The importance of radiation doses to the penile bulb vs. crura in the development of postbrachytherapy erectile dysfunction

Abstract

Purpose: Recent studies have implicated the proximal penis as a potential site-specific structure for radiation-related erectile dysfunction (ED). In this study, we evaluated by means of a validated patient-administered questionnaire whether radiation doses to the bulb of the penis and/or the proximal corporeal bodies were predictive for the development of brachytherapy-induced ED. Methods and Materials: Thirty patients who underwent permanent prostate brachytherapy between April 1995 and October 1999 and developed brachytherapy-induced ED were paired with 30 similar men who maintained potency after implantation. None of the 60 patients received supplemental external beam radiation therapy, either before or after implantation. Potency was assessed by patient self-administration of the specific erectile questions of the International Index of Erectile Function. The questionnaire consisted of 5 questions with a maximum score of 25. Postimplant potency was defined as an International Index of Erectile Function score ≥11. Mean and median follow-up was 48.3 ± 14.4 months and 48.0 months, respectively (range: 26.6–79.3 months). The bulb of the penis and the proximal crura were outlined at 0.5-cm intervals on the Day 0 postimplant CT scan. The radiation dose distribution to the bulb of the penis and adjacent crura was defined in terms of the minimum dose delivered to 25%, 50%, 70%, 75%, 90%, and 95% of the bulb ( D 25, D 50, D 70, D 75, D 90, and D 95). Results: The radiation dose delivered to the bulb of the penis and the proximal crura in men with brachytherapy-induced ED was statistically greater for all evaluated dosimetric parameters ( D 25, D 50, D 70, D 75, D 90, and D 95). Stepwise linear regression analysis indicated that penile bulb dose parameter D 50, the postimplant prostate CT volume, and patient age at implant were predictive of postimplant ED, whereas the crura dose D 25 approached statistical significance. Seventy-five percent of the impotent men had a bulb D 25 >60% of prescribed minimum peripheral dose (mPD), whereas 80% of potent men had a bulb D 25 ≤60% mPD. Using the D 50 bulb parameter, 70% of ED men had a dose >40% mPD, whereas 90% of potent men had a dose ≤40% mPD. Similar cut points for D 25 and D 50 crura doses were 40% and 28% mPD. The crura D 25 cut point was exceeded by 50% of the ED patients and only 7% of the potent patients. Conclusion: This is the first study to evaluate potency preservation and radiation doses to the proximal penis by means of a validated patient-administered quality-of-life instrument. Our data confirm prior reports that radiation doses to the proximal penis are predictive of brachytherapy-induced ED. In a stepwise linear regression analysis, the strongest predictors of potency preservation were bulb D 50, postimplant prostate CT volume, and patient age. With Day 0 dosimetric evaluation, the penile bulb D 50 and D 25 should be maintained below 40% and 60% mPD, respectively, whereas the crura D 50 and D 25 should be maintained below 40% and 28% mPD, respectively, to maximize posttreatment potency.