Archivio Italiano di Urologia e Andrologia 2016; 88, 3186 ORIGINAL PAPER Testicular prosthesis: Patient satisfaction and sexual dysfunctions in testis cancer survivors Francesco Catanzariti ¹, Benedetta Polito ², Massimo Polito ¹ 1 Polytechnic University of Marche, Faculty of Medicine, Department of Odontostomatologic and Specialized Clinical Sciences, Urology Clinic, Department of General and Specialized Surgery, University Hospital, Ancona, Italy; ² Degree in Educational and childhood Psychology, Salesian Pontifical University, Rome, Italy. Purpose: We studied patient satisfaction about sexual activity after prosthesis implantation using validated questionnaires with the aim to discover if testicular prosthesis could be responsible of sexual dysfunctions (erectile dysfunction or premature ejaculation). Materials and Methods: We evaluated a total of 67 men who underwent radical orchiectomy for testicular cancer and a sil- icon testicular prosthesis implantation from January 2008 to June 2014 at our Hospital. These patients completed 5 validat- ed questionnaires the day before orchiectomy and 6 months after surgery: the International Index of Erectile Function 5 (IIEF5), the Premature Ejaculation Diagnostic Tool (PEDT), the Body Exposure during Sexual Activities Questionnaire (BESAQ), the Body-Esteem Scale and the Rosenberg Self- Esteem Scale. We also evaluated 6 months after surgery any defects of the prosthesis complained by the patients. Results: The questionnaires completed by patients didn’t show statistically significant changes for erectile dysfunction (p > 0.05) and premature ejaculation (p > 0.05). On the contrary the psychological questionnaires showed statistically signifi- cant change for the BESAQ (p < 0.001) and the Body Esteem Scale (p < 0.001), but not for the Rosenberg Self-Esteem Scale (p > 0,05). A total of 15 patients (22.37%) were dissatisfied about the prosthesis: the most frequent complaint (8 patients; 11.94%) was that the prosthesis was firmer than the normal testis. Conclusions: Testicular prosthesis implantation is a safe surgi- cal procedure that should be always proposed before orchiec- tomy for cancer of the testis. The defects complained by patients with testicular prosthesis are few, they don’t influence sexual activity and they aren’t able to cause erectile dysfunc- tion or premature ejaculation. KEY WORDS: Testicular cancer; Testicular prostheses; Sexual dys- function; Patient satisfaction. Submitted 26 March 2016; Accepted 5 August 2016 Summary No conflict of interest declared. most important period of life for sexual activity. The find of being affected by cancer of the testis and the following loss of the testis from the scrotal sac after orchiectomy are both responsible of a great psychological trauma in these young men, as described in literature (3). The implantation of testicular prostheses could be the solu- tion, but even if good aesthetic results can be obtained, the presence of an artificial testis can be cause of shame and loss of self confidence during sexual activity. Most of the papers in literature analyse patient satisfac- tion for testicular prosthesis just about aesthetic side (size, texture, weight, position), in our study, on the con- trary, we studied patient satisfaction after prosthesis implantation about sexual activity using validated ques- tionnaires with the aim to discover if testicular prosthe- sis could be responsible of any sexual dysfunction (erec- tile dysfunction or premature ejaculation). METHODS In lieu of a formal ethics committee, the principles of the Helsinki Declaration were followed. A total of 95 men underwent radical orchiectomy for testicular cancer from January 2008 to June 2014 at our Hospital. Of these patients, 67 underwent also a silicon testicular prosthesis implantation. This group of patient completed 5 validated question- naires the day before orchiectomy and 6 months after surgery: the International Index of Erectile Function - 5 (IIEF-5) (4) to evaluate erectile function; the Premature Ejaculation Diagnostic Tool (PEDT) (5) to assess prema- ture ejaculation; the Body Exposure during Sexual Activities Questionnaire (BESAQ) (6) a 28 item scale to measure anxiety during sexual activity and to evaluate desires and attempts to selectively avoid exposing one’s body (or parts of one’s body) to sexual partners; the Body-Esteem Scale (7) and the Rosenberg Self-Esteem Scale (8) those are respectively 35 and 10 item scales cre- ated to measure self confidence of each patient towards sexuality and other general aspects of life. We also evaluated any defects of the prosthesis com- plained by the patients within 6 months after surgery: pain, abnormal size of the prosthesis (larger or smaller than the normal testis), prosthesis texture (firmer than the normal testis), sense of coldness of the prosthesis and DOI: 10.4081/aiua.2016.3.186 INTRODUCTION Testicular cancer is one of the most frequent carcinoma in young males. In USA about 8000 men discover to be affected by testicular cancer every year and about 400 men of these die for this disease in a year, but fortunate- ly the five-year survival rate of patients with testicular cancer is 95% (1). Peak incidence is in the third decade of life for non-seminoma, and in the fourth decade for pure seminoma (2), so that this disease occurs during the Catanzariti_Stesura Seveso 21/09/16 08:48 Pagina 186 187Archivio Italiano di Urologia e Andrologia 2016; 88, 3 Testicular prosthesis: Patient satisfaction and sexual dysfunctions in testis cancer survivors abnormal position of the prosthesis in the scrotal sac (higher than the normal testis). Surgical technique We used a silicone testicular prosthesis, with a protective suture guard for easy implantation. The size of the pros- thesis to use was determined by ultrasound before sur- gery. All the implants were placed at the initial surgery via the inguinal approach and none was inserted after orchiectomy as a second procedure. The prosthesis was fixed in the scrotum with a non-absorbable suture. Statistical methods All the scores of questionnaires before and after surgery and defects of the prosthesis complained by the patients were collected into a database. General descriptive statistics were measured for categorical and continuous variables. We per- formed Student's t-test to compare mean score of all the five questionnaires (IIEF5, PEDT, BESAQ, Body-Esteem Scale and Rosenberg Self-Esteem Scale) before and after surgery. Student's t-test was considered significant if < 0.05. Statistical analyses were performed with IBM SPSS Statistics Base®. RESULTS From January 2008 to June 2014 we performed 95 orchiectomy for cancer of the testis and 67 (70.52%) patients of these decided also to undergo a silicone testic- ular prosthesis implantation. The remaining 28 (29.47%) patients refused testicular prosthesis for different reasons (Table 1): 15 (53.57%) patients were afraid of infection and of the need of a second surgery to repair it; 10 (35.71%) patients didn’t care of remaining just with one testis in the scrotal sac; 3 (10.71%) patients didn’t want prosthesis because they couldn’t accept an artificial testis in the scrotal sac for psychological reasons (shame with the partner during sexual activity or bad memories evoked by self-palpation of the testicular prosthesis). Age and marital status of patients who accepted testicular prosthesis implantation are described in Table 2. Between the 67 patients who underwent implantation two (2.98%) had inflammation with scrotal edema that healed in few days with anti-inflammatory and just one (1.49%) had an hematoma resorbed spontaneously without a sec- ond surgery. No major complications (extrusion or migra- tion of the prosthesis) have been described (Table 3). The questionnaires (Table 4) completed by patients before and 6 months after surgery (mean follow up: 49.42 months) didn’t show statistically significant changes in the score for erectile dysfunction (p > 0.05) and premature ejaculation (p > 0.05). On the contrary the psychological questionnaires showed statistically sig- nificant change in the score for the BESAQ (p < 0.001) and the Body Esteem Scale (p < 0.001), but not for the Rosenberg Self-Esteem Scale (p > 0.05). We also collect- ed data about dissatisfaction of patients about the pros- thesis and defects of the prosthesis complained by the patients within 6 months from surgery (Table 5). Fifteen patients (22.37%) were dissatisfied about the pros- thesis: one (1.49%) patient reported chronic pain, six (8.95%) men reported abnormal size of the prosthesis compared to the normal testis (five patients reported that the prosthesis was larger than the normal testis and one patient reported that the prosthesis was smaller than the normal testis); eight (11.94%) patients reported that the prosthesis was firmer than the normal testis; two (2.98%) patients complained of sense of coldness of the prosthesis and four (5.97%) patients reported that the prosthesis was higher than the normal testis in the scrotal sac. DISCUSSION Our study is one of the few studies available in the litera- ture about testicular prosthesis satisfaction after orchiecto- No. (%) Fear of infection 15 (53.57%) Regardless of remaining with only one testicle 10 (35.71%) Psychological reasons (shame with the partner or other) 3 (10.71%) Table 1. Reasons of refusal of testicular prosthesis implantation. No. (%) Inflammation with scrotal edema 2 (2.98%) Hematoma 1 (1.49%) Table 3. Complications of testicular prosthesis implantation. Mean age 34.39 Median age 33.00 Standard deviation of age 11.24 No. marital status at surgery (%): Single or divorced 45 (67.16) Married or a partner in a steady relationship 22 (32.83) No. marital status 6 months later (%): Single or divorced 48 (71.64) Married or a partner in a steady relationship 19 (28.35) Table 2. Age and marital status of patients who accepted testicular prosthesis implantation. Mean score ± SD p value change IIEF-5 tº 22.83 ± 2.46 t1 22.20 ± 2.84 p > 0.05 PEDT tº 7.79 ± 5.30 t1 8.39 ± 5.27 p > 0.05 BESAQ tº 37.59 ± 11.5 t1 46.17 ± 10.91 p < 0.001 Body Esteem Scale tº 85.14 ± 12.14 t1 77.77 ± 10.24 p < 0.001 Rosenberg Self Esteem Scale tº 27.30 ± 3.04 t1 26.45 ± 3.26 p > 0.05 Table 4. Score changes in the 5 questionnaires (IIEF-5, PEDT, BESAQ, Body Esteem Scale and Rosenberg Self Esteem Scale) at testicular prosthesis implantation (tº) and 6 months later (t¹). Catanzariti_Stesura Seveso 21/09/16 08:48 Pagina 187 Archivio Italiano di Urologia e Andrologia 2016; 88, 3 F. Catanzariti, B. Polito, M. Polito. 188 my for testicular cancer. This is a great and serious lack in andrology if we consider that there is a great number of studies in literature about breast implants satisfaction after mastectomy. Moreover most of these few studies (9, 10) analyse just satisfaction about aesthetic factors (size, tex- ture, weight, position) but not about sexual activity after testicular prosthesis implantation. Furthermore the few studies (11, 12) who analyse this aspect use simple and generic questions without using validated questionnaires. The only paper in literature analysing sexual activity after testicular prosthesis implantation with validated question- naires is the study by Turek et al. (13). These authors used the same psychological validated questionnaires (BESAQ, Body-Esteem Scale and Rosenberg Self-Esteem) that we used in our study but they didn’t use IEEF-5 and PEDT for the analysis of erectile dysfunction and premature ejacula- tion before and after testicular prosthesis implantation as we did. Moreover their study is about testicular prosthesis implantation not only after orchiectomy for cancer of the testis but also for torsion, trauma or agenesis of the didimus so that Turek et al. included in their work 73 chil- dren and 76 adults. Our study demonstrated that testicular prosthesis implantation is a safe surgical procedure with few risks of complications as the other papers cited showed. The dissatisfaction rate is quite low (22.37%). The changes of the mean scores of psychological questionnaires are sta- tistically significant for BESAQ and Body Esteem Scale (p < 0.001) but not for the Rosenberg Esteem Scale (p > 0.05) and the changes of the mean scores of IIEF-5 and PEDT before and 6 months after orchiectomy are not statistically significant. These results demonstrate that a testicular prosthesis implantation modifies psychological approach towards the partners during sexual activity because some patients with testicular prosthesis feel shame of it and they try to not show the prosthesis dur- ing sexual activity. We also showed that testicular pros- thesis doesn’t cause sexual dysfunction (erectile dysfunc- tion or premature ejaculation). However our study has some limitations. First the follow up after testicular pros- thesis implantation is short (6 months), second we did- n’t compare sexual activity satisfaction of our patients with sexual activity satisfaction of patients those refused testicular prosthesis implantation. CONCLUSIONS This study confirms that testicular prosthesis implanta- tion is a safe surgical procedure that should be always proposed before orchiectomy for cancer of the testis because complications and defects complained by patients with testicular prosthesis are few. We also showed for the first time that implant doesn’t influence sexual activity and it isn’t able to cause erectile dysfunction or premature ejaculation even if further studies with a control group are needed to confirm this. REFERENCES 1. Cancer Facts & Figures 2014 and the NCI Surveillance Epidemiology and End Results (SEER) database 1975-2010. 2. Bosl GJ, Motzer RJ.Testicular germ-cell cancer. N Engl J Med. 1997; 337:242. 3. 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J of Pers Assess. 1984; 48:173. 8. Rosenberg M. Society and the adolescent self-image. Princeton, NJ 1965; Princeton University Press. 9. Adshead J, Khoubehi B, Wood J, Rustin G. Testicular implants and patient satisfaction: a questionnaire-based study of men after orchidectomy for testicular cancer. BJU Int. 2001; 88:559-62. 10. Xylinas E, Martinache G, Azancot V, et al. Testicular implants, patient's and partner's satisfaction: a questionnaire-based study of men after orchidectomy. Prog Urol. 2008; 18:1082-6. 11. Incrocci L, Bosch JL, Slob AK. Testicular prostheses: body image and sexual functioning. BJU Int. 1999; 84:1043-5. 12. Yossepowitch O, Aviv D, Wainchwaig L, Baniel J. Testicular Prostheses for Testis Cancer Survivors: Patient Perspectives and Predictors of Long-Term Satisfaction. J Urol. 2011; 186:2249-2252. 13. Turek PJ, Master VA. Testicular Prosthesis Study Group. Safety and effectiveness of a new saline filled testicular prosthesis. J Urol. 2004; 172:1427-30. No. (%) Dissatisfaction of patients about the prosthesis 15 (22.37) Defects of the prosthesis complained by the patients Chronic pain 1 (1.49) Abnormal size of the testicular prosthesis Larger than the normal testis 5 (7.46) Smaller than the normal testis 1 (1.49) Testicular prosthesis firmer than the normal testis 8 (11.94) Sense of coldness of the prosthesis 2 (2.98) Testicular prosthesis higher than the normal testis in the scrotal sac 4 (5.97) Table 5. Dissatisfaction of patients about the prosthesis and defects of the prosthesis complained by the patients 6 months after surgery. Correspondence Francesco Catanzariti, MD frenzis83@gmail.com Massimo Polito, MD Polytechnic University of Marche, Faculty of Medicine, Department of Odontostomatologic and Specialized Clinical Sciences, Urology Clinic, Department of General and Specialized Surgery,University Hospital, Ancona, Italy Benedetta Polito, MD Educational and Chlidhood Psychologist, Salesian Pontifical University, Rome, Italy Catanzariti_Stesura Seveso 21/09/16 08:48 Pagina 188