Erectile Dysfunction and Its Impact on Health-Related Quality of Life in Prostate Cancer Patients: A Multicenter Cross-Sectional Study from Pakistan.

Preface Currently, there are many wellestablished therapeutic options for early prostate cancer, and therefore, it is difficult for both urologists and patients to choose the optimal treatment. It is essential for urologists to counsel their patients according to reliable information about the advantages and disadvantages of each therapeutic option. We picked the topic for this issue, “Characteristics and management of erectile dysfunction after various treatments for prostate cancer,” because erectile dysfunction (ED) is one of the most frequent adverse events encountered in the management of prostate cancer. We invited six specialists to review each therapeutic option: radical prostatectomy, laparoscopic radical prostatectomy, robot-assisted laparoscopic radical prostatectomy, external beam radiotherapy, brachytherapy, and androgen deprivation therapy (ADT). Among these modalities, surgical interventions tend to induce a quick drop in erectile function with slow postoperative recovery. Early postoperative rehabilitation has been introduced, aiming at the early recovery of ED. On the contrary, radiation therapy tends to maintain the patient’s erectile function for a while after treatment but it gradually decreases. ADT may compromise not only the erectile function but also the libido level, and may result in significant deterioration of the patient’s quality of life. We hope these reviews will help urologists to counsel their patients with regards to decision-making in the management of early prostate cancer.

Longitudinal Changes in U.S. Parameters of Neurovascular Bundles Suggest Mechanism for Radiation-Induced Erectile Dysfunction

To evaluate the association between dose-volume histogram (DVH) values in organs at risk (OAR) and patient-reported HRQoL outcomes. Data on the association between DVHs and health-related quality of life (HRQoL) in prostate cancer (PCa) patients are limited. Five-year follow-up study of 154 patients with organ-confined (stage T1/T2) PCa treated with EBRT between January 2003 and November 2005. HRQoL was evaluated with the Expanded Prostate Cancer Index (EPIC). DVH for OARs (penile bulb, rectum and bladder) were created for all patients for whom data were available (119/154; 77%). The functional data analysis (FDA) statistical method was used. HRQoL data was collected prospectively and data analysis was performed retrospectively. Worsening of urinary incontinence and obstructive symptoms correlated with higher DVH dose distributions at 24 months. Increased rectal bleeding at months 24 and 60 correlated with higher DVH dose distributions in the 40-70 Gy range. Patients with deterioration in rectal incontinence presented a higher DVH distribution range than patients without rectal incontinence. Penile bulb DVH values and erectile dysfunction were not significantly associated. DVH parameters and post-radiotherapy HRQoL appear to be closely correlated, underscoring the importance of assessing DVH values prior to initiating EBRT to determine the risk of developing HRQoL related adverse effects. Advanced treatment modalities may be appropriate in high risk cases to minimize treatment-related toxicity and to improve treatment outcomes and HRQoL. Future studies are needed to better elucidate the association between pre-treatment DVH parameters in organs at risk and subsequent HRQoL.

Objectives Radiotherapy for prostate cancer causes erectile dysfunction (ED) in about 40% of the patients. Hypofractionated radiotherapy has become the new clinical standard for prostate cancer. Several randomized trials reported non-inferiority of hypofractionated radiotherapy with respect to late toxicity. We investigated the effect on erectile function of moderate hypofractionation (MHF = 20x3/3.1Gy) and ultra-hypofractionation (UHF = 7x6.1Gy) in clinical practice. Methods We evaluated n = 168 cT1-cT2 prostate cancer patients treated with UHF (n = 113) or MHF (n = 55) without androgen-deprivation therapy who were included in the prospective cohort study “Health-Related Quality of Life in Prostate Cancer Patients treated with Radiotherapy” (PRORAD) in 2019-2023. UHF was restricted to patients with adequate urinary function. The radiation dose was prescribed to the prostate +/- base of seminal vesicles, depending on the risk group. Questionnaires were distributed at baseline, end of treatment, 3-6-12-24-36-48-60 months post-radiotherapy. Erectile function was scored with the abridged five-item version of the International Index of Erectile Function (IIEF-5). We evaluated collected data at baseline, and 6-12-24-36 months after treatment. Defined ED categories were: no (22-25 points), mild (17-21), mild-to-moderate (12-16), moderate (8-11), and severe ED (5-7). Results Median follow-up was 24 months. Of those patients who had none-to-mild ED at baseline (score > =17, n = 73, 43%), 7.2%, 18.9% and 13.9% reported severe ED at 12-24-36 months, respectively. At baseline, n = 49 (29%) reported severe ED. Average scores (with 1 standard error) over time are shown in the Figure for the remaining n = 119, per treatment group. The risk of developing severe ED significantly correlated with baseline erectile function (p < 0.001). At last follow-up, severe ED was reported in 5%, 24%, 33% and 68% in the subgroup with no, mild, mild-to-moderate and moderate ED at baseline, respectively. In patients with a baseline IIEF score > =12 (n = 100), 19% had developed severe ED at last follow-up (MHF 24%, UHF 17%, p = 0.5). Conclusions MHF and UHF were associated with a similar decrease in erectile function in this patient population, with results comparing favourably with conventionally fractionated radiotherapy reported in the literature. The risk of developing severe ED significantly correlated with baseline erectile function. Conflicts of Interest None.

Baseline Functional Status May Predict Decisional Regret Following Robotic Prostatectomy

Patients with cirrhosis have high prevalence of erectile dysfunction (ED). The aim of this study was to study the efficacy and safety of tadalafil for ED in patients with cirrhosis. 140 cirrhotic males with ED were randomized into tadalafil 10mg daily (n = 70) or placebo (n = 70) for 12weeks. ED was diagnosed if erectile function (EF) domain score was < 25 in International Index of Erectile Function (IIEF) questionnaire. The erectile function domain consists of six questions concerning erection frequency, erection firmness, frequency of partner penetration, frequency of maintaining erection after penetration, ability to maintain erection to completion of intercourse and confidence in achieving and maintaining erection. Primary outcome was proportion of patients having an increase in > 5 points in EF domain of the IIEF. Generalized Anxiety Disorder 7(GAD-7) questionnaire was used for screening and severity measuring of GAD. The presence of depression was screened using the Patient Health Questionnaire (PHQ-9) and the assessment of health related quality of life was done using the Short Form (36) Health Survey. At the end of 12weeks, more patients in tadalafil group achieved > 5 points increase in the EF domain of the IIEF when compared with the placebo group [44(62.9%) vs. 21(30%), p < 0.001]. At the end of 12weeks, patients receiving tadalafil had significantly more change in scores on the erectile function domain, orgasmic function domain, intercourse satisfaction domain, overall satisfaction domain, erection vaginal penetration rates and successful intercourse; significantly more decline in the GAD-7 and PHQ-9 scores; significantly more improvement in scores of five of the eight domains of SF-36 (general health perception, vitality score, social functioning, role emotional and mental health) and the mental component summary rates when compared with placebo. The development of side effects and the changes in HVPG were not significantly different between the two groups. Tadalafil therapy may enhance erectile function, improve anxiety, depression and quality of life; and is well tolerated by men with cirrhosis (CTP score < 10) and ED. However, further larger and long-term studies are needed to confirm these results and look for rarer side effects of using tadalafil in patients with cirrhosis. ClinicalTrials.gov identifier number NCT03566914; first posted date: June 25, 2018.

SILDENAFIL CITRATE AFTER RADICAL RETROPUBIC PROSTATECTOMY

Decrease in Intercourse Satisfaction in Men Who Recover Erections After Radical Prostatectomy

Erectile Dysfunction

Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy

Preoperative Erectile Function Represents a Significant Predictor of Postoperative Urinary Continence Recovery in Patients Treated With Bilateral Nerve Sparing Radical Prostatectomy

To prospectively study the effects of hyperbaric oxygen therapy (HBOT) on the recovery of erectile function (EF) after posterior urethral reconstruction. Between August 2006 and March 2010, a total of 24 male patients with posterior urethral reconstruction and without erectile dysfunction (ED) before urethral stricture were involved in the study. Twelve of them were assigned to HBOT group that received HBOT, and the others comprised the control group. All 24 participants were asked to assess their EF pre-operatively and 3 months postoperatively by using the International Index of Erectile Function (IIEF). All 24 participants completed the study. The total IIEF scores and scores in two domains of IIEF (erectile function (EF) and overall satisfaction (OS) domain) were significantly lower than the preoperative baseline scores in HBOT group (P < 0.05). Meanwhile, a significant decrease in the total IIEF scores and scores in three domains of IIEF (EF, OS and intercourse satisfaction (IS) domain) was observed in control group (P < 0.05). However, at 3 months postoperatively, the total IIEF scores and scores in three domains of IIEF (EF, OS and IS domain) after HBOT were significantly higher in HBOT group than in control group (P < 0.05). These preliminary results suggest that HBOT may be effective for improving EF recovery after posterior urethral reconstruction.

Objective To evaluate the health-related quality of life (HRQOL) for prostate cancer patients receiving androgen deprivation therapy (ADT). Methods We studied 200 patients with prostate cancer who were treated with primary ADT in Peking University People's Hospital from June 2014 to June 2015. The patients'average age was 73.9 years. The mean PSA level was 21.57 ng/ml when they were diagnosed with prostate cancer. Of these 200 patients, 79%(158/200) were localized and seclected ADT therapy due to age, body condition, basic diseases or individual will.21% (42/200) were locally advanced or metastasic, which accord with the indication of ADT therapy.The scales, including the MOS item short from health survey (SF-36), Functional Assessment of Cancer Therapy -General module (FACT-G), Functional Assessment of Cancer Therapy -Prostate instrument (FACT-P), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were used to evaluate their HRQOL. Results According to results of SF-36, the physical health component score and mental health component score was 67.41±16.39 and 64.81±17.51, respectively. They indicated that the overall quality of life of these patients was at an acceptable level. And the average score of domains exceeded 60 except general health domain, which the score was only 40.03±21.89. When it comes to FACT-P, the sum score, emotional well-being score and prostate cancer component score were 8.15±3.72, 12.30±4.04 and 77.41±9.95, respectively, which were less than half of their respective top score. However the physical well-being score was 20.41±4.29, which was a relatively satisfactory value. In addition, 61% (121/200) patient selected not at all in item I am able to have and keep an erection . The score of SDS and SAS was 46.76±8.29 and 43.25±9.69, respectively. And there were 23.0% (46/200) and 21.5% (43/200) patiens exhibited depression and anxiety, respectively. Conclusion In the present study, the prostate cancer patients receiving ADT showed acceptable HRQOL, but some patients sufferd from depression, anxiety and erectile dysfunction. Key words: Prostate cancer; Androgen deprivation therapy (ADT); Health-related quality of life (HRQOL)

Association of Financial Burden with Symptom Burden and Health Related Quality of Life in Prostate Cancer Patients Receiving Radiation Treatment

Prevalence and risk factors of erectile dysfunction in Japanese men with type 2 diabetes