Abstract
Objective
To evaluate and compare the effect of semi-rigid ureterorenoscopy on post-procedural sexual function with three different operating room settings.
Methods
In this prospective randomized study, consecutive sexually active patients with normal pre-operative sexual function undergoing uncomplicated semi-rigid ureterorenoscopy for distal ureteric stones were randomized into three groups, with three different operating room settings. Procedure-related anxiety and sexual function were assessed pre-operatively using Amsterdam Preoperative Anxiety and Information Scale and Brief Sexual Function Inventory (in males) and Female Sexual Function Index-6 (in females), respectively. All the participants were stented following the procedure, and the stent was removed after 3 weeks. Post-procedural sexual function and general discomfort were assessed and compared between three groups at 1 week, 3 weeks, and 12 weeks. The effect of surgery-related anxiety, preoperative sexual function, age, and general discomfort (including stent-related discomfort) on post-procedural sexual function were analyzed using multiple regression analysis. A p-value of less than 0.05 was considered statistically significant.
Results
Totally, 327 eligible patients were randomized into three groups. The group of patients who underwent the procedural with a screen separating the operating area from the patient vision, while the patient could watch the endoscopy through a separate monitor, had better post-procedural sexual function compared to those who had total vision of the operating area as well as to those whose eyes were blocked. This difference was statistically significant. This post-procedural reduction in sexual function could not be attributed to in situ stent alone.
Conclusions
Our study showed that semi-rigid ureterorenoscopy can have significant negative effect on sexual function, which can be reduced with proper preoperative counseling and an ideal operating room settings.
Keywords: Semi-rigid ureterorenoscopy, Post-procedural sexual dysfunction, Preoperative counselling, Operating room setting
1. Introduction
Endourology as a science has advanced in leaps and bounds since its advent for stone diseases. The miniaturization of scopes and novel energy sources has made endourology procedures one of the safest procedures in modern day urology [1]. However, the patients do complain of post-procedural discomfort and sexual dysfunction, most of which are attributed to the stent [2]. Many such patients do complain of sexual dysfunction, even after removal of stent, thus questioning the rationale of attributing them to the stent per se [3]. The literature on the said subject is so sparse that it is difficult to explain the mechanism of such dysfunction when the treating physician were confronted with such patients [4]. Hence, we decided to address this issue by conducting a prospective randomized study on consecutive sexually active patients with normal preoperative sexual function undergoing uncomplicated semi-rigid ureterorenoscopy for distal ureteric calculi using three different operating room settings in our institution.
2. Patients and methods
2.1. Study design
The prospective randomized, triple-arm, single-center study was initiated after obtaining institutional ethical committee approval (TSS/EC/04/2019–20). After obtaining the written informed consents, the eligible consecutive study participants were divided into three groups based on the computer-generated random numbers. All the participants were explained in detail about the procedure with the video demonstration of semi-rigid ureterorenoscopy which covered the procedure details. After this, the participants were assigned to the three groups as explained earlier. The participants in Group 1 underwent the procedure with a screen separating the operating area from the vision of the patient, while the patient could view the entire course of endoscopy through a separate monitor. The participants in Group 2 had similar arrangements except for the screen that separated operative area from the patient's vision allowing the patient to see everything including preparation, painting, draping, ureterorenoscope, lithotripsy. The participants in Group 3 had their eyes covered throughout the procedure.
2.2. Study population
The sexually active patients with normal preoperative sexual function admitted in our institute for semi-rigid ureterorenoscopy procedures for uncomplicated distal ureteric stones were included in the study. Those patients who had residual ureteric calculi were excluded from the study. The study period was 1 year. Patients who were not sexually active and those with the pre-existing sexual dysfunction, were excluded. Patients having at least one sexual activity per week were considered as sexually active. Participants did not receive any remuneration for participating in the study. Prior to the inclusion in the study, sexual function of the participants was assessed using validated tools, namely, Brief Sexual Function Inventory (BSFI) for males and Female Sexual Function Index-6 (FSFI-6) for females. BSFI is a validated tool to measure sexual function in males, which evaluates five sexual function domains on 5-item Likert scales, wherein the scores closer to 45 are considered as normal [5]. FSFI-6 is a validated tool to measure female sexual function which is an abridged version of the 19-item Female Sexual Function Index [6]. A total score of 19 and above was considered as normal.
2.3. The procedure
All the participants had their preoperative anxiety assessed prior to the procedure using Amsterdam Preoperative Anxiety and Information Scale (APAIS), which is a validated 6-item, 5-point Likert scale wherein each item is graded from 1 suggesting “no anxiety” to 5 suggesting “extreme anxiety” [7]. A patient with a total score of 11 or more was considered anxious clinically. Then, based on the random assignment to one of the three groups, the participant underwent semi-rigid ureterorenoscopy under spinal anesthesia. All the semi-rigid ureterorenoscopies were performed by the single urologist (Bhat GS), and the single anesthetist (Dr. Vinayak Tembadamane) gave aesthesia for all the procedures. All the patients were stented with 5 Fr double-J stent after ureterorenoscopy as part of the study protocol so as to nullify the bias that could have arisen due to stent effect in some patients, had we stented only few patients. These stents were removed after 3 weeks. Each patient stayed overnight in the hospital and got his or her catheter removed on the morning after ureterorenoscopy prior to discharge from the hospital.
2.4. The follow-up
The participants were called for follow-up 1 week, 3 weeks (for stent removal), and 12 weeks after the procedure for assessment of their sexual function, stent-related discomfort, and general discomfort. The follow-up at 1 week was to specifically look for any post-procedural infection. The second follow-up at 3 weeks was for double-J stent removal. The sexual function in the males was assessed using BSFI and the sexual function in females was assessed using FSFI-6 during these visits. At the same time, they were asked to rate their comfort on a Verbal Numerical Rating Score (VNRS) of 1–10, with 1 being “no comfort” and 10 being “most comfortable” [8]. In case of persistence of sexual complaints as well as discomfort even after 12 weeks, the participants were asked to follow up at the outpatient department, till such time when the participants were relieved of these symptoms.
2.5. Outcomes
The post-procedural change in sexual function from the baseline in the three prospectively randomized groups of participants under study was the planned primary outcome measure. The study was planned to assess the effect of procedure-related anxiety, stent-related discomfort, and general discomfort on post-procedural sexual dysfunction as the secondary outcome measures. The qualitative assessment was planned for those who had persistent post-procedural sexual dysfunction after 12 weeks of the procedure. The qualitative data of such patients were collected.
2.6. Sample size calculation
We calculated the sample size based on 95% confidence interval and 5% acceptable margin of error. Considering an incidence of 12% for urolithiasis in our geographic area [9], calculated minimum sample size was 315 for an adequate powered study for a population of 300 000 (the population of the study area).
The equation used was n=Nx/((N–1)E2+x), where n is the sample size, N is the population size, and E is the acceptable margin of error. Here x was calculated by the formula, x=Z(c/100)2r(100–r), where r is the incidence of the problem under study and Z(c/100) is the critical value for the confidence interval c [10].
2.7. Statistical analysis
The randomization was done based on the computer generated random numbers. The allocation was sealed and the treating doctor (Bhat GS) as well as the patient was blinded for the random allocation. Operation room superintendent was given sealed envelope containing the allocated group details about 15 min prior to the procedure to enable her to make arrangements inside the operating room as per the group to which the participant was allocated.
The data were analyzed using MedCalc statistical software, 2020 edition, Ostend, Belgium. The student's t-test was used to compare the means of the categorical variables. Multiple regression analysis was performed to assess the role of independent variables as risk factors affecting the post-procedural sexual function. A p-value of less than 0.05 was considered statistically significant. The qualitative data were analyzed separately.
3. Results
The study was conducted from January 2020 to December 2020. A total of 441 patients underwent semi-rigid ureterorenoscopy procedure for ureteric calculi in 2020, of which 55 refused to be part of the study and 59 patients had to be excluded based on the exclusion criteria (Fig. 1). The mean stone sizes in the largest dimension in the three groups were 8.9 (range 7.0–11.0) mm, 8.5 (range 7.3–9.2) mm, and 9 (range 7.5–10) mm, respectively. There was no statistically significant difference among the three groups as far as the stone sizes were concerned.
Figure 1.
Participant flow diagram. URS, ureterorenoscopy.
Summary of patients characteristics such as age, sex, procedure-related APAIS, preoperative as well as post-procedural BSFI scores in males and preoperative as well as post-procedural FSFI-6 scores in females and post-procedural VNRS scores are given in Table 1.
Table 1.
Patient characteristics.
| Characteristic | Group 1a (n=108) | Group 2a (n=109) | Group 3a (n=110) | p-Value |
|---|---|---|---|---|
| Age, year | 37.9±9.6 | 39.5±8.5 | 39.2±9.6 | >0.05 |
| Male:female | 3.5:1 | 3.5:1 | 3.4:1 | >0.05 |
| Preoperative APAIS score | 8.9±2.1 | 8.7±1.7 | 8.8±2.0 | >0.05 |
| BSFI score in males (highest possible 45) | ||||
| Pre-procedural | 39.7±2.0 | 39.4±2.2 | 39.6±2.2 | >0.05 |
| 1 week postoperatively | 29.5±2.4 | 21.4±1.8 | 20.8±2.6 | >0.05 (between Groups 2 and 3); <0.05 (between Groups 1 and 3, 1 and 3) |
| 3 weeks postoperatively | 31.3±3.4 | 24.9±2.9 | 27.3±2.8 | <0.05 (all inter groups) |
| 12 weeks postoperatively | 37.6±1.4 | 36.9±0.9 | 36.3±1.5 | >0.05 |
| FSFI-6 score in females (highest possible 30) | ||||
| Pre-procedural | 26.4±1.7 | 26.3±1.7 | 26.2±1.8 | >0.05 |
| 1 week postoperatively | 13.8±2.3 | 11.3±2.4 | 9.9±1.9 | <0.05 (all inter groups) |
| 3 weeks postoperatively | 16.5±1.9 | 14.0±2.4 | 14.4±1.9 | >0.05 (between Groups 2 and 3); <0.05 (between Groups 1 and 3, 1 and 3) |
| 12 weeks postoperatively | 23.8±1.7 | 21.5±1.9 | 20.7±1.8 | >0.05 (between Groups 2 and 3); <0.05 (between Groups 1 and 3, 1 and 3) |
| VNRS | ||||
| 1 week postoperatively | 2.6±0.6 | 2.7±0.6 | 2.7±.5 | >0.05 |
| 3 weeks postoperatively | 3.6±1.2 | 3.8±1.4 | 4.3±1.2 | >0.05 (between Groups 1 and 2); <0.05 (between Groups 1 and 3, 1 and 3) |
| 12 weeks postoperatively | 7.9±0.8 | 8.2±0.8 | 8.2±0.7 | >0.05 |
APAIS, Amsterdam Preoperative Anxiety and Information Scale; BSFI, Brief Sexual Function Inventory; VNRS, Verbal Numerical Rating Score; FSFI-6, Female Sexual Function Index-6.
Note: Group 1, the participants underwent the semi-rigid ureterorenoscopy with a screen separating the operating area from the vision of the patient, and could view the entire course of endoscopy through a separate monitor; Group 2, the participants underwent the semi-rigid ureterorenoscopy without any screen so that the patient could see both the operating area as well as the monitor; Group 3, the participants underwent the semi-rigid ureterorenoscopy having their eyes covered throughout the procedure.
data are present as mean±standard deviation.
3.1. Primary outcome
There was a reduction in the post-procedural sexual function in all the domains in both the males and females. It was more profound in the first week and gradually returned almost to baseline at 12 weeks in males. The degree of reduction in sexual function was more in Group 2 and Group 3 and the differences between Group 1 and the other two groups were statistically significant. However, in females, the return of sexual function to baseline was not seen even at 12 weeks postoperatively and the degree of difference of sexual function from the baseline to the sexual function at 12 weeks was statistically significant in all the three groups. However, this was more so in Group 2 and Group 3. In both the males and females, degree of reduction in sexual function was in the following order: Group 3, Group 2, and Group 1.
The details of post-procedural negative effect on different sexual domains in the three groups of participants as assessed by BSFI (in males) and FSFI-6 (in females) are given in Table 2.
Table 2.
Summary of post-procedural negative effect on various domains of sexual function as assessed by BSFI (in males) and FSFI-6 (in females).
| Sexual domain | Group 1 (n=108) |
Group 2 (n=109) |
Group 3 (n=110) |
|||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Males (n=84) |
Females (n=24) |
Males (n=85) |
Females (n=24) |
Males (n=85) |
Females (n=25) |
|||||||||||||
| 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | |
| Sexual drive | 57 (67.9) | 46 (54.8) | 3 (3.6) | NA | NA | NA | 64 (75.3) | 55 (64.7) | 11 (12.9) | NA | NA | NA | 75 (88.2) | 68 (80.0) | 7 (8.2) | NA | NA | NA |
| Erectile function | 39 (46.4) | 26 (31.0) | 4 (4.8) | NA | NA | NA | 52 (61.2) | 35 (41.2) | 8 (9.4) | NA | NA | NA | 43 (50.6) | 38 (44.7) | 8 (9.4) | NA | NA | NA |
| Ejaculatory function | 55 (65.5) | 27 (32.1) | 0 (0) | NA | NA | NA | 60 (70.6) | 38 (44.7) | 4 (4.7) | NA | NA | NA | 71 (83.5) | 42 (49.4) | 7 (8.2) | NA | NA | NA |
| Sexual satisfaction | 62 (73.8) | 44 (52.4) | 4 (4.8) | 18 (75.0) | 15 (62.5) | 6 (25.0) | 60 (70.6) | 50 (58.8) | 10 (11.8) | 22 (91.7) | 15 (62.5) | 8 (33.3) | 70 (82.4) | 62 (72.9) | 6 (7.1) | 23 (92.0) | 15 (60.0) | 9 (36.0) |
| Sexual desire | NA | NA | NA | 17 (70.8) | 13 (54.2) | 5 (20.8) | NA | NA | NA | 20 (83.3) | 16 (66.7) | 9 (37.5) | NA | NA | NA | 22 (88.0) | 17 (68.0) | 8 (32.0) |
| Sexual arousal | NA | NA | NA | 18 (75.0) | 12 (50.0) | 4 (16.7) | NA | NA | NA | 21 (87.5) | 12 (50.0) | 8 (33.3) | NA | NA | NA | 22 (88.0) | 15 (60.0) | 6 (24.0) |
| Vaginal lubrication | NA | NA | NA | 13 (54.2) | 10 (41.7) | 4 (16.7) | NA | NA | NA | 18 (75.0) | 11 (45.8) | 6 (25.0) | NA | NA | NA | 17 (68.0) | 15 (60.0) | 8 (32.0) |
| Orgasm | NA | NA | NA | 14 (58.3) | 9 (37.5) | 4 (16.7) | NA | NA | NA | 16 (66.7) | 13 (54.2) | 6 (25.0) | NA | NA | NA | 18 (72.0) | 15 (60.0) | 6 (24.0) |
| Pain | NA | NA | NA | 11 (45.8) | 7 (29.2) | 2 (8.3) | NA | NA | NA | 13 (54.2) | 11 (45.8) | 3 (12.5) | NA | NA | NA | 15 (60.0) | 10 (40.0) | 3 (12.0) |
BSFI, Brief Sexual Function Inventory; FSFI-6, Female Sexual Function Index-6; NA, not applicable.
Note: Group 1, the participants underwent the semi-rigid ureterorenoscopy with a screen separating the operating area from the vision of the patient, and could view the entire course of endoscopy through a separate monitor; Group 2, the participants underwent the semi-rigid ureterorenoscopy without any screen so that the patient could see both the operating area as well as the monitor; Group 3, the participants underwent the semi-rigid ureterorenoscopy having their eyes covered throughout the procedure. The data are presented as negative effect number among the total patients, and the percentages are given in brackets.
On qualitative analysis, 94.2% of the patients in Group 2, felt, visuals of violation of genitals by a long rod like structure (ureteroscope) affected their sexual health. Almost all patients in Group 3 felt that mere thinking of some foreign object entering their genitals with their eyes covered with lower body being in paralyzed state was very disturbing and stressful. Some of them had a belief that the scope had damaged their genitals and hence their sexual function was inadequate after the procedure. The patients in Group 1 tried to correlate the visuals on the monitor with the demonstration video which was shown to them prior to the procedure and they had least problems with the sexual function after the procedure. In essence, the degree of unexplainable procedure-related psychological disturbance was in the following order, Group 3 > Group 2 > Group 1, and the degree of reduction in sexual function was also in the same order.
3.2. Secondary outcomes
The results of regression analysis with age, APAIS score, VNRS, and the pre-procedural sexual function index score as independent factors and post-procedural sexual function as dependent variable are shown as Table 3.
Table 3.
Summary of p-values obtained during regression analysis.
| Independent variables | Group 1 (n=108) |
Group 2 (n=109) |
Group 3 (n=110) |
|||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Males (n=84) |
Females (n=24) |
Males (n=85) |
Females (n=24) |
Males (n=85) |
Females (n=25) |
|||||||||||||
| 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | 1 week | 3 weeks | 12 weeks | |
| Age | 0.855 | 0.222 | 0.093 | 0.957 | 0.454 | 0.029 | 0.564 | 0.137 | 0.681 | 0.393 | 0.941 | 0.014 | 0.210 | 0.335 | 0.232 | 0.398 | 0.653 | 0.909 |
| APAIS score | 0.004 | 0.002 | 0.001 | 0.105 | 0.592 | 0.930 | 0.021 | 0.278 | 0.693 | 0.088 | 0.348 | 0.039 | 0.001 | 0.361 | 0.023 | 0.601 | 0.060 | 0.225 |
| Pre-procedural sexual function score | 0.227 | 0.407 | 0.002 | 0.872 | 0.787 | 0.442 | 0.622 | 0.084 | 0.001 | 0.424 | 0.078 | 0.010 | 0.806 | 0.671 | 0.006 | 0.472 | 0.668 | 0.607 |
| VNRS | 0.477 | 0.520 | 0.862 | 0.951 | 0.568 | 0.846 | 0.698 | 0.012 | 0.269 | 0.633 | 0.770 | 0.502 | 0.747 | 0.685 | 0.706 | 0.632 | 0.934 | 0.157 |
APAIS, Amsterdam Preoperative Anxiety and Information Scale; VNRS, Verbal Numerical Rating Score.
Note: Group 1, the participants underwent the semi-rigid ureterorenoscopy with a screen separating the operating area from the vision of the patient, and could view the entire course of endoscopy through a separate monitor; Group 2, the participants underwent the semi-rigid ureterorenoscopy without any screen so that the patient could see both the operating area as well as the monitor; Group 3, the participants underwent the semi-rigid ureterorenoscopy having their eyes covered throughout the procedure. The significant values are in bold.
In males, in all the three groups, pre-procedural anxiety was associated with statistically significant reduction in post-procedural sexual function for the first week after the procedure. The participants from Group 1 had statistically significant reduction in sexual function up to 12 weeks after the procedure, which was attributable to pre-procedural anxiety.
Age of the participant was a statistically significant factor for non-return of the sexual function to the baseline in females in Group 1 and Group 2 even after 12 weeks of the procedure. In males, pre-procedural anxiety had a statistically significant impact on post-procedural sexual function from 1st to 12th weeks in Group 1, 1st week in Group 2, and 1st and 12th week in Group 3. Similarly, in females, pre-procedural anxiety had a statistically significant impact on post-procedural sexual function at 12th week in Group 2.
It is important to note that the general discomfort after the procedure, which includes stent-related discomfort, has no statistically significant contribution to the post-procedural reduction in sexual function in all the groups except for the females in Group 2 at 3 weeks.
4. Discussion
We are presenting here the outcome of the study which assessed the effect of semi-rigid ureterorenoscopy on post-procedural sexual dysfunction. We also compared the post-procedural sexual function in patients undergoing uncomplicated semi-rigid ureterorenoscopy for distal ureteric calculi using three different operating room settings. Our study participants had better post-procedural sexual function, when they witnessed the procedure live on a monitor, with their vision of the operating area blocked, compared with those who could see all the instrumentation live as well as to those whose eyes were covered during the procedure. The post-procedural sexual dysfunction in our study participants was more due to unexplainable procedure-related psychological disturbance than due to the in situ stent.
The discourse on sex and sexuality in a public platform is a rarity even now [11]. Even in a clinical setting, female sexual dysfunction is rarely addressed adequately [12]. Advanced curative concepts have hardly involved in sexual health across the globe, especially in an oriental setting [13]. The literature on the post-procedural sexual function in patients undergoing therapeutic endourology procedures such as ureteroscopy is very sparse across the globe, and the patients tend to report reduction in sexual function from baseline, if specifically enquired about [14]. As therapists, we tended to ask more complaints related to infection, hematuria, or pain after an endourology procedure, rather than the sexual function. Even when the patients themselves complain of post-procedural sexual dysfunction, it is difficult to address due to lack of literature support. Therefore, we conducted this study and found that the majority of the patients suffered from a reduction of sexual function after semi-rigid ureteroscopy for uncomplicated distal ureteric calculi.
The majority of the available literature on post-procedural sexual dysfunction following endourological procedures, points towards the indwelling stents as the major risk factors for development of sexual dysfunction in these patients [[15], [16], [17], [18]]. If that being the case, the sexual function should return to baseline after stent removal. However, our study results were slightly different, with the continued sexual dysfunction in certain sexual domains even after 12 weeks of stent removal in almost 3%–13% of the males and about 8%–38% of the females, thus questioning the logic of the stent in situ alone being the reason for post-procedural sexual dysfunction in such patients. Sofer et al. [19] reported findings similar to our study in 50 men who underwent endourological procedures, which included ureteroscopy, retrograde intra renal surgery, and percutaneous nephrolithotomy.
The literature on the post-endourological procedure sexual function in males, has mainly addressed the issue of erection and majority has reported temporary reduction in erectile function in males as the major affected domain which returned to baseline after 3 months [4,16,[18], [19], [20]]. Only Sofer et al. [19] have opined that all the domains of male sexual function are temporarily affected after an endourological procedure in males. Similarly, we found that almost all domains of sexual function were temporarily affected in males and 7.9% of them reported to have continued erectile dysfunction even after 3 months of the procedure, which required additional treatment modalities. Our male participants had post-procedural reduction in sexual drive as the major complaint.
The available literature is divided on the issue of effect of endourological procedure on female sexual function. Similar to our study, Kazmi et al. [15], Fawzi and Ali [16], and Akdeniz and Bolat [17] have reported significant reduction in female sexual function. However, their study participants had a higher mean age compared to our study participants. It is important to note that our study participants had reduced orgasmic function even after 3 months of the procedure, which never returned to baseline, unlike the participants from the above-mentioned studies. In contrast to this, Eryildirim et al. [21] have reported no significant effect of ureteroscopy on female sexual function.
The exact mechanism underlying the post-procedural reduction in sexual function is still unknown. Though many researchers have suggested in situ stent as the main reason for this, we could not attribute the post-procedural sexual dysfunction to the indwelling stent as such. Pre-procedural anxiety had a definite role in reduced sexual function in males especially during the first postoperative week. As seen in our study, it is the unexplainable procedure-related psychological disturbance related to the sense of violation of the genitals, which is the reason for reduced post-procedural sexual function in our study participants.
Our study has clearly shown the importance of proper operation room setting with a separate monitor showing the procedure live to the conscious patient along with a screen separating the operating area from the patients’ vision as the most appropriate operating room setting to limit the unexplainable procedure-related psychological disturbance and also the resultant reduction in sexual function following semi-rigid ureterorenoscopy. The strength of our study is the use of validated tools to assess all the variables under the study and the prospective randomized design. The limitation of the study is inability of the study to provide direct biological basis for post-procedural reduction in sexual function in our study participants.
5. Conclusion
Semi-rigid ureterorenoscopy for uncomplicated distal ureteric stones had a significant negative effect on sexual function of the participants in the sample studied. The sexual function almost returned to the baseline after 12 weeks in the majority of our participants. However, a significant percentage of our participants had reduced sexual function even after 12 weeks of the procedure; this required prolonged treatment. An ideal operative room setting could contribute to reduction in unexplainable procedure-related psychological disturbance. Such an ideal operating room setting resulted in lesser reduction in the post-procedural sexual function in our patients. An operating room setting wherein the patient can view the procedure live on a separate monitor, with a screen blocking the view of operating area resulted in a statistically significant reduction in negative effect on post-procedural sexual function.
Author contributions
Study concept and design: Gajanan S. Bhat, Anuradha Shastry.
Data acquisition: Gajanan S. Bhat, Anuradha Shastry.
Data analysis: Gajanan S. Bhat.
Drafting of manuscript: Gajanan S. Bhat, Anuradha Shastry.
Critical revision of the manuscript: Anuradha Shastry.
Conflicts of interest
The authors declare no conflict of interest.
Footnotes
Peer review under responsibility of Tongji University.
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