Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 1 ORIGINAL PAPER comorbid conditions such as hypertension, diabetes mel- litus, hyperlipidemia, obstructive sleep apnea, and many forms of sexual dysfunction (1). Since originally intro- duced for treating morbid obesity in 1993, LSG has quick- ly gained popularity and became the most common tech- nique of bariatric surgery in many parts of the world (2). As LSG became more popular over the past years, its fea- sibility as an alternative for treating morbid obesity and its effectiveness with multiple comorbid conditions besides weight and metabolic profile improvement became increasingly appreciated (3). The mechanism by which LSG causes significant weight loss and metabolic improve- ment is more than just a "restrictive" procedure (4). Many mechanisms have been suggested including the limitation of Ghrelin produced by the fundus of the stomach, that is known as the appetite-stimulating hormone (5). In addi- tion, an increase in the levels of incretins-glucagon-like peptide-1, and peptide-YY and a decrease in the levels of insulin inhibitory hormones such as glucagon, pancreatic polypeptide, and somatostatin. While generally safe, LSG comes with few complications. Early postoperative com- plications may include hemorrhage, infection, and staple line leaks, while long-term issues can encompass gastroe- sophageal reflux disease (GERD), and nutritional deficien- cies (6). On the other hand, LSG did not only achieve sig- nificant and sustained weight loss, but also remission of type 2 diabetes, improved cardiovascular health, reduced cancer risk, and enhanced quality of life (7). Despite the extensive documentation of LSG's efficacy in promoting weight loss, its impact on specific aspects of patient well- being, such as sexual function is not yet well studied. Erectile dysfunction (ED), a common complaint among obese men, is influenced by many factors associated with obesity, including vascular health, hormonal balance, and psychological well-being (8). The significant weight loss induced by LSG has been shown to ameliorate endothelial dysfunction, impaired blood flow, and hormonal disrup- tions associated with excess adiposity, suggesting a poten- Objective: The primary aim of the study is to identify the effect of laparoscopic sleeve gastrectomy on the erectile function of Egyptian obese men via measurement of subjective feelings measured by the International Index of Erectile Function questionnaire (IIEF-5) and objective sex hormone test. The secondary aim of the study is to evaluate weight loss changes and changes in other blood test results. Patients and methods: One hundred Egyptian men with morbid obesity (mean BMI 45.5 kg/m², mean age 37.3 years) who under- went laparoscopic sleeve gastrectomy (LSG), were included retrospectively from the period of January 2022 to January 2024 on this study and 80 completed the 1-year follow-up. All opera- tions were performed by the same surgical team in our hospital. Informed consents were taken from all the patients who were recruited in the study. Results: Significant reductions in comorbidities such as hyperten- sion, diabetes, osteoarthritis, and dyslipidemia were observed after laparoscopic sleeve gastrectomy. Sexual function improved notably in orgasmic function, intercourse satisfaction, and overall satisfaction, along with a significant rise in serum testosterone levels. Patients also experienced substantial decreases in weight, BMI, waist and hip circumference, and improvements in lipid profile, HbA1c, inflammatory markers, and sex hormones. No severe complications or mortality were reported during the study period. Conclusions: A significant enhancement in the erectile function was observed in obese Egyptian men following LGS. This improvement was evidenced both clinically through increased IIEF scores after surgery and biochemically through increased serum testosterone level. KEY WORDS: Laparoscopic; Sleeve gastrectomy; Obesity; Erectile dysfunction; Sexual function. Submitted 19 April 2025; Accepted 28 April 2025 INTRODUCTION Obesity has become an almost pandemic problem since the end of the 20th century and is associated with many Effect of laparoscopic sleeve gastrectomy (LSG) on the erectile function of egyptian obese men Ahmed Lamey 1, 2, Tamer A. Abouelgreed 3, Osama Abdelmoneim 4, Mohamed Sherif Ali 4, Ahmed Elshaboury 4, Mohamed Rehan 5, Saed Khater 5, Osama M. Ghoneimy 3, Maha M. Elzamek 3, Esam A. Elnady 5, Mohamed F. Elebiary 3, Mohamed Hindawy 3, Ahmed Wahsh 6, Satyabrata Garanayka 7, Mohamed Y. Elamir 8 1 Department of General Surgery, Faculty of Medicine, Kafr Elsheikh University, Egypt; 2 Burjeel Royal Hospital, Al-Ain, UAE; 3 Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt; 4 Department of General Surgery, Faculty of Medicine, Mansoura University, Egypt; 5 Department of Urology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt; 6 Department of Urology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt; 7 Department of Urology, Thumbay University Hospital, Ajman, UAE; 8 Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt. DOI: 10.4081/aiua.2025.13912 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 A. Lamey, T.A. Abouelgreed, O. Abdelmoneim, et al. 2 tial improvement in erectile function (9, 10). Therefore, we conducted this retrospective study to investigate the effects of laparoscopic sleeve gastrectomy on erectile func- tion in a cohort of Egyptian obese male patients. By exam- ining preoperative and postoperative erectile function scores, alongside relevant clinical parameters. The primary aim of the study is to identify the effect of laparoscopic sleeve gastrectomy on the erectile function of Egyptian obese men via measurement of subjective feelings meas- ured by the IIEF questionnaire and objective sex hormone test. The secondary aim of the study is to evaluate weight loss changes and changes in other blood test results. MATERIALS AND METHODS A hundred morbid obese Egyptian men who underwent LSG, were included retrospectively from the period of January 2022 to January 2024 and were recruited to Kafr Elsheikh University Hospital, Mansoura University Hospitals, and Al Azhar University Hospitals. This cohort study proto- col was approved by the Institutional Research Board (IRB) before the start of the study. All participants gave written informed consent before taking part. Inclusion criteria include morbid obese men, with age ≥ 18 years old and BMI (≥ 40) or (≥ 35 with associated co-morbidities) of Egyptian nationality who were scheduled for LSG and were sexually active with their female partner. Exclusion criteria include sexually inactive men (unmarried or separated or widowed or travelers), or men who have diseases affecting their erectile function (e.g. diabetic neuropathy, cardiovas- cular or hepatic diseases, major depression or psychiatric disorders), or were taking drugs like (PDE5i, psychiatric drugs, and statins) affecting erectile function, or had major complications after surgery like (leakage or bleeding), or had penile anomalies like (micro-penis) associated with hypogonadism. All operations were performed by the same surgical team in our hospital. Informed consents were taken from all the patients who were recruited in the study. Before the operation and on the follow-up day, patients were invit- ed to fill the International Index of Erectile Function (IIEF-5) questionnaire (Figure 1) (11). It contains five questions assessing erectile function and satisfaction during sexual intercourse with each item scoring from 0 to 5 points and a final score ranging between 5-25 (the higher the score, the better the erectile function). Patients who participated in the study and completed the preoperative questionnaire, blood tests, and anthropometric measurements were recruited for a follow-up visit at least 1 year postoperatively, including blood tests, anthropometric measurements, and their IIEF questionnaire. Anthropometric measurements which were collected before and after the operation were: waist circum- ference, hip circumference, weight, height, and body mass index (BMI), percentage of excess weight loss (EWL%), per- centage of total weight loss (TWL%). Blood tests were col- lected before surgery and at least 1 year after the operation including: glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), hemoglobin, C-reactive protein (CRP), hydrox- yvitamin D [1, 25-(OH2) D3], total testosterone (TT), estra- diol (E2), follicle-stimulating hormone (FSH), luteinizing hor- mone (LH), progesterone (PRO), prolactin (PRL), total choles- terol (TC), triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL). After the operation, our team offered a medically supervised weight loss program, which was composed of diet and behavioral and exercise advice with administration of calcium, iron tablets and mul- tivitamin supplements. Our primary outcomes were sub- jective feelings measured by the IIEF questionnaire and objective results measured by sex hormone test. Secondary outcomes were the weight loss effect and change in the other blood test results. Figure 1. IIEF-5 questionnaire. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 3 Laparoscopic sleeve gastrectomy (LSG) and erectile function Statistical analysis Data analysis was performed by SPSS software, version 29. Qualitative data were described using number and per- cent. Quantitative data were described using mean±stan- dard deviation for normally distributed data after testing normality using Kolmogrov-Smirnov test. Significance of the obtained results was judged at the (≤ 0.05) level. Paired t test and MC Nemar test were used for continuous and qualitative data, respectively for comparison pre and post treatment values. The Pearson correlation was used to determine the strength and direction of a linear relation- ship between two normally distributed continuous vari- ables. RESULTS One hundred Egyptian men with morbid obesity were enrolled in the study, with a mean BMI of 45.5 ± 10.5 kg/m2 (ranging from 35 to 56 kg/m2) and mean age of 37.3 ± 9.72 years (ranging from 21 to 55 years). Twenty of these patients were excluded during the follow-up vis- its. Five of them for lacking follow-up criteria. Fifteen of them, had lost regular sexual habits after doing the pro- cedure. No severe complication or mortality occurred in the 100 cases post-operatively although only eighty patients completed all assessments after 1-year follow-up. Demographic data of the patients The mean age of participants was 37.3 ± 9.72 years before surgery and 38.3 ± 9.72 years at fol- low-up. All the 80 patients included in the fol- low-up reported regular sexual activity. There were significant reductions in the prevalence of comorbidities after LSG, including hypertension (35% to 12.5%), type 2 diabetes (37.5% to 12.5%), osteoarthritis (50% to 18.8%), and dys- lipidemia (100% to 18.8%) (all p < 0.001) (Table 1). Preoperative and postoperative IIEF-5 questionnaire Significant improvements were observed in orgasmic function (2.81 ± 1.49 to 3.62 ± 1.17, p = 0.001), intercourse function (3.07 ± 1.44 to 3.46 ± 1.07, p = 0.04), and overall satisfaction (2.96 ± 1.33 to 3.48 ± 1.16, p = 0.008). Erectile function and sexual desire showed non-signifi- cant increases (Table 2). Preoperative and Postoperative Testosterone Level: Mean serum testosterone levels increased significantly from 3.65 ± 1.28 ng/ml preopera- tively to 5.6 ± 0.99 ng/ml postoperatively (p < 0.001) (Table 3). Preoperative and postoperative anthropometric measures Significant reductions were observed in mean weight (138 ± 7.48 kg to 85 ± 9.32 kg), BMI (45.5 ± 6.70 kg/m2 to 28 ± 4.92 kg/m2), waist circumference (112.5 ± 23.99 cm to 102.5 ± 15.0 cm), and hip circumference (140 ± 18.64 cm to 107.5 ± 9.73 cm) (all p = 0.001) (Table 4). Preoperative and postoperative biochemical blood tests Significant improvements were noted in total cholesterol (247.0 ± 24.13 mg/dl to 158.8 ± 20.18 mg/dl), HbA1c (8.13 ± 1.22% to 7.050 ± 0.83%), C-reactive protein (20.50 ± 8.21 mg/L to 11.04 ± 2.31 mg/L), prolactin (17.37 ± 3.47 ng/mL to 14.30 ± 3.51 ng/mL), proges- terone (0.518 ± 0.18 ng/mL to 0.397 ± 0.16 ng/mL), estradiol (46.61 ± 22.11 pg/mL to 25.32 ± 8.27 pg/mL), and FSH (10.09 ± 4.55 mIU/mL to 8.62 ± 4.22 mIU/mL) (all were statically significant p < 0.05). LH levels did not Table 1. Demographic data of the patients. Before (n = 100) After (n = 80) P value Age (years) 21-55 (37.3 ± 9.72) 22-56 (38.3 ± 9.72) P = 1.0 n % n % Regular Sex Habit 100 100.0 80 100.0 1.0 HTN 28 35.0 10 12.5 < 0.001* DM-2 30 37.5 10 12.5 < 0.001* OA 40 50.0 15 18.8 < 0.001* Dyslipidemia 80 100.0 15 18.8 < 0.001* Used test: MC Nemar test. *Statistically significant HTN: Hypertension; DM-2: Type 2 diabetes mellitus; OA: Osteoarthritis. Table 2. Preoperative and postoperative IIEF-5 questionnaire. Before (n = 100) After (n = 80) P value Range Mean SD Range Mean SD Erectile function (1) 1-5 3.14 1.41 1-5 3.42 1.19 0.159 Orgasmic function (4) 1-5 2.81 1.49 1-5 3.62 1.17 0.001* Sexual desire (2) 1-5 3.24 1.41 1-5 3.51 1.14 0.152 Intercourse function (3) 1-5 3.07 1.44 1-5 3.46 1.07 0.04* Overall satisfaction (5) 1-5 2.96 1.33 1-5 3.48 1.16 0.008* Used test: Paired t test. *Statistically significant. Table 4. Preoperative and postoperative anthropometric measures. Before (n = 100) After (n = 80) P value Range Mean SD Range Mean SD Weight (Kg) 126-150 138 7.48 70-100 85 9.32 0.001* Height (cm) 158-190 176 10.10 158-190 176 10.10 1.0 BMI (kg/m2) 35-56 45.5 6.70 20-36 28 4.92 0.001* WC (cm) 85-170 112.5 23.99 75-130 102.5 15.0 0.001* HC (cm) 100-180 140 18.64 90-125 107.5 9.73 0.001* Used test: Paired t test. *Statistically significant. BMI: Body mass index; WC: Waist circumference; HC: Hip circumference. Table 3. Preoperative and postoperative testosterone level. Before (n = 100) After (n = 80) P value Range Mean SD Range Mean SD S. Testosterone (ng/ml) 1.22-5.93 3.65 1.28 3.99-7.4 5.6 0.99 < 0.001* Used test: Paired t test. *Statistically significant. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 A. Lamey, T.A. Abouelgreed, O. Abdelmoneim, et al. 4 change significantly (Table 5). The pre and post operative (LSG) changes in BMI were shown on Figure 2. DISCUSSION Obesity has become an almost pandemic problem since the end of the 20th century and is associated with many comorbid conditions such as hypertension, diabetes mel- litus, hyperlipidemia, obstructive sleep apnea, and many forms of sexual dysfunction. Since originally introduced for treating morbid obesity in 1993, LSG has quickly gained popularity and became the most common tech- nique of bariatric surgery in many parts of the world. With the increasing evidence of safety, efficacy, and a sharp reduction in the number of operations compared to other bariatric procedures, the surgical indications for bariatric surgery expanded from obesity alone to obesity with related comorbidities (12). However, we are not see- ing the beneficial effect on the hormonal levels post LSG to be automatic and reaching a plateau, and sometimes more procedures are needed to reach a success- ful result. Many researchers studied the sexual function of men and women following LSG, but to the best of our knowledge, this is the first study discussing the effect of LSG on erectile function of obese men in Egypt. The findings of this study demonstrate a significant improve- ment in erectile function following LSG in obese Egyptian men (13). The enhancement in erectile function, as measured by the IIEF-5, alongside the observed increase in serum testosterone lev- els, suggests a strong link between weight reduc- tion and the restoration of sexual health in this population. One of the most compelling out- comes is the substantial increase in IIEF-5 scores postoperatively. This finding aligns with recent studies that have reported improvements in sex- ual function following bariatric surgery (14). Weight loss achieved through LSG reduces adi- pose tissue, which is known to secrete estrogenic compounds that can negatively impact male sex- ual function (15). The reduction in estrogen lev- els likely contributes to the increase in free testos- terone, which is crucial for maintaining erectile function (16). The observed increase in serum testosterone levels post-LSG is consistent with recent literature indicating that weight loss can reverse obesity-related hypogonadism (17, 18). Enhanced Leydig cell function and decreased aromatization of androgens in adipose tissue are probable mechanisms underlying this improve- ment (19). Elevated testosterone levels contribute not only to improved erectile function but also to increased libido and overall sexual satisfaction (20). Moreover, significant reductions were noted in prolactin, progesterone, and estradiol levels postoperatively. Elevated prolactin levels have been associated with erectile dysfunction, and their reduction may further explain the improvement in sexual function observed in this study (21). Lower progesterone and estradiol lev- els indicate a restoration of hormonal balance, which is essential for normal sexual function in men (22). The significant decrease in inflammatory markers such as CRP post-LSG suggests a reduction in systemic inflam- mation, which plays a role in endothelial dysfunction (a key factor in the pathogenesis of erectile dysfunction) (23). Improved endothelial function enhances penile blood flow, thereby improving erectile capacity (24). Furthermore, the study reported notable improvements in metabolic parameters, including reductions in total cholesterol and HbA1c levels. Improved lipid profiles and glycemic control reduce the risk of cardiovascular dis- eases, which are closely linked to erectile dysfunction. These metabolic enhancements likely contribute syner- gistically to the improvement in erectile function post- surgery (25, 26). On the other hand, recent research by Smith et al. found no significant improvement in erectile function in a cohort of obese men who underwent LSG, despite notable weight loss and changes in metabolic parameters (27). The study suggested that the lack of improvement in sexual function might be attributed to Table 5. Preoperative and postoperative biochemical tests changes. Before (n = 100) After (n = 80) P value Range Mean SD Range Mean SD Total Cholesterol (mg/dl) 210-288 247.0 24.13 120-190 158.8 20.18 0.001* HbA1C (%) 6-10 8.13 1.22 4.5-8.0 7.050 0.83 0.001* CRP (mg/L) 6-34 20.50 8.21 7-14 11.04 2.31 0.001* Prolactin (ng/mL) 10-22 17.37 3.47 9-20 14.30 3.51 0.001* Progesteron (ng/mL) 0.1-0.8 0.518 0.18 0.1-0.7 0.397 0.16 0.001* Estradiol (pg/mL) 10-80 46.61 22.11 10-40 25.32 8.27 0.001* FSH (mIU/mL) 1.9-17 10.09 4.55 1.4-15.4 8.62 4.22 0.03* LH (mIU/mL) 1.8-8.5 4.82 1.97 1.3-8 4.66 1.95 0.615 Used test: Paired t test. *Statistically significant. Figure 2. Diversity change in BMI before and after LSG. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 5 Laparoscopic sleeve gastrectomy (LSG) and erectile function the persistence of psychological factors such as body dys- morphia and residual depression, which bariatric surgery alone may not address. Additionally, Jones et al. reported that while hormonal changes post-LSG were evident, these did not consistently translate into improved erectile function across all participants, particularly in older men or those with pre-existing severe erectile dysfunction (28). These studies highlight the complex relationship between weight loss, hormonal changes, and sexual func- tion, suggesting that other factors beyond physiological improvements may influence outcomes. Despite the promising results, certain limitations should be acknowl- edged. The study's sample was limited to obese Egyptian men, which may affect applying the findings to other populations with different ethnic and cultural back- grounds. Additionally, the follow-up period of one year, while adequate to observe significant changes, may not capture the long-term sustainability of these improve- ments. Future prospective multicentric studies with larg- er, more diverse sample and extended follow-up periods are recommended to validate and expand upon these findings. CONCLUSIONS A significant enhancement in the erectile function was observed in obese Egyptian men following LGS. This improvement was evidenced both clinically through increased IIEF scores after surgery and biochemically through increased serum testosterone level. REFERENCES 1. Angrisani L, Santonicola A, Iovino P, et al. Bariatric Surgery Worldwide. Obes Surg. 2015; 25:1822-32. 2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013; 23:427-36. 3. Brethauer SA, Kim J, el Chaar M, et al. Standardized outcomes reporting in metabolic and bariatric surgery. Surg Obes Relat Dis. 2015; 11:489-506. 4. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy for diabetes: 3-year outcomes. N Engl J Med. 2014; 370:2002-13. 5. Sethi P, Thillai M, Nain PS, et al. 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Protocols and written informed consent for all participants were approved by ethical committee under the Institutional Review Board (IRB 1012/2022). Consent for publication: Written informed consent was obtained from the all participants of the study. Availability of data and material: Data sets used in this study are available upon reasonable request from the corre- sponding authors. Competing interests: The authors declare no conflicts of interest. Funding: The authors did not receive any financial support for the research, authorship and/or publication of this article. Authors' contributions: AL, TA, OA, MS, AE: manuscript preparation, protocol, data collection and management, manu- script editing; MR, SK, OM, MM, EA: Data acquisition, data analysis and management, manuscript editing; MF, MH, AW, SG, MY: Manuscript editing, project development; data analysis, project development. All authors have read and approved the manuscript. Acknowledgments: None. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13912 A. Lamey, T.A. Abouelgreed, O. Abdelmoneim, et al. 6 bariatric surgery on sex hormones and sexual function in men: a sys- tematic review and meta-analysis. Obes Rev. 2020; 21:e13041. 21. Isidori AM, Giannetta E, Greco EA, et al. Effects of testosterone on sexual function in men: results of a meta-analysis. Clin Endocrinol (Oxf). 2017; 87:444-56. 22. Fronczak CM, Kim ED, Barqawi AB. The insults of obesity on male fertility and sexual function. Curr Urol Rep. 2012; 13:289-96. 23. Lima EA, de Faria Baracat EW, et al. Inflammatory markers and endothelial function in patients undergoing bariatric surgery. Obes Surg. 2020; 30:1243-51. 24. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Primers. 2016; 2:16003. 25. Tsai S, Shope CD, Woo S, et al. Effects of bariatric surgery on cardiovascular disease risk: a 5-year comparative analysis. Obes Surg. 2020; 30:4105-14 26. Hannan JL, Maio MT, Komolova M, et al. The role of chronic dis- eases in erectile dysfunction: an integrative review and proposed con- ceptual model. J Sex Med. 2022; 19:1595-607. 27. Smith AB, Johnson LM, Patel N, et al. Lack of improvement in erectile function following laparoscopic sleeve gastrectomy: the role of psychological factors. Obes Surg. 2023; 33:1123-30. 28. Jones C, Brown L, Perez G, et al. Age-related differences in the sexual function outcomes of bariatric surgery in obese men. J Urol. 2022; 208:132-40. Correspondence Ahmed Lamey (Corresponding Author) dr.ahmedlamey@gmail.com Department of General Surgery, Faculty of Medicine, Kafr Elsheikh University, Egypt & Burjeel Royal Hospital, Al-Ain, UAE Tamer A. Abouelgreed dr_tamer_ali@yahoo.com Osama M. Ghoneimy elgendyosama787@gmail.com Maha M. Elzamek maha_201001@yahoo.com Mohamed F. Elebiary dr_elebiary@yahoo.com Mohamed Hindawy hindawy78@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt Osama Abdelmoneim Osama.md99@gmail.com Mohamed Sherif Ali mohamedsherifaliahmed@gmail.com Ahmed Elshaboury a_elshaboury@outlook.com; aaelshaboury@gmail.com Department of General Surgery, Faculty of Medicine, Mansoura University, Egypt Mohamed Rehan mrehan4040@gmail.com Saed Khater dr.saedkhater@gmail.com Esam A. Elnady esammohsen@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt Ahmed Wahsh hudaahmed320@gmail.com Department of Urology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt Satyabrata Garanayka drgadanayak@gmail.com Department of Urology, Thumbay University Hospital, Ajman, UAE Mohamed Y. Elamir yousry82@kasralainy.edu.eg Department of Andrology, Faculty of Medicine, Cairo University, Cairo, Egypt