In this study we evaluated the mortality rates in patients with ED who underwent PPI at our institute for up to duration of eight years, and we observed an overall 3.6% of mortality- which had mainly occurred after prolonged duration of the perioperative period. Here, preoperative high systolic pressure was associated with mortality, and low preoperative testosterone level was an independent risk factor for mortality.
The deceased subjects were characterised with multiple co morbidities, poor control of diabetes and vascular disease risk procedures. There were no significant differences in length of hospital stay or ICU admission.
We aimed to analyse factors affecting mortality of those patients and examine how to optimize their pre-operative health conditions and improve their survival. We observed in group1 that the elderly subjects were characterized by high morbidities and poor control of diabetes, which needed to be optimized preoperatively. This observation falls in line with previous studies that have highlighted that there are many risk factors have can be implicated in the development of ED in elderly patients, including smoking, poor diabetic control (9),hypertension (HTN) (22), coronary artery disease (23) and iatrogenic pelvic surgery (24). Previous studies found that coronary artery risk factors and hypertension are significantly associated with severe cases of erectile dysfunction (23), (22).Hence, optimization of HTN prior to surgery is crucial in our patients who have ASA III status and multiple co morbidities.
A quality improving project investigated the first postoperative month adverse event rates after PPI at a North American institute where it was discovered that only one patient died in 30 days post operatively, but they did not analyse long term mortality (10). However, in our study, there were no deaths at the first 60 postoperative days. Only four patients expired in this cohort with a survival follow-up for up to eight postoperative years. None of our patients were admitted to the ICU, which suggested a smooth perioperative course, and perfect anaesthesia management. Similar to our results, about 54% of patients had an ASA score equal or higher than 3 with numerous co morbidities (10).
Palma-Zamora and colleagues discovered that most of the surgical complications are infectious in their elderly subjects (10). In this study, we found only 3.6% of infection rate in spite of a tight infection control strategy and perioperative antibiotic coverage (17),(18, 19). When looking at past studies, Habous and colleagues showed that HbA1c predicts increased risk of PPI infection, which could explain our infection rate (9).
There is an expected rise of the prevalence of diabetes in Qatar, i.e., from 16.7% in 2016 to 24.0% in 2050(25), which requires great efforts to be under control. A similar study in Saudi Arabia discovered that 71% of their patients exhibited HbA1c greater than 7% and associated with the increasing severity of ED and IHD which augmented their morbidities (9). Even in North America, diabetics constituted more than twenty percent of subjects undergoing PPI (26).
There is a strong relationship between vasculopathy in patients with ED who are exhibiting either diabetes or Ischemic heart diseases (IHD). Benvenuti and his associates described that pathophysiology of diabetic ED is strongly attributed to vasculopathy more than neuropathic theory (27). A generalized pathophysiological process of occlusive atherosclerosis is the contributing factor that impairs arterial blood flow in patients with ED and IHD (28). Cardiovascular mortality increased among diabetic individuals whose HbA1c exceeded 7% (29). The conclusions from these previous studies can thereby explain the degree of poor diabetic control with ED and the poor outcome regarding their cardiovascular risk and survival rate after surgery, in our study.
Taussig and colleagues (30), for the first time discovered an increase in PSA levels after cross-clamping in open heart surgery and Parlaktas et al., described its relation to this surgery (31). Another study attributed such rise in PSA levels to the pelvic ischemia and a relative infarction in the prostate (32). Interestingly, a group of scientists showed that a slight trauma to the prostate and urethral catheterization could initiate high PSA levels. A recent Korean study observed that total serum PSA levels within the reference range of young-aged men is inversely proportional to cardiovascular mortality, therefore indicating that PSA is a predictor for cardiovascular risk (33). However, this study did not observe high PSA levels in majority of our patients, but it was taken in consideration particularly in individuals who had cardiovascular co morbidities.
Epidemiological studies have proven that low testosterone levels can be associated with high cardiovascular risk (34), (35), (36), (37)and its optimization can reduce incidence of myocardial injury and death (38) which is parallel to our results. But a controversial debate about the safety of testosterone treatment along with randomized trials with sufficient numbers is required for such conclusion (39),(40), (41).
There have been many antagonizing replies for Dr Vigen and his colleagues’ study which supported risk of testosterone therapy. These replies suggested serious flaws in both design and interpretation. Several researchers pointed out that the original data of Dr Vigen’s Study, before various statistical adjustment, was supportive for use of testosterone therapy (42),(43) .
Our results are in line with a study conducted by Yeap et al.,(34)which concluded that low testosterone level is associated with a higher mortality as an independent risk factor. Moreover, in agreement with a large observational study with a long-term follow-up, they found that normalization of testosterone level had significantly associated with reduced mortality and cardiovascular events (38).
In both younger and older men, hypogonadism should be managed using testosterone therapy. Therefore, it appears to have no major concerns for treating young, healthy men with testosterone. Counselling should be suggested for asymptomatic, middle-aged and older men without a history of heart disease. Individuals with a recent myocardial injury, stroke, and uncontrolled heart failure are not good candidates for initiation of such a controversial therapy (35).
Anaesthesia role in our observational study was smooth and none of our patients required ICU admission. Majority of our cases had surgery under spinal anaesthesia. Other related studies discussed the use of dorsal penile nerve block which enhanced safe and effective early postoperative pain control (44), or using different local anaesthetics in this block (45).
This study provides short-term information on the complications, ICU admission, hospital stay, and long-term data about patient mortality rate. The results of this study can aid in providing information about the procedure during patient counselling to individuals that are seeking to undergo PPI.
When looking at the limitations of the present study, there are a few deficits that can be noted. This study was observational and retrospective in nature, with a relatively small number of participants. As a result, we could not correlate the lower physiologic reserves and perioperative outcomes. For future studies, it can be recommended to conduct a comprehensive prospective study.