Erectile Preservation Research Articles

Sexual Preservation With Radiotherapy: Think Target, Not Tool

With the refinement and advancement of diverse radiation, surgical, and systemic treatment strategies, prostate cancer (PCA) patients have significant survivorship after treatment. The goal of modern PCA treatment, therefore, encompasses not just cure, but also optimization of long-term patient quality of life (QOL). To that end, sexual QOL, and particularly erectile function (EF), is a critical metric in patient’s determination of their overall treatment satisfaction.1 Technology has expanded curative radiotherapy techniques to include brachytherapy (BT), external beam/intensity-modulated RT (EBRT/IMRT), stereotactic-body radiotherapy (SBRT), and proton therapy (PT), and various combinations of the above techniques. More advanced disease commonly includes the addition of androgen deprivation therapy (ADT). There is increasing interest by patients about whether a particular type of RT can offer superior erectile preservation. This editorial will, therefore, review the difficulties of comparing EF across RT modalities and summarize the current literature on EF. We will also suggest future directions to maximize EF through further refinements of RT technique.

Preliminary Experience of Nontransecting Urethroplasty for Pelvic Fracture-related Urethral Injury

To evaluate the urinary outcomes and preservation of erectile function in patients with pelvic fracture-related urethral injury (PFUI) after nontransecting spongiosum anastomotic urethroplasty (NTSAU). Fifty-nine male patients with PFUI following traumatic pelvic fracture underwent NTSAU. Inclusion criteria were age 18-60 years, posterior urethral stenosis <2.5 cm without previous urethroplasty, and intact erectile function. Exclusion criteria were history of open urethroplasty, long-segment posterior urethral stenosis (>2.5 cm), preoperative impotency, or age over 60 years. Pre- and postoperative outcome analyses were performed with a paired t test and chi-square test. Between January 2011 and August 2015, 59 patients with a mean age of 38.5 years (range, 21-59 years) and a mean stricture length of 2.0 cm (range, 1-2.5 cm) underwent simple NTSAU (group 1, n = 41) or NTSAU with inferior pubectomy (group 2, n = 18). Patients were followed for a mean 25 months (range, 12-60 months). The primary success rate was 96.6% (57 of 59), and stricture recurrence occurred in 2 (3.4%) patients. The secondary outcomes revealed no significant changes in number of events, tip rigidity, or duration of best episode between pre- and postoperative nocturnal penile tumescence test (on RigiScan) in group 1, but a slight decrease in group 2 (P <.05). The limitation was the small sample size and heterogeneous population. NTSAU is a safe, feasible, minimally invasive procedure for PFUI, optimizing erectile preservation.

Association between long-term erectile dysfunction and biochemical recurrence after permanent seed I125 implant brachytherapy for prostate cancer. A longitudinal study of a single-institution

We aimed to investigate the predictive factor of erectile dysfunction (ED) in prostate cancer (PCa) patients who underwent low-dose permanent I125 seed implant brachytherapy and to investigate if ED could represent a patient’s reported outcome measures (PROMs) of efficacy of BT and indirectly associated with biochemical recurrence free survival (BRFS). From 2000 to 2012, 176 consecutive patients with low-risk PCa underwent BT. ED was evaluated with the International Index of Erectile Function (IIEF-5). Cox regression analysis was performed to assess significant predictors of mild-to-severe ED and BRFS after BT, including covariates. The 10-year actuarial rate of ED was 66%. Subjects with severe ED had higher values of D90 (183.0 versus 177.0; p < 0.05) and V100% (40.1 versus 31.4; p < 0.05) compared with normal. At the multivariate logistic regression analysis, D90 (OR: 1.10; p < 0.05) was an independent predictor of ED. Multivariate Cox-regression analysis did not demonstrate significant association between erectile preservation and biochemical recurrence (BCR) after 10 years of follow up (HR: 2.15; p = 0.20), while D90 ≤ 180 Gy independently predicted BCR (HR: 4.65; [95%CI: 1.25–17.34]; p < 0.05). Erectile preservation should be addressed as valuable PROMs after permanent seed I125 implant, but it is not associated with better BRFS.

Long-term outcome for prostate cancer using pseudo pulse–dosed rate brachytherapy, external beam radiotherapy, and hormones

We report the long-term outcomes of pulse-dose rate (PDR) brachytherapy used in a nonstandard style (pseudo-PDR) with an high-dose rate brachytherapy technique in conjunction with external beam radiotherapy (EBRT) and hormonal manipulation on prostate cancer (PC). We treated 253 patients with Stage T1-T3 N0M0 PC, between December 1999 and March 2006. All patients received neoadjuvant androgen deprivation for a median 6 months. Treatment consisted of three pulses of pseudo-PDR brachytherapy to a median dose of 18Gy with 50.4Gy in 28 fractions of EBRT. At a median 6 years followup, (range, 1-11 years), 5-year overall survival was 92%, and PC-specific survival was 96%. The 5-year biochemical control (biochemical no evidence of disease) by the Phoenix definition for low-, intermediate-, and high-risk groups was 95%, 90%, and 71%, respectively (p<0.00001). At 6 years, the incidence of Radiotherapy Oncology Group Grade 2 and 3 genitourinary toxicity was 1% and 6%; Radiotherapy Oncology Group Grade 2 and 3 gastrointestinal toxicity was 4% and 0%. Erectile preservation at 3 years was 58%. The Phoenix definition best predicted clinical failure with a high specificity (94%). Pseudo-PDR brachytherapy plus EBRT with limited neoadjuvant hormonal manipulation is an effective treatment option in localized PC, with minimal and tolerable morbidity and provides excellent control. This technique of a modified PDR-delivery technique appears as effective as high-dose rate therapy.

Biochemical and functional outcomes of brachytherapy for young men (≤50) with prostate cancer.

245 Background: NCCN guidelines endorse prognostic risk grouping to select therapy, and lend equal support to surgery and radiation therapy (RT). Despite this, the optimal treatment of prostate cancer in young men remains contentious, with the majority treated surgically. This may be because there are few reports of RT outcomes with long follow-up (FU) in this cohort. Thus, we report long-term biochemical and functional outcomes after prostate brachytherapy (BT) +/- supplemental therapies in men ≤ 50 years old. Methods: With IRB approval we analyzed outcomes of 47 patients ≤ 50 yrs old (median 48, range 48-50) implanted with curative intent by a single physician (DS) at Beth Israel Medical Center (New York City) between 2000-2009. Supplemental external beam therapy (45-50.4 Gy) was delivered to patients with NCCN intermediate risk (IR) and high risk (HR) disease, and to select patients with high volume low risk (LR) disease. Androgen deprivation therapy (ADT) was used in all HR patients, for pre-implant prostate downsizing, and for biopsy demonstrating very high volume disease. Biochemical failure (BF) was defined as “nadir +2.” Genitourinary (GU), gastrointestinal (GI) and erectile functional outcomes are included. Results: Median follow up (FU) was 5.2 yrs (range: 2-11). Only 1 patient experienced BF, thus, overall freedom from BF was 97.9%. Grade 2 acute and late 2 GU toxicity were reported in 10.6 % (n = 5) and 8.5% (n = 4), respectively. Grade 2 proctitis was seen 4.3 % (n=2). Erectile function was preserved in 41 of 47 men (87.2 %) with or without phosphodiesterase-5 inhibitors. Conclusions: With median FU of 5.2 years, excellent biochemical control with minimal toxicity was achieved in men ≤ 50 years old. The finding of only a single patient exhibiting BF over the 11 years of FU in this study is highly encouraging. Erectile preservation rates were high, and acute and late GI and GU toxicity were low. These results support prostate BT as an excellent option for patients in this age group.

Long-Term Satisfaction and Predictors of Use of Intracorporeal Injections for Post-Prostatectomy Erectile Dysfunction

Intracorporeal injections have low use rates and high discontinuation rates. We examined factors associated with intracorporeal injection use, long-term satisfaction with intracorporeal injection and reasons for discontinuation in men treated with radical prostatectomy. Between October 2000 and September 2003, 731 men who underwent open radical retropubic prostatectomy were enrolled in a prospective outcomes study. The 8-year followup evaluation included the UCLA-PCI, and a survey capturing intracorporeal injection use, satisfaction and reasons for discontinuation. Logistic regression was used to determine associations between intracorporeal injection use and preoperative variables. The 8-year self-assessment was completed by 368 (50.4%) men. Of these men 140 (38%) indicated prior or current intracorporeal injection use, with only 34 using intracorporeal injection at 8 years. Overall, 44% of the men were satisfied with intracorporeal injections. Reasons for discontinuation included dislike (47%), pain (33%), return of erection (19%), inefficacy (14%) and no partner (6%). Men trying intracorporeal injections had greater preoperative UCLA-PCI sexual function scores (75.2 vs 65.62, p = 0.00005) as well as greater decreases in this score at 3 months (p = 0.0002) and 2 years (p = 0.003). Higher preoperative sexual function scores were independently associated with the use of intracorporeal injections in a model adjusted for age, marital status, nerve sparing status and body mass index (OR 1.021, 95% CI 1.008-1.035). Men pursuing intracorporeal injections have better baseline erectile function and experience greater deterioration in erectile function during the early postoperative period. Despite the high efficacy of injections, many men discontinue intracorporeal injections due to dislike or discomfort. Satisfaction rates for intracorporeal injections indicate their long-term role in restoring sexual function in men with post-prostatectomy erectile dysfunction.

Emerging concepts in erectile preservation following radical prostatectomy: a guide for clinicians

Radical prostatectomy (RP) is a commonly performed procedure for the management of prostate cancer. While documented oncologic outcome for early stage disease is excellent, functional impairments such as incontinence and erectile dysfunction (ED) are common after the procedure. Recent evidence has implicated cavernous nerve damage and subsequent corporal oxygen deprivation, as well as corporal inflammation, in the pathogenesis of post-RP ED. Targeted therapies such as oral phosphodiesterase-5 inhibitors, mechanical vacuum erection devices, local alprostadil delivery and testosterone replacement (for hypogonal patients) have demonstrated some efficacy in the management of post-RP ED. This review aggregates much of the recent data in support of these therapies and critically reviews them. The article then presents tools to assess patients and partner sexual function to aid in identifying and monitoring post-RP ED. Finally, the article describes a protocol in use at Baylor College of Medicine as a guide toward the development of a protocol for erectile preservation (EP). The purpose of this work is to educate clinicians on emerging concepts in EP and provide an implementable protocol for use in practice.

Erectile preservation following radical prostatectomy

Prostate cancer is the most common cancer among men, representing approximately 25% of all new cancer diagnoses in the USA. For clinically localized prostate cancer, the gold standard for therapy remains radical prostatectomy. One of the main adverse effects of this procedure is erectile dysfunction, which can have a significant impact on the patient's quality of life. There are several mechanisms of erectile dysfunction postprostatectomy, including arteriogenic, venogenic and neurogenic types, as well as the potentially heightened risk of postprostatectomy patients to develop Peyronie's disease. The purpose of this review is to explain the various treatment options available, including phosphodiesterase type 5 inhibitors, intracavernosal injections, intraurethral alprostadil suppositories, vacuum erection devices, and penile prostheses. The role of these therapies in an erectile-dysfunction-treatment function, as well as in penile rehabilitation, will be discussed. Finally, a review of research on novel therapies will also be presented. A comprehensive literature review was performed using the PubMed database. Articles were chosen based on topical relevance and assessed for methodology and major findings. There are data to support the use of each of the therapeutic options in both treatment and rehabilitative roles. More study is needed, however, specifically in regard to penile rehabilitation, to confirm its benefits, as well as to determine optimal rehabilitation protocols.

The Female Factor: Predicting Compliance with a Post-Prostatectomy Erectile Preservation Program

Early post-radical prostatectomy (RP) erectile preservation (EP) therapy may be critical to preserve erections after surgery. To assess if pre-RP female sexual function predicts of partner compliance with an EP protocol. Compliance, defined as use of localized penile EP therapy (intracavernosal injections [ICIs], vacuum erection device [VED], or alprostadil) at 3 and 6 months after RP. Records of patients enrolled in our EP program from April 2007 to June 2008 were reviewed. Before surgery, patients completed the Sexual Health Inventory for Men (SHIM) and their female partners completed the Female Sexual Function Index (FSFI) questionnaire. Prior to surgery, patients were advised to take sildenafil 25 mg every nightly and use a 250-µg alprostadil suppository three times/week. At 1 month, additional daily use of a VED was encouraged. All patients unable to achieve erections sufficient for penetration were encouraged to initiate ICI of Trimix (phentolamine, papaverine, and PGE1) twice weekly after 3 months following surgery. Data were analyzed using binary logistic regression analysis holding all input variables constant. Twenty-nine patients had preoperative SHIM>7 and pre-RP partner FSFI data available. After a 4-week follow-up, compliance with alprostadil suppository declined and both ICI and VED usage increased. At 6 months, six (25.0%) patients had return of natural erectile function and 22 (91.7%) were achieving assisted erections. Higher preoperative partner FSFI scores were associated with greater compliance to the localized penile therapy component of our EP protocol (risk ratio 3.8, P=0.05). Preoperative female sexual function correlated with greater partner compliance with the localized component of our EP protocol. Consideration of a female partner's preoperative sexual function in predicting patient erectile function recovery after RP is warranted. Future studies are necessary to determine the clinical significance of this factor.

ERECTILE PRESERVATION FOLLOWING RADICAL PROSTATECTOMY: THE BAYLOR EXPERIENCE

You have accessJournal of Urology1 Apr 2009ERECTILE PRESERVATION FOLLOWING RADICAL PROSTATECTOMY: THE BAYLOR EXPERIENCE Mohit Khera, Osama Mohamed, John S Colen, Richard E Link, Brian J Miles, and Larry I Lipshultz Mohit KheraMohit Khera More articles by this author , Osama MohamedOsama Mohamed More articles by this author , John S ColenJohn S Colen More articles by this author , Richard E LinkRichard E Link More articles by this author , Brian J MilesBrian J Miles More articles by this author , and Larry I LipshultzLarry I Lipshultz More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)61478-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "ERECTILE PRESERVATION FOLLOWING RADICAL PROSTATECTOMY: THE BAYLOR EXPERIENCE." The Journal of Urology, 181(4S), p. 524 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 524 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Mohit Khera More articles by this author Osama Mohamed More articles by this author John S Colen More articles by this author Richard E Link More articles by this author Brian J Miles More articles by this author Larry I Lipshultz More articles by this author Expand All Advertisement PDF downloadLoading ...

Androgens and Erectile Function: A Case for Early Androgen Use in Postprostatectomy Hypogonadal Men

Erectile dysfunction affects up to 80% of men following a radical prostatectomy (RP) and is a common concern for these patients. Currently, hypogonadal men are not treated with testosterone after a RP for fear of stimulating dormant prostate cancer cells even though there is little evidence to support this hesitancy. There is data, however, to support the use of testosterone to aid in faster and better recovery of erections following RP. The aim of this article is to explore the relationship between testosterone replacement therapy (TRT) and erectile preservation following RP. The results of findings in the literature on the association between testosterone and its role in preserving erectile function, particularly in men following RP. This article reviews and evaluates the literature that demonstrates the role of testosterone in obtaining erections and preserving erectile function. Additional articles were reviewed to assess the role of testosterone in erectile preservation following RP. This review demonstrates that testosterone does play a role in erectile function, particularly for men who have undergone a RP. Testosterone has been shown to have an effect on nitric oxide synthase release, phosphodiesterase type 5 expression and activity, and in cavernosal nerve function, and to contribute to venoocclusive disease in the penis. All of these effects are of particular importance to men attempting to preserve erectile function following RP. While the relationship between TRT and improvement in erectile function has been well established, the role of testosterone in men following RP may be of even greater significance. However, further studies are needed to assess the true safety of TRT following RP.

High-Dose-Rate Brachytherapy of a Single Implant With Two Fractions Combined With External Beam Radiotherapy for Hormone-Naive Prostate Cancer

To evaluate the preliminary outcomes of high-dose-rate (HDR) brachytherapy of a single implant with two fractions and external beam radiotherapy (EBRT) for hormone-naive prostate cancer. Between March 2000 and Sept 2003, a total of 53 patients with tumor Stage T1c-T3b N0 M0 prostate cancer were treated with HDR brachytherapy boost doses (7.5 Gy/fraction) and 50-Gy EBRT during a 5.5-week period. Median follow-up was 61 months. Patients were divided into groups with localized (T1c-T2b) and advanced disease (T3a-T3b). We used the American Society for Therapeutic Radiology and Oncology (ASTRO) definition for biochemical failure. According to recommendations of the Radiation Therapy Oncology Group-ASTRO Phoenix Consensus Conference, biochemical failure-free control rates (BF-FCRs) at 3 years were investigated as 2 years short of the median follow-up. Between April 2000 and Sept 2007, Common Terminology Criteria for Adverse Events Version 2.0 late Grade 2 genitourinary and gastrointestinal toxicity rates were 0% and 3.8%, respectively. Erectile preservation was 25% at 5 years. Overall survival was 88.1% and cause-specific survival was 100%. At 3 years, ASTRO BF-FCRs of the localized and advanced groups were 100% and 42%, respectively (p = 0.001). The HDR brachytherapy of a single implant with two fractions plus EBRT is effective in treating patients with localized hormone-naive prostate cancer, with the least genitourinary and gastrointestinal toxicities; however, longer median BF-FCR follow-up is required to assess these findings.

Radiation thresholds and rehabilitative therapy with erectile preservation after radiotherapy for prostate cancer

Critical targets for radiation-induced erectile dysfunction have been proposed, with most studies supporting the proximal penis as an important site-specific structure. Pre-implant erectile function and dose to the proximal penis are the strongest predictors of post-treatment erectile function. Refinements in technique that minimize radiation dose to normal surrounding structures, especially the proximal penis, should result in improved rates of potency preservation.

Six year experience of external beam radiotherapy, brachytherapy boost with a 1Ci 192Ir source, and neoadjuvant hormonal manipulation for prostate cancer

To present preliminary outcomes of pulsed dose rate brachytherapy (PDR-BT), external beam radiotherapy (EBRT), and hormonal manipulation, for prostate cancer. Between December 1999 and January 2005, 165 consecutive patients with Stage T1-T3, N0, M0 prostate cancer were treated. Hormones were used in every patient. Median follow-up was 36 months. Risk groups were low (either Stage < or =T2a, +/- Gleason score < or =6, +/- Prostate-Specific Antigen [PSA] level < or =10 ng/mL); intermediate (either Stage T2b,c, +/- Gleason score 7, +/- PSA 10-20 ng/mL); and high (either Stage T3, +/- Gleason score 8-10, +/- PSA >20 ng/mL). At 3 years, Radiotherapy Oncology Group (RTOG) Grade 3 and 4 genito-urinary toxicity was 4% and 1.4%; RTOG Grade 3 and 4 gastro-intestinal toxicity was 2.6% and 0%, respectively. Erectile preservation was 61%. Overall survival was 93% (154 of 165) and cause-specific survival was 98% (162 of 165). At 3 years, disease free survival (DFS) was 93% (153 of 165). DFS for low-, intermediate-, and high-risk groups was 100%, 97%, and 81%, respectively (chi(2) (2) = 16.02, p = 0.0003). The nadir plus 2 ng/mL definition (chi(2) (2) = 14.49, p = 0.0007) best predicted clinical failure, having the lowest false-positive rate (3 of 165). The nadir plus 2 ng/mL PSA-progression-free survival (PSA-PFS) rate was 100%, 95%, and 87% for the low-, intermediate, and high-risk groups, respectively. Overall ASTRO PSA-PFS rate was 88%. Pulsed dose rate brachytherapy plus EBRT is effective in treating localized prostate cancer, with acceptable toxicity. However, a median 5-year PSA-PFS follow-up is required before providing a solid recommendation. This preliminary information supports continued use.