XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
Vascular OnlineFirst, published on March 10, 2015 as doi:10.1177/1708538115577290
Original Article
Impairment of erectile function after elective repair of abdominal aortic aneurysm
Vascular 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538115577290 vas.sagepub.com
P Majd, W Ahmad, Th Luebke, M Gawenda and J Brunkwall
Abstract The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm. Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year. The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction (p ¼ 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well. The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant.
Keywords Erectile dysfunction, endovascular repair, open repair, abdominal aortic aneurysm, KEED
Introduction Penile erection is to be understood as a neurovascular event involving the somatic and autonomic (sympathetic and parasympathetic) nerve fibers.1,2 The sympathetic fibres have an inhibitory effect, whereas the parasympathetic fibres are responsible for the erection and its maintenance. An increase in the arterial inflow supplied through the internal iliac arteries into the corpora cavernosa, the relaxation of smooth muscle structures and an increase in the venous outflow resistance by compression of the venous plexus beneath the tunica albuginea are in a complex interplay of erection.3,4 Based on the National Institutes of Health consensus, erectile dysfunction (ED) is defined as the inability to achieve and maintain a penile erection for adequate sexual intercourse.5 The effect of dissection of the efferent sympathetic pathway and hypogastric plexus during open aneurysm repair and the negative influence on sexual function and retrograde ejaculation has previously been well reported.6–9 Endovascular aneurysm exclusion can also cause a vascular ED by intentional or inadvertent over-stenting or embolization of the
internal iliac artery (IIA) with subsequent disruption of blood flow. The first prospective study on 21 open repair (OR) and 21 endovascular aneurysm repair (EVAR) patients showed an impaired sexual function in the open group but not in the EVAR group after one month, but thereafter there was no difference between the groups.10 A prospective study from the Netherlands on 77 EVAR and 76 OR patients described an impaired erectile function after EVAR as well as after OR in the early postoperative period, but after three months both groups reached the preoperative condition.11 Another prospective study from Sweden reported that following operation sexual interest and ability were decreased in both groups.12 Numerous other studies are retrospective with their known drawbacks.
Department of Vascular and Endovascular Surgery, University of Cologne, Germany Corresponding author: P Majd, Department of Vascular and Endovascular Surgery, University of Cologne, Germany. Email: [email protected]
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
2
Vascular 0(0)
The purpose of the present study was to prospectively capture the prevalence of ED in male patients with an abdominal aortic aneurysm (AAA) needing surgical treatment using a standardized questionnaire and to compare the functional change one year after EVAR or OR.
Methods Between April 2009 and December 2011, cohorts of consecutively admitted patients with elective AAA repair were invited to participate in the present study. The inclusion criteria were asymptomatic infrarenal AAA, male gender, no language barrier, good mental condition and informed consent after detailed information and finally interest in sex. Patients with ruptured aneurysm involving the renal arteries or thoracoabdominal aneurysms as well as duplicate entries (by redo-operation because of aneurysm) were excluded from the study. Imaging with computed tomographic angiography assessed the aneurysmal morphology. The choice of endovascular or open surgery was made after reviewing all the data and was based on mostly on the morphology and feasibility of EVAR in every patient together with the patient’s desire and not on the degree of general operative risk. In the group of OR, we have differentiated in the analysis between the patients who have had bifurcated prosthesis and those with tube graft in order to evaluate the effect of extended dissection of iliacs on the postoperative ED. The erectile function was evaluated by using a validated KEED questionnaire (Cologne assessment of ED).13,14 The KEED, developed and validated in Germany, is a questionnaire to identify symptoms of ED. Eight questions assess the baseline characteristics; two questions requested information on sexual desire and its frequency. The other six questions, with fivestage response, provide information on the erectile function including two questions to validate the answers of patients (questions 14 and 15). For each question, a maximum of five points can be achieved. By adding the columns, the ED total score can be calculated where 30 is the highest score and 6 the lowest (Appendices 1 and 2). The questionnaire is with a specificity of 0.93 and a sensitivity of 0.97 suitable for testing erectile function, and thus it has been used in several epidemiological studies. An ED total score over 17 is defined as presence of ED. Patients were admitted the day prior to surgery for both groups. This is a normal standard in our centre for performing all the needed preoperative preparation. All patients filled out the questionnaire preoperatively
privately on the day of admission, but when a patient has had a question about the questionnaire, this has been answered by an investigator one day before surgery and one year after the operation at the annual work up. All patients have themselves completed the questionnaire after one year. We were able to capture the morbidity, new risk factors and changes in medication after a year. In the EVAR group, follow-up was performed half yearly with computed tomographic scans as well as physical examination, and the open group was monitored with duplex ultrasonography and physical examination.
Statistical analysis Continuous data are expressed as mean standard deviation and categorical variables as number of patients and percentages. For comparison of categorical data, the frequencies were compared by two-tailed 2 test with a Yates correction, or Fishers exact test, when appropriate. Continuous variables were compared with the Student’s t test. All statistical analyses were performed using computed software (SPSS version 21).
Ethical considerations The study protocol was approved by the EthicCommission of the Medicine Faculty at Cologne University according to the Helsinki Declaration 2000/2004. Every patient was well informed about this study and has given his written consent.
Results During this period, a total number of 189 patients with elective AAA repair were admitted. Figure 1 shows the flow chart of study patients. Twenty-seven were women and consequently excluded from the study. Within the remaining groups of 162 men, only 135 patients met the inclusion criteria (asymptomatic infrarenal AAA, male gender, no language barrier, good mental condition and informed consent after detailed information) and were enrolled in the present study. All patients completed the questionnaire, but 35 of these 135 patients had no interest in sexual activity. Thus, with respect to the inclusion criterion (interest in sex), they were excluded from further analysis. The mean age of these 35 patients was 79 4.1 years. Finally, 100 patients having either EVAR (n ¼ 70; mean age: 70 7.9 years) or OR (n ¼ 30; mean age: 68 6.5 years) remained for investigation. The mean age of the 35 patients with no interest in sexual activity was clearly higher than that of the remaining 100 patients
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
Majd et al.
3
Figure 1. Flow chart of study patients. OR: open repair; EVAR: endovascular aneurysm repair.
(p ¼ 0.003). All patients completed the questionnaire preoperatively, and thus the response was 100% in both groups. The baseline characteristics and risk factors are shown in Table 1. There was no significant difference between the EVAR and OR group with respect to the risk factors, comorbidities and medication, except for the aneurysm diameter, that was significantly greater in the OR than in the EVAR group. In the EVAR group, 68 patients received an aortobi-iliac endograft, five of whom got an iliac side branch in the IIA, and three received EVAR with concomitant unilateral hypogastric artery occlusion. One patient got an aorto-aortic tube graft and one aorto-uni-iliacal graft with femoro-femoral crossover bypass. In the OR group, 15 patients received an aortoaortic tube graft, 12 an aorto-bi-iliac graft and 3 an aorto-bi-femoral prosthesis. To preserve the innervation of the pelvis (the vegetative plexus), the operative preparation of the abdominal aorta was routinely performed transperitoneal and only from the right side of the aorta. After one year, a total number of 98 patients have completed the questionnaire. Two patients in the EVAR group deceased during the first year due to malignancy and thus could not complete the questionnaire. Other patients reached the one-year follow-up. Two patients in the open group and one patient in the EVAR group had a cerebrovascular insult (transit
ischemic attack (TIA)), and one patient in the open group had a myocardial infarction. One patient in the EVAR group needed more hypertensive medication. There was no change in the medications that impair the erectile function postoperatively. A total of nine patients had an occlusion of the IIA. Four (44.4%) of those patients have reported ED preoperatively. Thirty-four (37.4%) of the remaining 91 patients without an occlusion of the iliac artery reported ED preoperatively. The difference was not statistically significant (p ¼ 0.727). The hypogastric arteries were fully patent without significant stenosis before open surgery in 27 of the 30 OR patients and in 64 of the 70 EVAR patients. Postoperatively three patients in the EVAR group had unilateral occlusion of the IIA out of whom two had preoperative ED and the third one did not develop ED postoperatively. There was no new incidence of occlusion of the IIA in the OR group. Table 2 shows the change in ED over time. Preoperatively, the total number of patients with ED was 38 (38%). As shown, the increase in the number of patients with ED was 8 (26.6%) to 16 (53.3%) in the OR group vs. 30 (42.6%) to 40 (58.8%) in the EVAR group. Postoperatively, at one year after surgery, the number of patients with new incidence of ED was 8 in the open surgical group (three patients with new incidence of ED in the group with bifurcated graft and in four patients with tube graft, but the increase of ED
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
4
Vascular 0(0)
EVAR (n ¼ 70)
OR (n ¼ 30)
70 7.9 56.3 8.1 12 (17.1) 10 (83.3) 2 (16.6) 61 (87.1) 30 (49.2) 31 (50.8) 31 (44.3) 8 (25.8) 9 (29.0) 20 (28.6)
68 6.5 61.3 9.3 5 (16.7) 4 (80.0) 1 (20.0) 28 (93.3) 16 (57.1) 12 (42.9) 13 (43.3) 3 (23.1) 4 (30.8) 9 (30.0)
49 (70.0)
25 (83.3)
0.166
groups is shown (the OR and the EVAR patients), but the increase between both groups was not statistically significant. All of the six patients over 80 years belong to the EVAR group, of whom five had already ED. In addition, the mean value of ED scores postoperatively has increased by three points in both groups but without significant difference between OR and EVAR. The mean value of ED score was 16 5.1 in the OR (30 patients) vs. 17 6.1 in the EVAR (68 patients) without significant difference (p ¼ 0.43). The mean value of ED score increased postoperatively to 19 6.8 in the OR and 20 6.5 in the EVAR (p ¼ 0.59). Also patients without a preoperative ED showed an increase of the mean ED score during follow-up. In this case, the mean value of the ED score was 13 3.4 in the OR group (22 patients) vs. 12 3.2 in the EVAR group (38 patients) without significant difference (p ¼ 0.20). The mean value of the ED score increased postoperatively to 16.8 6.0 in the OR and 15.7 5.1 in the EVAR groups (p ¼ 0.48).
24 (43.4)
12 40.0)
0.587
Discussion
Table 1. Baseline characteristics according to age, risk factors and medication with a potential influence on erectile function.
Mean age (years) Aneurysm size (mm) Diabetes Controlled by oral agents Insulin controlled Hypertension Needed single drug Needed 2 drugs or more Coronary artery disease Myocardial infarction Coronary revascularization Chronic obstructive lung disease Tobacco use (Current or smoked in last 10 years) Renal disease (GFR less than 60 ml/min) Hyperlipidaemia Peripheral vascular disease Statin Beta-blocker Calcium channel-blocker Diuretics
46 13 40 46 14 19
(65.7) (18.6) (57.1) (65.7) (20.0) (17.1)
22 9 19 21 5 6
(73.3) (30.0) (63.3) (70.0) (16.7) (20.0)
p 0.339 0.009 0.954
0.497
0.930
0.886
0.465 0.208 0.566 0.678 0.698 0.452
Data are presented as n(%) for categorical variables and mean standard deviation for continuous variables.
Table 2. Number and percent of erectile dysfunction before and one year after surgery in both group. The difference between the groups was no statistically significant (p ¼ 0.412). Before surgery
OR EVAR Total
One year after surgery
Number (%)
n
Number (%)
n
8 (26.6) 30 (42.6) 38 (38.0)
30 70 100
16 (53.3) 40 (58.8) 56 (57.1)
30 68 98
EVAR: endovascular aneurysm repair; OR: open repair.
between both graft groups was not significant) and 10 patients in the EVAR group. There was no statistically significant difference between OR and EVAR groups in order of new incidence of ED (p ¼ 0.412). Table 3 shows ED pre- and postoperatively in different age decades. The most operated patients were between 61 and 80 years, and after one year an increase of ED in both
With increasing age the ED increases, which has been shown in several epidemiological studies. Kinsey15 has reported on the correlation between age and ED, increasing between 25 and 80 years from
(VAS)
[1–7] [PREPRINTER stage]
Vascular OnlineFirst, published on March 10, 2015 as doi:10.1177/1708538115577290
Original Article
Impairment of erectile function after elective repair of abdominal aortic aneurysm
Vascular 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538115577290 vas.sagepub.com
P Majd, W Ahmad, Th Luebke, M Gawenda and J Brunkwall
Abstract The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm. Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year. The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction (p ¼ 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well. The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant.
Keywords Erectile dysfunction, endovascular repair, open repair, abdominal aortic aneurysm, KEED
Introduction Penile erection is to be understood as a neurovascular event involving the somatic and autonomic (sympathetic and parasympathetic) nerve fibers.1,2 The sympathetic fibres have an inhibitory effect, whereas the parasympathetic fibres are responsible for the erection and its maintenance. An increase in the arterial inflow supplied through the internal iliac arteries into the corpora cavernosa, the relaxation of smooth muscle structures and an increase in the venous outflow resistance by compression of the venous plexus beneath the tunica albuginea are in a complex interplay of erection.3,4 Based on the National Institutes of Health consensus, erectile dysfunction (ED) is defined as the inability to achieve and maintain a penile erection for adequate sexual intercourse.5 The effect of dissection of the efferent sympathetic pathway and hypogastric plexus during open aneurysm repair and the negative influence on sexual function and retrograde ejaculation has previously been well reported.6–9 Endovascular aneurysm exclusion can also cause a vascular ED by intentional or inadvertent over-stenting or embolization of the
internal iliac artery (IIA) with subsequent disruption of blood flow. The first prospective study on 21 open repair (OR) and 21 endovascular aneurysm repair (EVAR) patients showed an impaired sexual function in the open group but not in the EVAR group after one month, but thereafter there was no difference between the groups.10 A prospective study from the Netherlands on 77 EVAR and 76 OR patients described an impaired erectile function after EVAR as well as after OR in the early postoperative period, but after three months both groups reached the preoperative condition.11 Another prospective study from Sweden reported that following operation sexual interest and ability were decreased in both groups.12 Numerous other studies are retrospective with their known drawbacks.
Department of Vascular and Endovascular Surgery, University of Cologne, Germany Corresponding author: P Majd, Department of Vascular and Endovascular Surgery, University of Cologne, Germany. Email: [email protected]
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
2
Vascular 0(0)
The purpose of the present study was to prospectively capture the prevalence of ED in male patients with an abdominal aortic aneurysm (AAA) needing surgical treatment using a standardized questionnaire and to compare the functional change one year after EVAR or OR.
Methods Between April 2009 and December 2011, cohorts of consecutively admitted patients with elective AAA repair were invited to participate in the present study. The inclusion criteria were asymptomatic infrarenal AAA, male gender, no language barrier, good mental condition and informed consent after detailed information and finally interest in sex. Patients with ruptured aneurysm involving the renal arteries or thoracoabdominal aneurysms as well as duplicate entries (by redo-operation because of aneurysm) were excluded from the study. Imaging with computed tomographic angiography assessed the aneurysmal morphology. The choice of endovascular or open surgery was made after reviewing all the data and was based on mostly on the morphology and feasibility of EVAR in every patient together with the patient’s desire and not on the degree of general operative risk. In the group of OR, we have differentiated in the analysis between the patients who have had bifurcated prosthesis and those with tube graft in order to evaluate the effect of extended dissection of iliacs on the postoperative ED. The erectile function was evaluated by using a validated KEED questionnaire (Cologne assessment of ED).13,14 The KEED, developed and validated in Germany, is a questionnaire to identify symptoms of ED. Eight questions assess the baseline characteristics; two questions requested information on sexual desire and its frequency. The other six questions, with fivestage response, provide information on the erectile function including two questions to validate the answers of patients (questions 14 and 15). For each question, a maximum of five points can be achieved. By adding the columns, the ED total score can be calculated where 30 is the highest score and 6 the lowest (Appendices 1 and 2). The questionnaire is with a specificity of 0.93 and a sensitivity of 0.97 suitable for testing erectile function, and thus it has been used in several epidemiological studies. An ED total score over 17 is defined as presence of ED. Patients were admitted the day prior to surgery for both groups. This is a normal standard in our centre for performing all the needed preoperative preparation. All patients filled out the questionnaire preoperatively
privately on the day of admission, but when a patient has had a question about the questionnaire, this has been answered by an investigator one day before surgery and one year after the operation at the annual work up. All patients have themselves completed the questionnaire after one year. We were able to capture the morbidity, new risk factors and changes in medication after a year. In the EVAR group, follow-up was performed half yearly with computed tomographic scans as well as physical examination, and the open group was monitored with duplex ultrasonography and physical examination.
Statistical analysis Continuous data are expressed as mean standard deviation and categorical variables as number of patients and percentages. For comparison of categorical data, the frequencies were compared by two-tailed 2 test with a Yates correction, or Fishers exact test, when appropriate. Continuous variables were compared with the Student’s t test. All statistical analyses were performed using computed software (SPSS version 21).
Ethical considerations The study protocol was approved by the EthicCommission of the Medicine Faculty at Cologne University according to the Helsinki Declaration 2000/2004. Every patient was well informed about this study and has given his written consent.
Results During this period, a total number of 189 patients with elective AAA repair were admitted. Figure 1 shows the flow chart of study patients. Twenty-seven were women and consequently excluded from the study. Within the remaining groups of 162 men, only 135 patients met the inclusion criteria (asymptomatic infrarenal AAA, male gender, no language barrier, good mental condition and informed consent after detailed information) and were enrolled in the present study. All patients completed the questionnaire, but 35 of these 135 patients had no interest in sexual activity. Thus, with respect to the inclusion criterion (interest in sex), they were excluded from further analysis. The mean age of these 35 patients was 79 4.1 years. Finally, 100 patients having either EVAR (n ¼ 70; mean age: 70 7.9 years) or OR (n ¼ 30; mean age: 68 6.5 years) remained for investigation. The mean age of the 35 patients with no interest in sexual activity was clearly higher than that of the remaining 100 patients
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
Majd et al.
3
Figure 1. Flow chart of study patients. OR: open repair; EVAR: endovascular aneurysm repair.
(p ¼ 0.003). All patients completed the questionnaire preoperatively, and thus the response was 100% in both groups. The baseline characteristics and risk factors are shown in Table 1. There was no significant difference between the EVAR and OR group with respect to the risk factors, comorbidities and medication, except for the aneurysm diameter, that was significantly greater in the OR than in the EVAR group. In the EVAR group, 68 patients received an aortobi-iliac endograft, five of whom got an iliac side branch in the IIA, and three received EVAR with concomitant unilateral hypogastric artery occlusion. One patient got an aorto-aortic tube graft and one aorto-uni-iliacal graft with femoro-femoral crossover bypass. In the OR group, 15 patients received an aortoaortic tube graft, 12 an aorto-bi-iliac graft and 3 an aorto-bi-femoral prosthesis. To preserve the innervation of the pelvis (the vegetative plexus), the operative preparation of the abdominal aorta was routinely performed transperitoneal and only from the right side of the aorta. After one year, a total number of 98 patients have completed the questionnaire. Two patients in the EVAR group deceased during the first year due to malignancy and thus could not complete the questionnaire. Other patients reached the one-year follow-up. Two patients in the open group and one patient in the EVAR group had a cerebrovascular insult (transit
ischemic attack (TIA)), and one patient in the open group had a myocardial infarction. One patient in the EVAR group needed more hypertensive medication. There was no change in the medications that impair the erectile function postoperatively. A total of nine patients had an occlusion of the IIA. Four (44.4%) of those patients have reported ED preoperatively. Thirty-four (37.4%) of the remaining 91 patients without an occlusion of the iliac artery reported ED preoperatively. The difference was not statistically significant (p ¼ 0.727). The hypogastric arteries were fully patent without significant stenosis before open surgery in 27 of the 30 OR patients and in 64 of the 70 EVAR patients. Postoperatively three patients in the EVAR group had unilateral occlusion of the IIA out of whom two had preoperative ED and the third one did not develop ED postoperatively. There was no new incidence of occlusion of the IIA in the OR group. Table 2 shows the change in ED over time. Preoperatively, the total number of patients with ED was 38 (38%). As shown, the increase in the number of patients with ED was 8 (26.6%) to 16 (53.3%) in the OR group vs. 30 (42.6%) to 40 (58.8%) in the EVAR group. Postoperatively, at one year after surgery, the number of patients with new incidence of ED was 8 in the open surgical group (three patients with new incidence of ED in the group with bifurcated graft and in four patients with tube graft, but the increase of ED
Downloaded from vas.sagepub.com at WEST VIRGINIA UNIV HEALTH on July 7, 2015
XML Template (2015) [9.3.2015–5:25pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/VASJ/Vol00000/150016/APPFile/SG-VASJ150016.3d
(VAS)
[1–7] [PREPRINTER stage]
4
Vascular 0(0)
EVAR (n ¼ 70)
OR (n ¼ 30)
70 7.9 56.3 8.1 12 (17.1) 10 (83.3) 2 (16.6) 61 (87.1) 30 (49.2) 31 (50.8) 31 (44.3) 8 (25.8) 9 (29.0) 20 (28.6)
68 6.5 61.3 9.3 5 (16.7) 4 (80.0) 1 (20.0) 28 (93.3) 16 (57.1) 12 (42.9) 13 (43.3) 3 (23.1) 4 (30.8) 9 (30.0)
49 (70.0)
25 (83.3)
0.166
groups is shown (the OR and the EVAR patients), but the increase between both groups was not statistically significant. All of the six patients over 80 years belong to the EVAR group, of whom five had already ED. In addition, the mean value of ED scores postoperatively has increased by three points in both groups but without significant difference between OR and EVAR. The mean value of ED score was 16 5.1 in the OR (30 patients) vs. 17 6.1 in the EVAR (68 patients) without significant difference (p ¼ 0.43). The mean value of ED score increased postoperatively to 19 6.8 in the OR and 20 6.5 in the EVAR (p ¼ 0.59). Also patients without a preoperative ED showed an increase of the mean ED score during follow-up. In this case, the mean value of the ED score was 13 3.4 in the OR group (22 patients) vs. 12 3.2 in the EVAR group (38 patients) without significant difference (p ¼ 0.20). The mean value of the ED score increased postoperatively to 16.8 6.0 in the OR and 15.7 5.1 in the EVAR groups (p ¼ 0.48).
24 (43.4)
12 40.0)
0.587
Discussion
Table 1. Baseline characteristics according to age, risk factors and medication with a potential influence on erectile function.
Mean age (years) Aneurysm size (mm) Diabetes Controlled by oral agents Insulin controlled Hypertension Needed single drug Needed 2 drugs or more Coronary artery disease Myocardial infarction Coronary revascularization Chronic obstructive lung disease Tobacco use (Current or smoked in last 10 years) Renal disease (GFR less than 60 ml/min) Hyperlipidaemia Peripheral vascular disease Statin Beta-blocker Calcium channel-blocker Diuretics
46 13 40 46 14 19
(65.7) (18.6) (57.1) (65.7) (20.0) (17.1)
22 9 19 21 5 6
(73.3) (30.0) (63.3) (70.0) (16.7) (20.0)
p 0.339 0.009 0.954
0.497
0.930
0.886
0.465 0.208 0.566 0.678 0.698 0.452
Data are presented as n(%) for categorical variables and mean standard deviation for continuous variables.
Table 2. Number and percent of erectile dysfunction before and one year after surgery in both group. The difference between the groups was no statistically significant (p ¼ 0.412). Before surgery
OR EVAR Total
One year after surgery
Number (%)
n
Number (%)
n
8 (26.6) 30 (42.6) 38 (38.0)
30 70 100
16 (53.3) 40 (58.8) 56 (57.1)
30 68 98
EVAR: endovascular aneurysm repair; OR: open repair.
between both graft groups was not significant) and 10 patients in the EVAR group. There was no statistically significant difference between OR and EVAR groups in order of new incidence of ED (p ¼ 0.412). Table 3 shows ED pre- and postoperatively in different age decades. The most operated patients were between 61 and 80 years, and after one year an increase of ED in both
With increasing age the ED increases, which has been shown in several epidemiological studies. Kinsey15 has reported on the correlation between age and ED, increasing between 25 and 80 years from
