Prediction of erectile function following treatment for prostate cancer

The natural history of penile length after radical prostatectomy: a long-term prospective study

OBJECTIVE

To describe the penile length after radical prostatectomy (RP) in a long-term follow-up.

MATERIALS AND METHODS

We evaluated prospectively the penile length of 105 patients with localized prostate cancer treated by open RP. Participants using therapy for penile rehabilitation were excluded from statistical analysis. Measurements of the stretched penis were taken preoperatively and at 3, 6, 12, 24, 36, 48, and 60 months postoperatively. The International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaire was used to evaluate erectile function. The penile anthropometric measure used was the stretched length of the flaccid penis, from the pubopenile skin angle to the end of the glans, after the prepubic fat was depressed under maximum manual traction.

RESULTS

The mean stretched penile length 3 months after RP decreased an average of 1 cm from baseline (P <.001). This mean difference persisted until 24 months. At 36 months, the penile length differed 0.6 cm. At 48 months (-0.3 cm) and 60 months (+0.4 cm), the mean differences in penile length before and after RP were not significant (P = .080 and P = .065, respectively). Erectile function was a predictor for early return of penile length.

CONCLUSION

Nearly 1 cm of penile shortening after RP may be expected up to 12 months. However, a trend toward recovery of penile length occurs after 24 months of follow-up and is completely re-established after 48 months. The preserved erectile function after RP is a predictor for penile length recovery.

Validation of online administration of the sexual health inventory for men

PURPOSE

Previously we reported the development of a novel, inexpensive, online method to collect health related quality of life information to facilitate responses among patients and decrease loss to followup. We validated the practice by comparing responses to the SHIM (Sexual Health Inventory for Men), a representative validated instrument, when administered on line and in the traditional paper form.

MATERIALS AND METHODS

Consented patients were administered validated health related quality of life instruments, including the SHIM, in office and via e-mail. Responses to the SHIM were compared between the administration formats. Paired sample testing was done to analyze test-retest reliability, concordance was assessed by intraclass analysis and a Bland-Altman plot, and the Cronbach α was used to examine internal reliability. Criterion validity was measured using SHIM defined erectile function categories and a dichotomized potency definition (SHIM 17 or greater).

RESULTS

Of the 508 men who consented to participate 359 (71%) completed the SHIM in person, 277 (55%) completed the online form (p <0.001) and 116 (23%) contemporaneously completed each instrument. Comparison of scores revealed little variation and strong correlation (r(2) = 0.83, p <0.001). Intraclass and Bland-Altman analysis revealed strong agreement between the media. The Cronbach α was excellent (0.97) for the online tool. Erectile function classification was identical in 73% of patients with only 7% differing by more than 1 class. Dichotomized potency was consistently defined in 94% of patients.

CONCLUSIONS

The online administered SHIM maintains validity and provides consistent responses. Online administration can capture patients who do not complete paper questionnaires and may serve as a reliable adjunct to paper administration for validated outcomes research.

Nursing care program for erectile dysfunction after radical prostatectomy

The prevalence of erectile dysfunction (ED) in 114 patients with prostate cancer treated with radical prostatectomy was examined to determine the efficacy of an ED care program in which nurse-provided education plays a fundamental role in the detection and follow-up of ED as well as in treatment compliance. The nursing program consists of four visits during which specific treatment-related information, education and support, active listening, and selection of the treatment best suited to each patient (in consultation with the healthcare team) are provided. One month following bladder catheter removal, 77 of the 114 patients (69%) in the study had ED, with a majority suffering from severe ED. A nursing care program could help minimize ED and enable patients to adapt to their new situation.

A 2-stage genome-wide association study to identify single nucleotide polymorphisms associated with development of erectile dysfunction following radiation therapy for prostate cancer

PURPOSE

To identify single nucleotide polymorphisms (SNPs) associated with development of erectile dysfunction (ED) among prostate cancer patients treated with radiation therapy.

METHODS AND MATERIALS

A 2-stage genome-wide association study was performed. Patients were split randomly into a stage I discovery cohort (132 cases, 103 controls) and a stage II replication cohort (128 cases, 102 controls). The discovery cohort was genotyped using Affymetrix 6.0 genome-wide arrays. The 940 top ranking SNPs selected from the discovery cohort were genotyped in the replication cohort using Illumina iSelect custom SNP arrays.

RESULTS

Twelve SNPs identified in the discovery cohort and validated in the replication cohort were associated with development of ED following radiation therapy (Fisher combined P values 2.1×10(-5) to 6.2×10(-4)). Notably, these 12 SNPs lie in or near genes involved in erectile function or other normal cellular functions (adhesion and signaling) rather than DNA damage repair. In a multivariable model including nongenetic risk factors, the odds ratios for these SNPs ranged from 1.6 to 5.6 in the pooled cohort. There was a striking relationship between the cumulative number of SNP risk alleles an individual possessed and ED status (Sommers' D P value=1.7×10(-29)). A 1-allele increase in cumulative SNP score increased the odds for developing ED by a factor of 2.2 (P value=2.1×10(-19)). The cumulative SNP score model had a sensitivity of 84% and specificity of 75% for prediction of developing ED at the radiation therapy planning stage.

CONCLUSIONS

This genome-wide association study identified a set of SNPs that are associated with development of ED following radiation therapy. These candidate genetic predictors warrant more definitive validation in an independent cohort.

A prospective longitudinal survey of erectile dysfunction in patients with localized prostate cancer treated with permanent prostate brachytherapy

PURPOSE

Few studies have evaluated changes in erectile function with time before and after prostate brachytherapy using the International Index of Erectile Function-15, a sensitive, validated tool for assessing male sexual dysfunction. In this prospective study we evaluated the natural history of erectile function after prostate brachytherapy without supplemental therapy (external beam radiotherapy, phosphodiesterase-5 inhibitors or androgen deprivation therapy) using the International Index of Erectile Function-15.

MATERIALS AND METHODS

We identified 119 patients who were followed at least 12 months after prostate brachytherapy between 2004 and 2010. Sexual and erectile function status were assessed before brachytherapy (baseline), and 3, 6, 12, 18, 24 and 36 months postoperatively using the International Index of Erectile Function-15.

RESULTS

Mean total International Index of Erectile Function-15 score, and scores on the erectile function, orgasmic function, sexual desire and intercourse satisfaction domains 3 months after brachytherapy were significantly lower than at baseline (p <0.05). They remained lower until 36 months after prostate brachytherapy. Erectile function was maintained 12 months after brachytherapy in 16 of the 48 men (33.3%) with a baseline erectile function domain score of 11 or greater. There was no significant difference in clinical features except the age of patients who maintained the erectile function domain score and their counterparts 12 months after brachytherapy. Multivariate analysis revealed that age 70 years or greater was the only predictive factor for deteriorating erectile function after brachytherapy (p = 0.035).

CONCLUSIONS

Findings indicate a global decrease in all domains of the International Index of Erectile Function-15 score 12 months after prostate brachytherapy. Also, patient age may influence the preservation of brachytherapy related potency.

Standard operating procedure for the preservation of erectile function outcomes after radical prostatectomy

INTRODUCTION

Prostate cancer is common, and, thus, more men are being treated surgically. Long-term functional outcomes are of significant importance to the patient and their partners. Erectile function (EF) preservation (rehabilitation) has gained significant traction worldwide, despite the absence of definitive evidence supporting its use.

AIM

To review the effectiveness of specific pharmacological therapies and other erectogenic aids in the treatment of post-radical prostatectomy (RP) erectile dysfunction.

METHODS

A systematic literature review of original peer-reviewed manuscripts and clinical trials reported in Medline.

MAIN OUTCOME MEASURE

This review focused on the evaluation of interventions that aimed to improve EF recovery following RP.

RESULTS

Although well documented in animal models, studies supporting the rehabilitation with phosphodiesterase type 5 inhibitors in humans are scarce. Daily sildenafil has been used in trials (only one randomized placebo-controlled trial) with a significant improvement in erection recovery when compared to placebo or no rehabilitation but with a low return to baseline rates (27% vs. 4% placebo). Nightly vardenafil vs. on demand vs. placebo has been studied in the Recovery of Erections: INtervention with Vardenafil Early Nightly Therapy trial with no difference in erection recovery following RP. Intracavernosal injections, although widely used and attractive from a rehabilitation standpoint, does not yet have definitive supporting its role in rehabilitation. Vacuum erection devices use following RP has been reported, but there are no data to support its role as monotherapy. Intraurethral alprostadil was also studied vs. sildenafil in a multicenter, randomized, open-label trial, and no superiority was found.

CONCLUSIONS

At this time, we are unable to define what represents the optimal rehabilitation program in regard to strategies utilized, timing of intervention, or duration of treatment.

Stamp test delivers message on erectile dysfunction after high-dose intensity-modulated radiotherapy for prostate cancer

OBJECTIVE

To evaluate erectile function after high-dose radiotherapy for prostate cancer using the International Index of Erectile Function, Expanded Prostate Cancer Index Composite, and stamp test.

METHODS

Men with favorable and intermediate-risk prostate cancer were assigned to receive prostate intensity-modulated radiotherapy (IMRT) versus an erectile tissue-sparing IMRT technique in a Phase III randomized, prospective study. The stamp test and International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires were completed at baseline and 6 months, 1 year, and 2 years after IMRT. The Sexual Health Inventory for Men scores were abstracted from the International Index of Erectile Function questionnaire. A partner questionnaire, designated IIEF-P, modeled after the International Index of Erectile Function questionnaire but from the perspective of the partner, was also collected.

RESULTS

The data from 94 men who were enrolled in the trial and who had completed ≥1 questionnaire or 1 stamp test were analyzed. The median age of the patient population was 62.5 years. The median radiation dose was 76 Gy (range 74-80). At 6 months and 1 year after high-dose IMRT, a positive stamp result correlated significantly with the median Expanded Prostate Cancer Index Composite sexual summary, sexual function, and bother subscale scores. Additionally, 6 months after IMRT, the stamp test correlated with the median International Index of Erectile Function, International Index of Erectile Function sexual function domain, and Sexual Health Inventory for Men scores. Robust concordance for the International Index of Erectile Function and Sexual Health Inventory for Men scores was appreciated between responding patient and partner pairs.

CONCLUSION

Nocturnal tumescence, as indicated by a positive stamp test, correlated well with established quality of life questionnaires after IMRT. The stamp test should strongly be considered as an objective measure of erectile function in future studies of erectile dysfunction in patients with prostate cancer.

Active surveillance for prostate cancer: past, present and future

PURPOSE OF REVIEW

This article reviews recent developments in the use of active surveillance for localized prostate cancer.

RECENT FINDINGS

The treatment of localized prostate cancer continues to be a major challenge for urologic oncologists. Screening with prostate-specific antigen has resulted in increased numbers of low-risk prostate cancers being detected. Aggressive whole-gland therapy with surgery, or radiation therapy is associated with potentially life-altering treatment-related side effects such as urinary incontinence, bowel toxicity and erectile dysfunction. The goal of active surveillance is to avoid or delay the adverse events associated with prostate cancer therapy while still allowing for curative intervention in the future, if needed.

SUMMARY

Active surveillance is a reasonable treatment option for many men with low-risk, and some men with intermediate-risk, prostate cancer. Additional research is needed to determine the optimal active surveillance inclusion criteria, monitoring schedule, and treatment triggers. It is hoped that advances in prostate imaging, biomarkers, and focal therapy will foster greater use of active surveillance in appropriately selected men to optimize quality-of-life without compromising cancer outcomes.

Health-related quality of life for men with prostate cancer--an evaluation of outcomes 12-24 months after treatment

OBJECTIVE

To determine the health-related quality of life (HRQoL) impact of prostate cancer interventions at 2 years post-treatment, and between the 12- and 24-month interval, to better characterize this measure.

MATERIALS AND METHODS

Patients treated at the Center for Prostate Disease Research between June 2003 and February 2010 were offered enrollment into a HRQoL study that entailed a baseline evaluation before prostate biopsy and at 3, 6, 9, 12, 18, 24, and 30 months thereafter. The instruments used were the Expanded Prostate Cancer Index Composite (EPIC), EPIC Demographic, and Medical Outcomes Study Short-Form 36 (SF-36). A Student's t-test and ANOVA were used to examine the association between HRQoL scores, patient demographic, and disease features. Multivariable regression models were used to analyze change over time. Estimates of risk, corresponding confidence intervals, and P values are presented for these longitudinal findings.

RESULTS

The study group was comprised of 595 patients. African Americans (AA) had slightly lower baseline raw scores in all EPIC and SF-36 HRQoL domains, but on bivariate analysis, there was no statistical difference in change of scores over time. Radical prostatectomy (RP) led to the greatest decline in urinary function. Bowel function significantly worsened with the addition of hormone therapy (HT) to external beam radiation therapy (EBRT). Sexual bother and function had a marked decline in all active treatment options. Despite these changes, there were no differences in overall satisfaction. SF-36 domains were not affected by RP, whereas EBRT and EBRT + HT had universal impact. For the 12- to 24-month interval, specifically, patients who underwent EBRT fared worse over this time period, showing continued worsening of urinary bother, hormonal function, physical role, physical component summary, and overall satisfaction. Patients who underwent RP did not show any further decline in the 12- to 24-month interval, but instead showed improvement.

CONCLUSIONS

Because of the protracted nature of recovery after surgery, delayed onset of effects from radiation, potential interval decline secondary to age-related symptoms, and longevity of patients with prostate cancer, determination of long-term HRQoL outcomes is integral. Counseling with regard to these outcomes should be balanced with oncologic expectations from treatment.

Prediction of functional outcomes after nerve-sparing radical prostatectomy: results of conditional survival analyses

BACKGROUND

In prostate cancer (PCa) patients treated with radical prostatectomy (RP), the rate of urinary continence (UC) and erectile function (EF) recovery may change significantly depending on the time interval between surgery and patient assessment. This effect, known as conditional survival, has not yet been assessed.

OBJECTIVE

Evaluate the conditional rates of UC and EF recovery after nerve-sparing RP (NSRP).

DESIGN, SETTING, AND PARTICIPANTS

We included 1135 PCa patients treated between January 2000 and June 2011 at a single referral center.

INTERVENTION

All patients underwent NSRP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The Kaplan-Meier method assessed the time to recovery of UC (defined as an International Consultation on Incontinence Questionnaire score<6) and of EF (defined as an International Index of Erectile Function-Erectile Function score≥22). Cumulative survival estimates were used to generate conditional recovery rates assessed at a 6-mo interval. Multivariable Cox regression analyses were performed to predict functional outcomes recovery after accounting for confounders.

RESULTS AND LIMITATIONS

UC recovery rates were 89.5%, 94.7%, and 97.0% at 6-, 24-, and 36-mo follow-up, respectively. Corresponding EF recovery rates were 53.6%, 65.0%, and 67.5%, respectively. In patients who were still incontinent at 1, 6, 12, 18, 24, 30, and 36 mo after surgery, UC recovery rates in the following 6-mo period significantly decreased as the time from surgery increased: 74.9%, 58.2%, 41.4%, 14.9%, 24.8%, 24.6%, and 13.3%, respectively. Similarly, in patients still impotent at the same time points, the 6-mo rate of sexual potency recovery was 36.9%, 26.8%, 17.8%, 8.2%, 3.1%, 4.0%, and 0%, respectively. Multivariable analyses confirmed these results. The study is limited by its retrospective design.

CONCLUSIONS

In incontinent and/or impotent patients, the period elapsed from surgery represents an important predictor of the recovery of subsequent functional outcomes. The highest increments in UC and EF recovery were observed during the first year after surgery; they were virtually null after 36 mo.

A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes

CONTEXT

The optimal management strategy for men with newly diagnosed clinically localized prostate cancer remains a matter of debate. Numerous series have reported cancer control and quality-of-life (QoL) outcomes following treatment with radical prostatectomy (RP).

OBJECTIVE

Critically review published oncologic and functional outcomes after RP, and evaluate factors associated with these outcome measures.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline and Web of Sciences databases. Relevant reports published between 1980 and 2011 identified using the keywords prostate cancer, radical prostatectomy, prostate-specific antigen, biochemical recurrence, incontinence, and erectile dysfunction were reviewed and summarized.

EVIDENCE SYNTHESIS

Cancer control rates following RP largely depend on the definition of treatment efficacy. While up to 40% of men have been reported to experience postoperative biochemical recurrence on long-term follow-up, death from prostate cancer has been noted in <10% of men at 15 yr after surgery in contemporary series. For men with high-risk disease, surgery affords pathologic staging, thereby facilitating the selective application of secondary therapies, and has been associated with decreased mortality risk versus radiation in retrospective series. Reported functional outcomes after surgery, particularly urinary continence and erectile dysfunction, have varied greatly to date. These assessments have been limited by nonstandardized reporting methodology. The use of robot-assisted radical prostatectomy has increased in recent years, and while follow-up is thus far short, available data do not suggest the superiority of either approach in terms of functional or oncologic outcomes.

CONCLUSIONS

RP is associated with excellent long-term cancer control. Continued efforts to conduct prospective assessments of postoperative functional outcomes are necessary using validated QoL instruments. The importance of surgical approach will also require further study, incorporating comparative oncologic, functional, and economic data.