Sexual dysfunction after open abdominal aortic aneurysm repair: 16 years’ experience in a quaternary center and literature review

Schmid, Bruno Pagnin; Muce, Marcelo Vezzi; Bocos, Rodrigo Gonzalez; Menezes, Fábio Hüsemann

doi:10.1590/1677-5449.202301352

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ORIGINAL ARTICLE • J. Vasc. Bras. 23 • 2024 • https://doi.org/10.1590/1677-5449.202301352 linkcopy

Sexual dysfunction after open abdominal aortic aneurysm repair: 16 years’ experience in a quaternary center and literature review

Disfunção sexual após correção aberta de aneurisma da aorta abdominal: 16 anos de experiência em um centro quaternário e revisão da literatura

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background Open abdominal aortic aneurysm (AAA) repair can lead to sexual dysfunction (SD) in men.

Objectives To determine the prevalence of SD following open AAA repair, explore whether surgical techniques for aortic reconstruction can have a differential impact on the occurrence of SD, and summarize current knowledge in this field.

Methods Retrospective review of 100 patients submitted to open AAA repair between 1995 and 2010 in a quaternary center. Sexual dysfunction was assessed according to questions from the modified International Index of Erectile Function (IIEF), considering the condition before surgical repair and 3 months after surgery. The chi-square test, Fisher’s exact test, and Student’s t test were used for statistical analyses.

Results 100 patients were included (mean age = 66.4 years old). Normal sexual activity, no sexual activity, erectile dysfunction, and retrograde ejaculation with preserved erectile function were found in 36%, 21%, 18%, and 24% of patients, respectively. The group of patients with no sexual activity was older (mean age = 72.3 years old vs 64.5 years old, p < 0.001). Erectile dysfunction prevalence was higher in patients submitted to an aorto-bifemoral bypass (p = 0.032). Retrograde ejaculation was more frequent in patients submitted to an aorto-aortic bypass (p = 0.007).

Conclusions Sexual function is a frequent condition intimately associated with the aortic reconstruction technique. The literature review found contradictory results regarding whether the endovascular approach is protective compared with open repair, but clearly demonstrated the importance of techniques targeting preservation of the internal iliac artery and the superior hypogastric plexus.

Keywords:
aneurysm; erectile dysfunction; ejaculation

Questions from the International Index of Erectile Function
1. How often were you able to get an erection during sexual activity?
2. When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
4. How much have you enjoyed sexual intercourse?
5. When you had sexual stimulation or intercourse, how often did you ejaculate?
6. How satisfied have you been with your overall sex life?

	No sexual activity (Total = 21)	Normal activity (Total = 34)	ED (Total = 18)	RE (Total = 27)
Aorto-aortic (Total=26)/ percentage of group	4/ 15.4%	7/ 30%	2/ 7.7%	13/ 50%
Aorto-biiliac (Total=50)/ percentage of group	12/ 24%	21/ 42%	6/ 12%	11/ 22%
Aorto-monoiliac (Total=14)/ percentage of group	2/ 14.3%	6/ 42.86%	5/ 35.71%	1/ 7.14%
Aorto-bifemoral (Total=10)/ percentage of group	3/ 30%	0/ 0%	5/ 50%	2/ 20%

Sexual status	Age in years (mean)	No sexual activity vs. other groups (mean age/number of patients)	p-value *
No activity (Total = 21)	72.3	72.3 years (21 patients)	< 0.001
Normal activity (Total = 34)	63.9	64.5 years (79 patients)
ED (Total = 18)	63.7
RE (Total = 27)	65.8

Author	Study Design	Number of patients/studies	Main results
Kalteis et al.¹⁷	Retrospective	106 (82 EVAR vs. 24 EVAR with IIA embolization)	EVAR with IIA embolization was associated with new onset ED (17.3% vs. 42.9%; p = 0.043).
	Single-center
	EVAR vs. EVAR with IIA embolization
Majd et al.¹⁸	Prospective	100 (70 EVAR vs 30 OR)	Increase of ED in both groups (53.3.% OR vs. 58.8% EVAR, p = 0.412).
	Single-center
	OR vs. EVAR
Machado et al.¹⁹	Retrospective	171	ED was more frequent in the elderly group (p<0.05)
	Single-center
	EVAR (patients were divided according to age groups < 70, 70-80, and > 80 years)
Shin et al.²⁰	Retrospective	14	No cases of ED
	Single-center
	EVAR (bifurcated-bifurcated repair)
Bosanquet et al.²¹	Meta-analysis	2671	Higher rates of ED after coiling (11.6% Coils vs. 3.03% Plugs)
Bosanquet et al.²¹	EVAR (coils vs. plugs)	2671
Regnier et al.²²	Meta-analysis	29 studies	Post-operative ED prevalence= (OR 7.4 to 79% vs. EVAR 4.7 to 82%). Post-operative RE prevalence= (OR 3.3 to 9% vs. Laparoscopic repair 6 to 6.6%)
Kudo et al.²³	Narrative Review	NR	Emphasized the importance of preservation of blood flow from IIA and of adequate preservation of the superior hypogastric plexus and lumbar splanchnic nerves
Gallitto et al.¹⁶	Retrospective	115 (58 EVAR, 57 OR)	RE occurred more often in OR patients (31%) than in EVAR patients (2%) (P = 0.001).
	Single-center
	EVAR vs. OR
van Schaik et al.²⁴	A questionnaire-based study aiming to analyze care for sexual health by medical specialists	101	A gap exists in knowledge of pathophysiology and anatomy. Vascular surgeons lack sexual counseling skills
Dariane et al.²⁵	Prospective. Multicenter.	25 (8 EVAR/ 13 Laparoscopic repair)	RE is frequent in both groups (Laparoscopic=61.5%/ EVAR=12.5%) Laparoscopic AAA repair caused no onset of ED or SD
Dariane et al.²⁵	EVAR vs. Laparoscopic repair	25 (8 EVAR/ 13 Laparoscopic repair)
Schmid et al. (This study)	Retrospective	100	The aorto-bifemoral configuration was the technique most associated with ED (p=0.03) and the aorto-aortic configuration was the technique most associated with RE (p= 0.01). OR is associated with 64% of SD, 24% of RE, 18% of ED, and 21% of no sexual activity
	Single-center
	OR (aorto-bifemoral bypass vs. Aorto-aortic vs. aorto-biiliac vs. aorto-monoiliac)

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[1] ED = erectile dysfunction, RE = retrograde ejaculation.