Annals of Vascular Surgery
Volume 20, Issue 2 , Pages 195-199, March 2006

Retroperitoneal Aortic Aneurysm Repair: Long-Term Follow-Up Regarding Wound Complications and Erectile Dysfunction

  • Jeffrey L. Ballard, MD, FACS

      Affiliations

    • Department of Surgery, University of California, Irvine, Orange, CA, USA
    • Vascular Institute, St. Joseph Hospital, Orange, CA, USA
    • Corresponding Author InformationCorrespondence to: Jeffrey L. Ballard, MD, FACS, 1140 W. La Veta Avenue, Suite 850, Orange, CA, 92868, USA
    • ,
  • Ahmed M. Abou-Zamzam Jr., MD

      Affiliations

    • Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
    • ,
  • Theodore H. Teruya, MD

      Affiliations

    • Department of Surgery, University of Hawaii, Honolulu, HI, USA
    • ,
  • Timothy R.S. Harward, MD

      Affiliations

    • Vascular Institute, St. Joseph Hospital, Orange, CA, USA
    • ,
  • D. Preston Flanigan, MD

      Affiliations

    • Department of Surgery, University of California, Irvine, Orange, CA, USA
    • Vascular Institute, St. Joseph Hospital, Orange, CA, USA

Article Outline

The long-term impact of retroperitoneal aortic exposure regarding wound complications in all patients and erectile dysfunction in men was studied in a consecutive group of 107 patients (81 males and 26 females). Postoperative wound complications were classified into the following groups: none, flank bulge, hernia, and chronic pain. Patient demographic features including body mass index (BMI) were statistically analyzed in relation to the incidence of long-term wound problems. Information regarding erectile dysfunction was obtained before surgery in all men and stratified into three groups after surgery: no change, inability to consistently obtain an erection, and retrograde ejaculation. Mean patient follow-up was 2.9 years (range 1–4.36, median 2.8). Flank bulge was the only long-term wound complication, and this was noted in nine patients (8%). The incidence of true hernia and chronic pain was 0%. BMI >28 was the only factor that positively impacted the incidence of wound complications (p < 0.0001). Erectile dysfunction prior to surgery was noted in 37 men (46%), while 44 (54%) reported normal erectile function. Erectile function improved after surgery in one patient but remained unchanged in the rest. Postoperative retrograde ejaculation occurred with a frequency of 9% (four of 45 patients). Retroperitoneal abdominal aortic aneurysm (rAAA) exposure with incision based on the twelfth rib tip and rectus abdominis muscle sparing results in an overall low incidence of long-term wound complications. Postoperative flank bulge is associated with patient BMI >28. In addition, erectile function is not worsened by infrarenal autonomic nerve sparing rAAA exposure. However, a small percentage of potent men will experience postoperative retrograde ejaculation.

 

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INTRODUCTION 

A flank incision affords retroperitoneal access to the abdominal aorta and its visceral/renal branches as well as the iliac arteries without entering the peritoneal cavity. The incision we use extends in a horizontal plane from the twelfth rib tip toward the umbilicus and spares the rectus abdominis muscle. Many authors have noted that this surgical approach to open abdominal aortic aneurysm (AAA) repair is associated with decreased complications, shorter hospital/intensive care unit (ICU) days, and decreased cost compared to transperitoneal aortic exposure.1, 2, 3, 4, 5, 6, 7 However, complications of this incision may include chronic incisional pain, intercostal neuropathy, hernia, or flank bulge/eventration. This last complication, while not a true hernia with a fascial defect, represents a laxity of abdominal musculature. It is thought to result from eleventh intercostal nerve injury if the incision is extended proximal and lateral to the tip of the twelfth rib.8 The incidence of this annoying complication is reported to range 11–23%.8

Notwithstanding other serious complications of aortoiliac procedures, one other potential complication that has received significant attention of late for other reasons (i.e., television advertising, new medications) is erectile dysfunction. Parasympathetic and sympathetic nerve fibers course along the infrarenal aorta and arch over the left common iliac artery, and damage to these autonomic fibers can result in erectile dysfunction and/or retrograde ejaculation in males.9, 10, 11, 12, 13, 14, 15, 16 The baseline incidence of erectile dysfunction in males presenting for aneurysm repair is at least 30%, and this incidence doubles over the ensuing 7 years with or without any aortoiliac procedure.10 An additional significant proportion of potent men undergoing either open or endovascular aortic aneurysm repair will experience worsening sexual function.10, 11, 12, 13, 14 Therefore, preservation of sexual function should be among the factors considered when treatment options for aneurysm repair are discussed with a sexually active male.

Previous reports describing retroperitoneal AAA (rAAA) exposure primarily discuss perioperative results and portray a multitude of incision/exposure strategies. In addition, there are few data available regarding the long-term results of rAAA exposure performed in a standard operative fashion with regard to wound complications and erectile dysfunction.15, 16, 17 With the above in mind, this clinical series is quite focused and specifically examines the impact of rAAA exposure on the incidence of wound complications in all patients and erectile dysfunction in men.

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METHODS 

One hundred seven consecutive patients (81 males, 26 females) had elective rAAA repair at a single institution from October 2000 to May 2003. These patients participated in an institutional review board-approved quality-of-life study that has been previously published, and they all followed the same pre- and postoperative surgical protocol.1, 2 The following list briefly describes key highlights of our standard approach for a left-sided procedure.9

1.The incision extends from the tip of the twelfth rib and is carried medially toward the lateral border of the rectus abdominis muscle in a horizontal plane that avoids crossing a dermatome. In males, resection of the anterior aspect of the twelfth rib facilitates retroperitoneal aortic exposure. However, in females, partial twelfth rib resection is not always required.

2.The anterior rectus sheath is opened to allow medial retraction (as opposed to transection) of the rectus abdominis muscle.

3.Autonomic nerve fibers that course along the anterolateral aspect of the infrarenal aorta and arch over the left common iliac artery origin are gently retracted from lateral to medial. Few to no nerve fibers are avulsed or cut during the procedure.

4.Ligation and division of the inferior mesenteric artery flush with the aorta is routinely performed. This facilitates exposure of the distal anterolateral surface of the infrarenal aorta and the right common and external/internal iliac arteries. Every effort is made to maintain bilateral hypogastric artery perfusion except in situations where exclusion/ligation is absolutely necessary.

5.Wound closure is accomplished in multiple anatomic layers. A #1 Vicryl suture is used to close the posterior rectus sheath and transversus abdominis muscle fibers in one layer. Then the internal oblique muscle fibers/aponeurosis is reapproximated from lateral to medial with a #1 Vicryl suture. The anterior rectus sheath and external oblique aponeurosis are then closed with a #1 PDS suture. Scarpa's fascia is reapproximated with a 2–0 Vicryl suture, and finally, the skin incision is closed in subcuticular fashion with 3–0 Monocryl suture.

All patients were asked preoperatively if they were sexually active in addition to responding to a standard set of life-quality (SF-12®) questions that were previously reviewed and published.1 Men were also specifically asked if they could consistently obtain an erection and if they considered themselves to be impotent. After surgery, at intervals of 3 weeks, 4 months, and 12 months, all patients were queried regarding sexual function and men specifically were again queried regarding erectile and ejaculatory function. No specific questionnaire regarding erectile dysfunction was administered.11, 12 In addition, the flank incisions in all patients were carefully examined for evidence of chronic pain (>6 months in duration), bulge, or true hernia with the patient supine and standing at all postoperative visits. Computed tomographic scan was used to differentiate flank bulge from a true hernia in selected cases.

All patients were clinically examined at least 1 year after surgery. Further long-term follow-up was achieved via either clinical examination (80% of patients) or telephone interview (20%). Mean patient follow-up was 2.9 years (range 1–4.36, median 2.8). Postoperative wound complications were classified into the following groups: none, flank bulge, hernia, and chronic pain. Patient demographic features including body mass index (BMI) were statistically analyzed in relation to the incidence of long-term wound problems (Table I). BMI is the number that results when a person's weight (in kg) is divided by height (in m) squared. A person with a BMI between 25 and 29.9 is considered overweight, and a person with a BMI ≥30 is considered obese. Information regarding sexual activity and erectile function was also obtained before surgery in all men and stratified into three groups after surgery: no change, inability to consistently obtain an erection, or retrograde ejaculation. These data are presented using statistical analysis of frequencies and chi-squared analysis.

Table I. Patient demographic features
rAAA repair (n/%)
Gender
Males81/76%
Females26/24%
Mean age (years)72
Range(56–89)
Nicotine abuse (present or past)78/73%
Hypertension (medically treated)87/81%
History of MI, CHF, or angina85/79%
History of COPD57/53%
↑ Cholesterol/lipid (medically treated)61/57%
Renal insufficiency (Cr >1.5 mg/dL)19/18%
Diabetes (IDDM or NIDDM)20/19%
BMI >2810/9%
Preoperative erectile dysfunction37/46%
Bifurcated graft88/82%
Tube graft19/18%

MI, myocardial infarction; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; Cr, creatinine; IDDM, insulin-dependent diabetes mellitus; NIIDDM, non-insulin-dependent diabetes mellitus.

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RESULTS 

Three patients (2.8%) required intercostal nerve block to treat perioperative wound pain, with complete resolution of this pain by 4 months postoperative. The incidence of chronic pain was 0%, as was the incidence of true hernia. Flank bulge was the only long-term wound complication, and this was noted in nine patients (8%). Two of these patients were female, and the other seven were male. Ninety-eight patients (92%) were free of wound problems at latest follow-up. BMI >28 was the only factor that positively impacted the incidence of wound complications (p ≤ 0.0001).

Erectile dysfunction prior to surgery was noted in 37 men (46%), while 44 (54%) sexually active men reported normal erectile function. Erectile function and sexual activity returned to normal after surgery in one patient who had aortobiiliac reconstruction but remained unchanged in the rest. Postoperative retrograde ejaculation occurred with a frequency of 9% (four of 45 sexually active postoperative patients). Impact of type of surgical reconstruction, aortobiiliac versus aortoaortic, on erectile function could not be determined with any reliability due to the lack of change in all but one patient.

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DISCUSSION 

This long-term study investigated two specific potential postoperative problems that could result from rAAA exposure. Wound problems are often cited as a downside when comparing rAAA exposure to transabdominal aortic exposure.3, 5, 6, 7 Perceived wound problems may be one reason the retroperitoneal approach is not necessarily considered the gold standard for open aortoiliac procedures despite its inherent advantages regarding decreased overall complications, hospital/ICU days, and cost.1, 2, 3, 4, 5, 6, 7 However, the incidence of wound complications in this series was low and influenced only by BMI >28. Postoperative erectile dysfunction is also cited as a reason one might endorse endovascular AAA repair over open repair, particularly in potent males.10, 11, 12, 13 Even so, worsening sexual function has been documented in patients having either open or endovascular aortoiliac procedures.12 In this series, postoperative retrograde ejaculation developed in a small percentage of potent men due to inadvertant sympathetic nerve fiber injury. The ability to obtain an erection did not appear to be affected by this autonomic nerve sparing rAAA exposure; however, a standardized questionnaire regarding erectile dysfunction was not administered to the men participating in this study.

The standardized surgical approach described in this series definitely seems to decrease the incidence of long-term wound complications. We believe there are a number of reasons for this finding. The incision length is kept to a minimum and is extended across the flank in a horizontal plane. This avoids crossing dermatomes. In addition, medial retraction of the rectus abdominis muscle instead of its transection facilitates maintenance of flank wall integrity. Multilayer closure of each fascial and muscular plane as opposed to bulk closure of all layers together returns the wound to its original state as much as possible. Finally, beginning the incision at the tip of the twelfth rib and not in the tenth or eleventh intercostal space protects the patient from injury to the eleventh intercostal nerve as well as from entry into the left chest.

The eleventh intercostal nerve changes its anatomic position from the inferior groove of the eleventh rib to the middle of the intercostal space as it courses anteriorly toward the midline.8 In the anterior aspect of the eleventh intercostal space, the nerve bifurcates into anterior and posterior branches. The anterior branch innervates the external oblique muscle and overlying skin while the posterior branch innervates the transversus abdominis and internal oblique muscle fibers.8 Injury to either branch will denervate a variable portion of muscle or skin in the corresponding nerve distribution that may be clinically undetectable. However, injury proximal to the point of nerve division will result in denervation of all three muscle layers and overlying skin, thereby potentially increasing the incidence of abdominal bulge, hernia, or chronic pain.8

Obese patients with BMI >28 were the only patients in this clinical series to experience a long-term wound complication. In our experience, this group of patients has attenuated abdominal musculature, thereby increasing the potential incidence of postoperative flank bulge. However, the multilayered fascial and muscle closure as described above appears to at least eliminate the incidence of true hernia. This potential postoperative flank asymmetry is discussed in full preoperatively with all patients but particularly those with BMI >28. We are more than willing to accept the risk of flank bulge as a tradeoff for the superior abdominal aortic exposure that is afforded by the retroperitoneal approach especially in very overweight patients.

In addition, autonomic nerve sparing rAAA exposure as described in this series appears to result in a low incidence of postoperative erectile dysfunction. The coalescence of parasympathetic and sympathetic nerve fibers, which interconnect at the para-aortic and superior hypogastric plexus levels, is readily palpable as one medially rotates the peritoneal contents off the terminal abdominal aorta.9, 15, 16, 17 Flush ligation and division of the inferior mesenteric artery facilitate mobilization of the nerve fibers medially across the aorta, and in some cases the nerves can be gently lifted over the aneurysm. Alternatively, the overlying nerve fibers can be left undisturbed and the left limb of a bifurcated graft, for instance, can be passed through the intact but ectatic or aneurysmal common iliac artery to its point of termination. In any case, care should be taken not to avulse or cut these fibers unless absolutely necessary, to effect complete repair of the aneurysm. When nerve fibers require transection, this should be performed as proximal as possible and the transection should proceed from lateral to medial, sparing as many fibers as possible. Complete transection of the autonomic nerve fibers will likely result in retrograde ejaculation as well as erectile dysfunction.

Furthermore, there was a higher than previously reported rate of preoperative erectile dysfunction in this clinical series, which may be related to the fact that the average age of males was 72 years.10, 14 Erectile dysfunction and/or retrograde ejaculation appear to be unavoidable aspects of all types of aortoiliac procedures. The incidence of either complication persists whether the procedure is endovascular or open. Patients having aortoiliac endografts can develop impotence due to hypogastric artery occlusion and a corresponding decrease in pelvic circulation. Patients having open aortoiliac repair may develop impotence due to a decrease in pelvic circulation or injury to parasympathetic nerve fibers, whereas retrograde ejaculation may occur due to sympathetic nerve injury. Autonomic nerve sparing rAAA exposure, in addition to preservation or improvement of hypogastric blood flow, is essential for maintenance of sexual function after aortoiliac procedures.15, 16, 17 Using these techniques, no patient in this series reported new-onset erectile dysfunction, although four patients experienced postoperative retrograde ejaculation.

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CONCLUSIONS 

rAAA exposure with incision based on the twelfth rib tip and rectus abdominis muscle sparing results in an overall low incidence of long-term wound complications. Postoperative flank bulge is associated with patient BMI >28. In addition, nearly 50% of men presenting for aneurysm repair already have erectile dysfunction, and erectile function is not worsened by infrarenal autonomic nerve sparing rAAA exposure. However, a small percentage of potent men will experience postoperative retrograde ejaculation.

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REFERENCES 

  1. Ballard JL , Abou-Zamzam AM , Teruya TH , Bianchi C . Quality of life before and after endovascular and retroperitoneal abdominal aortic aneurysm repair . J Vasc Surg . 2004;39:797–803
  2. Ballard JL , Yonemoto H , Killeen JD . Cost effective aortic exposure: a retroperitoneal experience . Ann Vasc Surg . 2000;14:1–5
  3. Sicard GA , Reilly JM , Rubin BG , et al.   Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial . J Vasc Surg . 1995;21:174–183
  4. Darling RC , Shah DM , McClellan WR , Chang BB , Leather RP . Decreased morbidity associated with retroperitoneal exclusion treatment for abdominal aortic aneurysm . J Cardiovasc Surg . 1992;33:65–69
  5. Lacroix H , Van Hemelrijk J , Nevelsteen A , Suy R . Transperitoneal versus extraperitoneal approach for routine vascular reconstruction of the abdominal aorta . Acta Chir Belg . 1994;94:1–6
  6. Grace PA , Bouchier-Hayes D . Infrarenal abdominal aortic disease: a review of the retroperitoneal approach . Br J Surg . 1991;78:6–9
  7. Quinones-Baldrich WJ , Garner C , Caswell D , et al.   Endovascular, transperitoneal, and retroperitoneal abdominal aortic aneurysm repair: results and costs . J Vasc Surg . 1999;30:59–67
  8. Hoffman RS , Smink DS , Noone RB , Noone RB , Smink RD . Surgical repair of the abdominal bulge: correction of a complication of the flank incision for retroperitoneal surgery . J Am Coll Surg . 2004;199:830–835
  9. Ballard JL . Anatomy and surgical exposure of the vascular system . In:  Moore WS editors. Vascular Surgery: A Comprehensive Review . 7th ed.. Philadelphia: W.B. Saunders; 2006;p. 46–68
  10. Jimenez JC , Smith MM , Wilson SE . Sexual dysfunction in men after open or endovascular repair of abdominal aortic aneurysms . Vascular . 2004;12:186–191
  11. Lee ES , Kor DJ , Kuskowski MA , Santilli SM . Incidence of erectile dysfunction after open abdominal aortic aneurysm repair . Ann Vasc Surg . 2000;14:13–19
  12. Karkos CD , Wood A , Bruce IA , Karkos PD , Baguneid MS , Lambert ME . Erectile dysfunction after open versus angio-plasty aortoiliac procedures: a questionnaire survey . Vasc Endovasc Surg . 2004;38:157–165
  13. Xenos ES , Stevens SL , Freeman MB , Pacanowski JP , Cassada DC , Goldman MH . Erectile function after open or endovascular abdominal aortic aneurysm repair . Ann Vasc Surg . 2003;17:530–538
  14. Lederle FA , Johnson GR , Wilson SE , et al.   Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small abdominal aortic aneurysm . J Vasc Surg . 2003;38:745–752
  15. Flanigan DP , Schuler JJ , Keifer T , Schwartz JA , Lim LT . Elimination of iatrogenic impotence and improvement of sexual function after aortoiliac revascularization . Arch Surg . 1982;117:544–550
  16. DePalma RG , Levine SB , Feldman S . Preservation of erectile function after aortoiliac reconstruction . Arch Surg . 1978;113:958–962
  17. Sieunarine L , Lawrence-Brown MM , Goodman MA . Comparison of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early and late results . Cardiovasc Surg . 1997;5:71–76

 Presented at the Western Vascular Society 20th Annual Meeting, Park City, UT, September 26, 2005.

PII: S0890-5096(06)60031-9

doi:10.1007/s10016-006-9014-2

Annals of Vascular Surgery
Volume 20, Issue 2 , Pages 195-199, March 2006

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