Ejaculatory dysfunction (EjD) after retroperitoneal lymph node dissection (RPLND) for testicular cancer (TC).

Abstract

Introduction & Objectives: EjD, including retrograde and anejaculation, is reported after RPLND in survivors of TC. Despite clear impacts on fertility, its impact on quality of life (QoL) is not well described, and treatments have not been systematically investigated. Alphaagonists, such as pseudoephedrine, have been used to treat EjD due to other causes. We explored the prevalence of EjD after RPLND, impacts on QoL, and the efficacy of pseudoephedrine as treatment in survivors of TC. Material(s) and Method(s): In a single-arm, phase 2 clinical trial (ACTRN12622000542796), participants (pts) >6 months post-RPLND completed QoL questionnaires (QLQ) (EORTC QLQ-C30/TC26, Brief Male Sexual Function Inventory). Eligible pts with EjD had baseline post-ejaculatory urine +/- semen analysis, followed by short course pseudoephedrine and repeat analyses. The primary objective was to improve emission/propagation of ejaculate at climax. The primary endpoint was sperm count >39x106/ejaculate (>5th centile), considered to be within normal range (associated with unassisted conception). Secondary endpoints included semen volume >1.5mL (>5th centile), safety and QoL. Change in sperm count and semen volume were assessed using random-slopes mixed models. Sample size of 25 gave >80% power to detect 36% pts meeting the primary endpoint using a one-sample exact binomial proportion test; a 0.05. Result(s): 58 pts enrolled: median age 35 years (range 20-65), median time from RPLND 37 months (range 6-164). EjD was reported in 33 (57%) pts and was more common after bilateral template RPLND (73% v 36%, p=0.03). 54/58 (93%) pts completed QLQ, including 31 (57%) with EjD. No differences in global QoL, physical, emotional, cognitive or social functioning were seen in pts with EjD. However, role functioning was poorer (mean 93 v 100/100, p=0.045). Sexual drive, erections and overall sexual satisfaction did not differ. 24/33 (73%) pts with EjD consented to pseudoephedrine; 2/24 non-evaluable for primary endpoint (vasectomy, baseline sperm count >39x106/ejaculate). Of the remaining pts, 4 (18%) achieved sperm count >39x106/ejaculate, however the primary endpoint of 36% was not reached (p=0.20). Semen volume >1.5mL was reached in 4 (18%) pts (p=0.20). Of 9 (36%) and 14 (58%) pts with measurable sperm or ejaculate at post-treatment evaluation respectively, a mean increase of 105x106 sperm/ejaculate (p=0.051) and 1.47mL increase in semen volume (p=0.01) was seen. No safety concerns arose. Conclusion(s): EjD is common following RPLND, impacting role functioning, but not global QoL in our pts. Pseudoephedrine improved EjD in a small proportion of pts, achieving normal sperm count and/or semen volume in 18%. However, this was lower than expected and the trial did not meet its primary endpoint. Strategies to improve EjD after RPLND are needed; however, pseudoephedrine appears safe and may help some survivors.Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.