Abstract
Orchiectomy is the recommended treatment for many testicular conditions. However, testicular prosthesis placement is not always performed for different reasons. In this study, we aimed to evaluate patients’ opinions and the impact on sexual function and quality of life. This retrospective observational single-center study included patients who underwent orchiectomy between January 2014 and December 2020 at the Department of Urology, Braga’s Hospital (Braga, Portugal), where testicular implants were always available and the decision to undergo the procedure was made fully independent of cost. Patients completed four questionnaires that assessed demographic data, satisfaction, self-esteem, and sexual function. Of the 96 patients who underwent orchidectomy, 59 replied to the questionnaires, and of these patients, 86.4% decided to undergo silicone-based testicular prostheses implantation. The remaining 13.6% refused the implant based on concerns about complications (37.5%), because they felt that it was unnecessary (37.5%), or because it was not offered by the doctor (25.0%). Overall, 96.1% of these patients were satisfied with the implant; however, 25.5% classified it as “too firm”. No statistically significant differences were found in sexual function (all P > 0.05). However, it can be observed that there are more patients with prostheses presenting normal sexual activity compared to patients without prostheses (74.0% vs 50.0%), and none of them reported severe erectile dysfunction (0 vs 16.7%). Regarding self-esteem, both patients with and without prostheses present very similar average scores with no statistically significant differences. The present study highlights the highest level of satisfaction among patients who received testicular prostheses. Testicular prostheses implantation is a safe procedure that does not hamper sexual function after orchiectomy.
Keywords: orchiectomy, patient satisfaction, quality of life, sexual dysfunction, sexual health, testicular prostheses
INTRODUCTION
Orchiectomy is the recommended treatment for many testicular conditions, such as severe testicular atrophy, cryptorchidism, malignancy, and emergent injuries such as torsion or testicular rupture.1 The loss of a testicle due to these conditions has a considerable impact on sexual life and overall quality of life.1,2,3,4,5 Furthermore, most of these conditions occur among young males, who are in the most important period of life for sexual activity.6 Testicular prostheses placement is available to patients following orchiectomy to minimize psychological distress and restore quality of life and self-esteem.1,2,3,5 Although a good aesthetic result can be obtained, the presence of an artificial testis could be a cause of shame and loss of self-confidence during sexual activity.6 The quality of testicular prostheses has improved considerably since the first prostheses were implanted in 1941.1,2,3 Technical refinements regarding the material of the device were reported until the silicone-made testicular prostheses was introduced in 1973, which is still in use and has only undergone a few modifications.4,7 More recently, saline-filled implants have been available since 1995. In this study, all testicular prostheses were made of silicone. Furthermore, testicular prostheses placement is not always performed in the Department of Urology at Braga’s Hospital (Braga, Portugal) for different reasons, such as doctors’ preferences and patients’ options. In fact, there were 71 000 new cases of testicular cancer globally in 2018, but only approximately 49 000 testicular implants were produced globally in 2018.1 This indicates a relatively low testicular prosthetic utilization rate compared to the potential.8 Interestingly, a study in 2014 reported that 43.3% of women who underwent a mastectomy opted for breast reconstruction,9 while a study in 2015 reported that only 15.7% of men who underwent orchiectomy opted for testicular prostheses placement.10 Nevertheless, only a few studies have investigated testicular prostheses counseling and patient satisfaction.1 In this study, we aim to evaluate patients’ and partners’ opinions regarding testicular prostheses implantation and its impact on sexual function and quality of life.
PATIENTS AND METHODS
Medical questionnaires were developed and sent by email to 96 patients who underwent orchiectomy between January 2014 and December 2020 at Braga’s Hospital, where testicular implants were always available and the decision to undergo a testicular implant was made fully independent of cost. We retrospectively analyzed the patients’ data and noted whether patients had been offered testicular prostheses and whether they had accepted. To examine the associations of prostheses acceptance with clinical characteristics, we also evaluated other parameters. After obtaining written informed consent, patients completed four structured questionnaires (Supplementary Information). One questionnaire assessed demographic data and testicular prostheses satisfaction across 31 questions. In addition, three validated questionnaires were administered: the International Index of Erectile Function-5 (IIEF-5) was used to evaluate erectile function, the Premature Ejaculation Diagnostic Tool (PEDT) was used to assess premature ejaculation, and the 10-item Rosenberg Self-Esteem Scale was used to measure the self-confidence of each patient with respect to sexuality and other general aspects of life. The study was approved by the Institutional Ethical Committee (Approval No. refª 09_2021) and by the institutional health data protection of Braga’s Hospital. All the answers and scores of questionnaires were entered into a database. Statistical analyses were performed with IBM SPSS Statistics for Windows (version 27.0; IBM Corp., Armonk, NY, USA). General descriptive analyses were performed for categorical and continuous variables. Categorical variables were compared using Fischer’s exact test and the Cochran–Armitage trend test. We performed Student’s t-test to compare the mean score of the Rosenberg Self-Esteem Scale of patients with and without prostheses. Statistically significance was considered for P < 0.05.
RESULTS
Of the 96 patients who underwent orchidectomy, 59 (61.5%) responded to the questionnaires. The most frequent reason for orchiectomy was malignancy/risk of malignancy (n=46, 78.0%), as shown in Table 1. Of these patients, 39 (84.8%) underwent testicular prostheses insertion. Otherwise, 5 (83.3%) patients who had testicular torsion, 4 (100.0%) of those who had agenesis/maldescent testis, and 1 (100.0%) patient whose cause for orchidectomy was trauma decided to have a testicular implant. The median age at prostheses insertion was 31.6 years, and the median duration between surgery and interview was 3.5 years. Regarding the patients who underwent orchiectomy for malignancy or risk of malignancy, there were no significant differences in acceptance rate based on histology or clinical stage between patients with and without prostheses (both P > 0.05).
Table 1.
Reasons for orchiectomy, the percentage of patients who chose to receive testicular prostheses, the average age at insertion, and the time between the operation and the interview
| Cause of loss | Patients, n (%) | Patients with prostheses, n (%) | Patient’s age at prostheses insertion (year), median (range) | Time from surgery to interview (year), median (range) |
|---|---|---|---|---|
| Malignancy/risk of malignancya | 46 (78.0) | 39 (84.8) | 31.6 (19–44) | 3.9 (1–8) |
| Torsion | 6 (10.2) | 5 (83.3) | 21.2 (18–31) | 4.6 (2–6) |
| Agenesis or maldescent | 4 (6.8) | 4 (100.0) | 30.5 (16–45) | 3.3 (2–5) |
| Trauma | 1 (1.7) | 1 (100.0) | 40.0 | 4.0 |
| Miscellaneousb | 2 (3.3) | 2 (100.0) | 45.0 (34–56) | 4.3 (1.5–7.0) |
| Total | 59 (100.0) | 51 (86.4) | 31.6 (16–56) | 3.5 (1–8) |
aMalignancy/risk of malignancy: seminoma, nonseminoma, sertoli cell tumor, leydig cell tumor, fibrothecoma, atypical lipomatous tumor, and angiomyolipoma; bmiscellaneous: necrosis and fibrosis
Patients who accepted testicular implants seemed to have some differences in demographic characteristics when compared to patients who refused the procedure. Regarding education level, 19 patients (37.3%) who decided to undergo the procedure had education > 12th, while none of the patients who refused testicular implantation had this level of education. Moreover, 28 (54.9%) patients who accepted the implant were married or in a steady relationship, and 41 (80.4%) patients were sexually active. A total of 43 (84.3%) patients who accepted the implant stated that the aesthetic reasons were very important or important, while only 2 (25.0%) patients who refused testicular prostheses mentioned aesthetic reasons being important. Partner opinion was shown to have a small and similar impact on the decision to accept (n = 6, 11.8%) or refuse (n = 1, 12.5%) testicular prostheses. Among the patients who decided to undergo testicular prostheses implantation, 43 (84.3%) said their decision was based on self-esteem and appearance. The remaining patients refused testicular prostheses for different motives: concerns about complications (n = 3, 37.5%), because they felt that it was unnecessary (n = 3, 37.5%), or because it was not offered by the doctor (n = 2, 25.0%). No significant associations were found between the reported reasons to accept prostheses and education level, marital status at surgery, sexual activity at surgery, the perceived importance of a normal appearance with two testicles, and the influence of the partner’s opinion (all P > 0.05; Table 2).
Table 2.
Significant associations between reasons to accept with particular items of patient’s demographics
| Demographic | Reasons to accept | P | Effect size | |
|---|---|---|---|---|
|
| ||||
| Self-esteem/appearance for me, n (%) | Doctor’s suggestion, n (%) | |||
| Educationa | 0.080 | Φc=0.25 | ||
| > 12th | 18 (41.9) | 1 (14.3) | ||
| 9th or 12th | 21 (48.8) | 4 (57.1) | ||
| <9th | 4 (9.3) | 2 (28.6) | ||
| Marital status at surgeryb | 0.430 | Φ=0.14 | ||
| Single/divorced | 21 (48.8) | 2 (28.6) | ||
| Married/steady relationship | 22 (51.2) | 5 (71.4) | ||
| Sexual activity at surgeryb | 0.319 | Φ=0.20 | ||
| Active | 33 (76.7) | 7 (100.0) | ||
| Not active | 10 (23.3) | 0 (0) | ||
| Normal appearance with two testiclesa | 0.080 | Φc=0.30 | ||
| Very important | 13 (30.2) | 1 (14.3) | ||
| Important | 25 (58.1) | 3 (42.9) | ||
| Not important | 5 (11.6) | 3 (42.9) | ||
| Influence of partner opinionb | 0.192 | Φ=0.21 | ||
| Yes | 4 (9.3) | 2 (28.6) | ||
| No | 39 (90.7) | 5 (71.4) | ||
aCochran-Armitage Trend Test; bFisher’s exact test. Φc: Cramér’s V; Φ: Phi
As shown in Table 3, the results of the questionnaire regarding patient satisfaction show that most patients were satisfied with the size, weight, shape, and position of the implant within the scrotum (≥88%). However, 13 (25.5%) patients classified the prostheses as “too firm”. Only 4 (7.8%) patients reported problems during physical exercise, and 2 (3.9%) documented problems such as pain and changes in desire during sexual intercourse.
Table 3.
Results of questionnaire regarding patient satisfaction with testicular prostheses implantation at the time of interview
| Question | Patients, n (%) |
|---|---|
| Size | |
| Right | 45 (88.2) |
| Too large | 4 (7.8) |
| Too small | 2 (3.9) |
| Weight | |
| Right | 50 (98.0) |
| Too heavy | 1 (2.0) |
| Shape | |
| Right | 50 (98.0) |
| Not right | 1 (2.0) |
| Consistence | |
| Right | 38 (74.5) |
| Too firm | 13 (25.5) |
| Position within scrotum | |
| Right | 45 (88.2) |
| Too high | 5 (9.8) |
| Too low | 1 (1.9) |
| Chronic pain | |
| Yes | 5 (9.8) |
| No | 46 (90.2) |
| Problems during physical exercise | |
| Yes | 4 (7.8) |
| No | 47 (92.2) |
| Problems during sexual intercourse | |
| Yes | 2 (3.9) |
| No | 49 (96.1) |
| If your answer to the previous question was Yes, how is sexual intercourse affected? | |
| Pain | 1 (50.0) |
| Desire | 1 (50.0) |
Table 4 reveals that 49 (96.1%) patients who underwent testicular prostheses implantation were overall satisfied with the implant, and 49 (96.1%) patients felt very comfortable or comfortable with it. In fact, 48 (94.1%) patients reported that they would undergo the procedure again, and 49 (96.1%) patients reported that they would recommend the procedure to a friend. Significant associations were observed between overall satisfaction and particular items. Patients who reported being satisfied, in general, were more likely to find the size, weight, shape, and position to be adequate (91.8%, 100.0%, 100.0%, and 91.8%, respectively), and fewer of these patients declared having problems during physical exercise (4.1%).
Table 4.
Results of questionnaire regarding patient overall satisfaction with testicular prostheses implantation at the time of interview
| Question | Patients, n (%) |
|---|---|
| Overall satisfaction | |
| Yes | 49 (96.1) |
| No | 2 (3.9) |
| Overall comfort | |
| Very comfortable | 19 (37.3) |
| Comfortable | 30 (58.8) |
| Uncomfortable | 2 (3.9) |
| Would you have an implant again? | |
| Yes | 48 (94.1) |
| No | 3 (5.9) |
| Would you recommend it to a friend? | |
| Yes | 49 (96.1) |
| No | 2 (3.9) |
We also conclude that there were no statistically significant differences between patients with and without prostheses with respect to their confidence in changing clothes in public space and confidence in intimacy (all P > 0.05). However, patients with prostheses were more likely to be confident in these two situations (88.2% [n = 45] and 96.1% [n = 49], respectively) than patients without prostheses (75.0% [n = 6] and 85.7% [n = 6], respectively).
Finally, Table 5 shows the results of the three validated questionnaires. No statistically significant differences were found between patients with and without prostheses in scores on the IIEF-5, PEDT, and Rosenberg Self-Esteem scale (all P > 0.05). However, patients with prostheses were more likely to report normal sexual activity (74.0% [n = 37] vs 50.0% [n = 3]), and none of them reported severe erectile dysfunction (0 [n = 0] vs 16.7% [n = 1]). On the other hand, patients with prostheses reported a higher prevalence of premature ejaculation (34.7% [n = 17] vs 0 [n = 0]). Regarding self-esteem, both groups present very similar average scores with no statistically significant differences.
Table 5.
Results of 3 validated questionnaires (the International Index of Erectile Function-5, the Premature Ejaculation Diagnostic Tool and Rosenberg Self-Esteem Scale) at the time of interview
| Questionnaire | With prosthesesc | Without prosthesesd | P | Effect size |
|---|---|---|---|---|
| IIEF-5a, n (%) | 0.117 | Φc=0.43 | ||
| Normal sexual activity | 37 (74.0) | 3 (50.0) | ||
| Mild erectile dysfunction | 8 (16.0) | 2 (33.3) | ||
| Mild to moderate erectile dysfunction | 3 (6.0) | 0 (0) | ||
| Moderate erectile dysfunction | 2 (4.0) | 0 (0) | ||
| Severe erectile dysfunction | 0 (0) | 1 (16.7) | ||
| PEDTa, n (%) | 0.136 | Φc=0.22 | ||
| No premature ejaculation | 32 (65.3) | 5 (100.0) | ||
| Probable premature ejaculation | 7 (14.3) | 0 (0) | ||
| Premature ejaculation | 10 (20.4) | 0 (0) | ||
| Rosenberg Self-Esteem Scale (mean score)b | 25.63 | 25.57 | 0.972 | g=0.00 |
aCochran-Armitage Trend Test. bStudent’s t-test for independent samples. cTotal number for IIEF-5 was 50 because 1 patient is not able to have sexual intercourse and total number for PEDT was 49 because of the previous and 1 more patient with moderate erectile dysfunction was not capable of evaluate his ejaculation. dTotal number for IIEF-5 was 6 because 2 patients are not able to have sexual intercourse and total number for PEDT was 5 because of the previous and 1 more patient with severe erectile diysfunction was not capable of evaluate his ejaculation. Φc: Cramér’s V; g: hedges’ g; IIEF-5: the International Index of Erectile Function-5; PEDT: the Premature Ejaculation Diagnostic Tool
DISCUSSION
One of the most frequently implanted devices is testicular prostheses placement. Therefore, it was expected that there would be many studies evaluating men’s perception of such implants. However, this is not true. Therefore, in this study, which was conducted in our department, we aim to evaluate patients’ and partners’ opinions regarding testicular prostheses implantation and its impact on sexual function and quality of life.
The most frequent reason for orchiectomy was malignancy/risk of malignancy (78.0%), but there were no significant differences in the acceptance rate based on histology and clinical stage between patients with and without prostheses (all P > 0.05). This result is consistent with previous findings by Dieckmann et al.2 In Table 1, we also analyzed the median age at prostheses insertion for the various categories of disease, and it appears that age has no impact on the decision.
In our study, 84.3% of patients stated that having two testicles was very important or important for aesthetic reasons, similar to what was reported by Clifford et al.;5 however, no significant association was found between the reasons to accept the implant and the perceived importance of a normal appearance with two testicles (P > 0.05).
Relationship status may also impact patient attitudes and the decision to accept testicular prostheses. While Adshead et al.11 found lower acceptance rates in married men and in those in a steady relationship, Yossepowitch et al.12 noted no such preference, and Clifford et al.5 noted that just a few patients (17.5%) were influenced by their relationship status. Herein, we found the opposite: more patients who were married or in a steady relationship accepted testicular implants (62.7% vs 37.3%), which may reflect cultural and societal norms and expectations in Portugal. Furthermore, there were no significant associations between the reported reasons to accept prostheses and marital status at surgery, sexual activity at surgery, and the influence of the partner’s opinion (all P > 0.05).
In recent years, a trend of higher acceptance rates of testicular implants was noted. In this study, 86.4% accept the implant, in contrast to the 26.9% rate observed by Dieckmann et al.,2 who also reported that counseling was too abbreviated and not comprehensive. Srivatsav et al.1 reported that 37.0% of men who did not receive testicular prostheses indicated that they had not received any form of counseling at the time of orchiectomy. These findings are similar to those of Nichols et al.,13 who reported that 42.0% of men who did not receive testicular prostheses were not offered the option by their surgeon. In this study, only 25.0% of the patients who did not undergo testicular prostheses stated that it was not offered by the doctor. Therefore, this proportion of patients seems to be smaller with time, which could mean that doctors have been increasingly concerned about patient information and counseling.
Few studies have explored patient satisfaction with testicular prostheses. The subjective satisfaction level reported by patients who received a silicone-based testicular implant in our cohort was the highest among previously published studies, as far as we know. In fact, we report that 96.1% of patients were overall satisfied with their implant. Satisfaction levels demonstrated in previous studies were approximately 71.0%–83.0%.1,2,5,11,13 The majority of studies1,2,13 did not specify the type of implant used. Clifford et al.5 report an overall satisfaction rate of 82.5% with saline-filled implants. Adshead et al.,11 on the other hand, used a gel-filled implant (silicone type) with a 75.0% overall satisfaction rate. As a result, we believe that nothing can be definitively concluded about what type of material is associated with the best outcomes. In addition to the high satisfaction levels, we report that 96.1% of patients felt very comfortable or comfortable with the implant, similar to what was reported by Clifford et al.5 (92.5%). A total of 94.1% of patients reported that they would undergo the procedure again, and 96.1% reported that they would recommend it to a friend; both of these rates are very similar to the satisfaction rate. Once more, this rate is superior to that reported in previous studies.1,2,5
Patients who reported being satisfied, in general, found the size, weight, shape, and position to be more frequently adequate (91.8%, 100.0%, 100.0%, and 91.8%, respectively). This analysis was performed, and statistical results were found for all variables. However, these results are not presented because they are limited by the sample size and the inequality in the size of the two groups. In our work, only 25.5% classified prostheses as “too firm”. Srivatsav et al.,1 stated that several patients indicated concerns about implant firmness within the scrotum, and in two other studies performed by Clifford et al.5 and Dieckmann et al.,2 44.0% and 52.4% of testicular prostheses recipients noted that their testicular prostheses were too firm, respectively. Only 7.8% in our patients reported problems during physical exercise, similar to the 8.6% reported by Dieckmann et al.2 Few patients (3.9%) have documented problems during sexual intercourse with pain or changes in sexual desire. It could be concluded that testicular implant manufacturers improved in design and perhaps that surgeons improved their technique.
Furthermore, this study is one of the few that has analyzed not only patient satisfaction with aesthetic factors but also sexual activity after testicular prostheses implantation. Moreover, this is also one of the few published studies to analyze sexual activity after testicular prostheses implantation with psychological and sexual validated questionnaires (Rosenberg Self-Esteem, IIEF-5, and PEDT). Catanzariti et al.6 used 3 psychological validated questionnaires (Body Exposure during Sexual Activities Questionnaire, Body-Esteem Scale, and Rosenberg Self-Esteem) and 2 sexual validated questionnaires (IIEF-5 and PEDT). Turek and Master14 only used 3 psychological validated questionnaires (Body Exposure during Sexual Activities Questionnaire, Body-Esteem Scale, and Rosenberg Self-Esteem). Here, no statistically significant differences were found between patients with and without prostheses with respect to scores on the IIEF-5, PEDT, and Rosenberg Self-Esteem scale (all P > 0.05). These results are consistent with those of Catanzariti et al.6 None of the patients who underwent testicular prostheses implantation reported severe erectile dysfunction, so we conclude that testicular prostheses do not cause erectile dysfunction. Improved body image and self-esteem were common in patients who received an implant, but patients with prostheses and without prostheses presented very similar average scores on the Rosenberg Self-Esteem scale (25.63 vs 25.57).
However, this study is not without limitations that warrant further discussion. As with any questionnaire-based studies, this work is also susceptible to the possibility of respondent bias and omission, which are augmented by its retrospective nature. In addition, it is limited by a sample size of 59, which limits the generalizability of the results and statistical comparisons to make meaningful conclusions. However, the number of patients included is similar to the studies that included more patients. Furthermore, the lack of a preoperative baseline assessment made it difficult to estimate the true impact on quality of life and sexual function. On the other hand, the strengths of our investigation included the largest number of patients who accepted testicular prostheses and having a comparison group of patients who did not receive the implant.
CONCLUSION
To the best of our knowledge, we report one of the highest level of overall satisfaction with the testicular implant following orchiectomy. Patients’ decisions are mainly based on aesthetic reasons. Therefore, this study confirms that all patients undergoing orchiectomy should be advised about the availability of a testicular implant. This study revealed that counseling by physicians has been increasingly enlightening, which is reflected in the high acceptance rate of the procedure. However, it must be noted that there is still some dissatisfaction with the consistency of the implant, but it is still smaller than that reported in other studies. Optimizing the texture of the implant may continue to improve this outcome. We also showed that testicular prostheses implantation does not hamper sexual function. Further studies with a baseline assessment are needed to confirm our findings.
AUTHOR CONTRIBUTIONS
ASA and RL participated in the study conception and design. ASA was responsible for data collection. ASA, RL, and CO participated in the analysis and interpretation of results. ASA, SA, RR, CT, and AC drafted the article. All authors reviewed the results, and read and approved the final manuscript.
COMPETING INTERESTS
All authors declare no competing interests.
Supplementary Information is linked to the online version of the paper on the Asian Journal of Andrology website.
Questionnaire 1
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