﬁlled the surveybeforesurgerypresentedseverebaselinesexualdys- function.Mostofthemdidnotansweredthequestionnaire at 3, 6 and 12 monthsand were then excluded fromthe study.These observations are correlated with the proﬁle ofolderpatientsundergoingEVARwithpatientspresenting morecardio-vascularissuesinourpopulationandmoreoften pre-operativesexualdysfunction.

Overall,preoperative sexualdysfunctionmayleadtoa decreaseinsexualinterest. On theother hand,it isdifﬁ- culttoknowwhetherthepatientswholackedinteresthad a change in the physical ability to achieve erection and orgasm.Finally,somepatientscouldstate thatthevascu- larsurgeryitselfismostworryingthatthesexualfunction, whichcouldbeconsideredasunimportantanditwouldbe interestingtoinvestigatethepotentialimpactofstressand anxietyinpatientsundergoingAAAsurgicalrepair.

Limitations

Our study is monocentric and the rate of inclusion is low.Indeed,despitea prospectiveconsecutivedesign,we includedonly17% ofpatientsfromtheeligiblepopulation which is a low response rate comparing to other studies[5,6]. However,76.2%of thelaparoscopic patientsdid answer to the postoperative questionnaire, due to their belongingtoagoodriskgroupofpatients,withlesscomor- bidities than EVAR patients. These results can also be explainedby low sexual interest beforesurgery in vascu- larpatientsandintheﬁrstpostoperativeyear.Indeed,some authorsreportedupto40%ofpatientsundergoingoperation forAAAwhofeltsomeanxietyofhavingsexbeforesurgery [5].Andtheseresultsdecreasedto7%afteroneyear,lead- ingtorepeatansweringofthequestionnairesafteroneyear toraisesexualinterestinpatients.

Inourstudy,theIIEF-15questionnaireisbasedonpatients self-reportedexperiencesoftheirsexualfunctionandnoton anyspeciﬁcphysiologicalmeasurementsandthusdoesnot indicatewhichtypeofinjuryisimplicated(distalcollateral iliacembolization, crucialnerves damage,useof medica- tionsorchangeintheirmentalstatus).

Finally,wedecidedtoexcludewomeninourstudysince thenumberofwomeninourcohortwasinsufﬁcient.Butit seemsimportant,inalaterstudy,tofurtherfocusalsoon theeffectsofLAS andEVARonwomen’ssexualfunctions, sincethe prevalence of AAA in women mayincrease [29]

andsincethereissmallamountofpublisheddata[5,29,30].

Conclusion

Laparoscopic AAA repair provides no onset of erectile or sexualdysfunction.Forpatientsdevelopingsexualtroubles afterlaparoscopic AAArepair,it isimportant tonote that we observed a global sexual improvement at 12 months after surgery. Ejaculations troubles arefrequent and persistent after laparoscopic repair. This study suggests that baselinesexualdysfunctionisfrequentinpatientsundergo- ingrepairofAAA,particularlyinpatientsundergoingEVAR whopresentwithmorecomorbidities.Mostpatientseligible forEVARhadsevereerectileandsexualdysfunctionatbase- lineandshowednoimprovementat1year,withnoonsetof ejaculationstroubles.

Appendix A. Appendix 1

Ejaculationquestions.

1. Over the past 4 weeks before surgery, did you experiment ejaculationtroubles likean absenceof sperm emission?

2. Sincesurgery, did you experiment ejaculation troubles?

3.Ifyouexperimentedejaculationtroublessincesurgery, wasitanabsenceofspermemission?

4.Ifyouexperimentedejaculationtroublessincesurgery, wasitamodiﬁcationinthevolumeofsperm?

5.Sincesurgery,didyouexperimentmodiﬁcationofthe consistenceofurines?

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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