Erectile function preservation after radiotherapy using a dose-optimization approach on sexual structures for localized prostate cancer

PURPOSE

Erectile function preservation is an important quality of life factor in patients treated for prostate cancer. A dose-optimization approach on sexual structures was developed and evaluated to limit erectile dysfunction after radiotherapy.

MATERIALS AND METHODS

Twenty-three men with localized prostate cancer and no erectile dysfunction were enrolled in the study. All patients received a prescription dose between 76 and 78Gy. Computed tomography/magnetic resonance image registration was used to delineate the prostatic volume and the sexual structures: internal pudendal arteries (IPA), penile bulb and corpus cavernosum. Erectile function was evaluated using the 5-items International Index of Erectile Function (IIEF-5) score every 6 months during the 2 years after radiotherapy and once a year afterwards. No erectile dysfunction, mild erectile dysfunction and severe erectile dysfunction were defined if the IIEF-5 scores were 20-25, 17-19 and < 17, respectively.

RESULTS

The mean follow-up was 4.5 years. The mean age of the patients was 66.3 years. At 2 years, 67% of the patients had no erectile dysfunction, 11% had mild erectile dysfunction and 22% had severe erectile dysfunction. No significant difference was found between the patients with and without erectile dysfunction (IIEF-5≥20 and IIEF-5<20, respectively) for any of the parameters: dosimetric values (internal pudendal arteries, penile bulb, corpus cavernosum), age, comorbidity and smoking status. The biochemical-relapse free survival was 100% at 2 years.

CONCLUSION

This approach with dose-optimization on sexual structures for localized prostate cancer found excellent results on erectile function preservation after radiotherapy, with 78% of the patients with no or mild erectile dysfunction at 2 years.

Erectile dysfunction and sexual quality of life in patients who underwent low-dose-rate brachytherapy alone for prostate cancer

This study evaluated erectile function and sexual quality of life (QoL), and predictive factors for erectile dysfunction (ED) and the deterioration of sexual QoL in 70 patients who underwent low-dose-rate brachytherapy (LDR-BT) alone for prostate cancer without androgen deprivation therapy. Erectile function and sexual QoL were evaluated before and 1, 3, 6, 12, 24, 36, 48 and 60 months after LDR-BT. Binary logistic regression analysis was used to determine whether age, prostate volume, hypertension, diabetes, Brinkman's index, testosterone, baseline Sexual Health Inventory for Men (SHIM) score and post-implant dosimetry parameters could predict ED and deterioration of sexual QoL at 24 and 60 months after LDR-BT. After 24 and 60 months, ED was noted in 39 of 70 patients and 42 of 64 patients respectively. Furthermore, sexual QoL worsened in 42 of 70 and 43 of 64 patients respectively. Baseline SHIM score was identified as a significant predictor of ED (24 months: odds ratio [OR]: 0.83, p = 0.02; 60 months: OR: 0.83, p = 0.03) and the deterioration of sexual QoL (24 months: OR: 0.84, p = 0.03). LDR-BT for prostate cancer promoted decreased erectile function and sexual QoL, with high preimplant potency being a significant predictor of ED and the deterioration of sexual QoL.

The management of sexual dysfunction resulting from radiotherapy and androgen deprivation therapy to treat prostate cancer: A comparison of uro-oncology practice according to disease stage

OBJECTIVES

To establish current uro-oncology practice in the management of sexual dysfunction (SD) following radiotherapy (RT) and/or androgen deprivation therapy (ADT) to treat prostate cancer. To identify differences in approach to the management of SD according to disease stage.

SUBJECTS AND METHODS

A 14-question mixed methods survey was designed to assess the current UK practice. Closed- and open-ended questions were used to quantify results while allowing participants to expand on answers. The survey was distributed to members of the British Uro-Oncology Group at the 2019 annual meeting.

RESULTS

Surveys were completed by 63 uro-oncologists attending the annual meeting of the British Uro-Oncology Group (response rate 66%). The major issue highlighted was a difference in approach to managing SD according to disease stage. More than half of the participants (56%) said 'advanced stage of disease' was a barrier to discussing SD. Clinicians were less likely to discuss SD, take baseline assessments, refer to a specialist clinic or offer rehabilitation when dealing with patients with advanced disease. Only a minority said that the management of SD was primarily their responsibility (11%). Nearly all clinicians (92%) had access to SD clinics; however, the majority of clinicians did not routinely refer patients.

CONCLUSIONS

This study shows that men with advanced prostate cancer need better support in managing SD. Patients receiving long-term ADT are less likely to be offered any kind of help or intervention. Specific guidance on managing SD in this cohort may result in improvements in sexual function, emotional well-being, quality of life, mental health and confidence.

Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function - A Randomized Clinical Trial

BACKGROUND

Urinary incontinence and sexual dysfunction are common after robot-assisted radical prostatectomy (RALP). New surgical techniques to improve these functions after the operation are under evaluation for example, preservation of endopelvic fascia during RALP. However, the benefits of this technique have not been critically scrutinized in a randomized setting.

AIM

In this study, we compared endopelvic fascia preserving operation with the standard surgical procedure in a randomized trial at the Tampere University Hospital, Finland.

METHODS

A total of 158 men with localized prostate cancer and scheduled for RALP were randomized 1:1 into endopelvic fascia-preserving RALP or a control group that is, standard operation. All operations were performed by a single surgeon.

OUTCOMES

Urinary and sexual function were evaluated by the Expanded Prostate Cancer Index Composite-26 questionnaire at baseline and 3, 6, and 12 months after the surgery.

RESULTS

There was no difference in urinary incontinence or sexual function between the groups at any time point (urinary incontinence domain at 12 months after RALP for fascia preserving and control group 73.6 ± 3 vs 78.9 ± 2.5 and sexual domain 43 ± 3.2 vs 40.3 ± 3, respectively). Clinical and pathologic tumor characteristics, duration of surgery, blood loss, rate of complications, and time to hospital discharge were similar between the study arms. Compliance of filling out the Expanded Prostate Cancer Index Composite-26 questionnaire varied from 91% to 98%, with no difference between study arms.

CLINICAL IMPLICATIONS

Based on our results, endopelvic fascia preservation alone during RALP is not recommended over the standard surgical method.

STRENGTHS & LIMITATIONS

This is a randomized clinical study with sufficient statistical power. As a limitation, only a minority of participants underwent magnetic resonance imaging before the operation, thus we could not evaluate the role of urethral length or shape of the prostate. Urinary and sexual function results are based on questionnaires filled out by the patients, however, participants completed the surveys independently unassisted by health care personnel.

CONCLUSION

Endopelvic fascia-preserving RALP does not improve urinary continence or sexual function as compared with the standard surgical technique. Future studies aiming to improve functional outcomes after RALP should focus on evaluating other technique modifications. Siltari A, Riikonen J, Murtola TJ. Preservation of Endopelvic Fascia: Effects on Postoperative Incontinence and Sexual Function - A Randomized Clinical Trial. J Sex Med 2021;18:327-338.

Association Among Lower Urinary Tract Symptoms, Erectile Function, and Sexual Satisfaction: Results from the Brazil LUTS Study

INTRODUCTION

Lower urinary tract symptoms (LUTS) affect ≥60% of adult men and are associated with erectile dysfunction (ED) and sexual dissatisfaction.

AIM

The aim of this study was to evaluate the relationship among male LUTS, ED, and sexual satisfaction.

METHODS

This was a secondary analysis of the Brazil LUTS study, a cross-sectional, epidemiological survey conducted by telephone interview in 5 cities in Brazil. This analysis included men aged ≥40 years.

MAIN OUTCOME MEASURE

LUTS were identified using International Continence Society definitions. LUTS severity was assessed using the International Prostate Symptom Score questionnaire. Erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5) questionnaire and sexual satisfaction was rated on a 5-point scale.

RESULTS

2,433 men participated in the study. Of 2,183 men reporting data on LUTS, 873 (40%) had LUTS "about half the time" or more. The prevalence of ED and sexual dissatisfaction was 14.4% and 7.8%, respectively. The proportion of men reporting ED and sexual dissatisfaction was higher among men with LUTS (24.6% and 13.8%, respectively) than men without LUTS (8.7% and 4.5%, respectively; P < .001). LUTS severity was negatively correlated with IIEF-5 scores (r = -0.199; P < .001); we estimated a 0.431-point decrease in IIEF-5 score per 3-point increase in International Prostate Symptom Score. Increased age and the presence of LUTS were associated with a greater chance of ED and sexual dissatisfaction; depression/anxiety and diabetes were associated with a greater chance of sexual dissatisfaction only. Among men with LUTS, urgency with fear of leaking, urgency urinary incontinence, and nocturnal enuresis were associated with a greater chance of ED, whereas slow stream and urgency urinary incontinence were associated with a greater chance of sexual dissatisfaction.

CONCLUSION

These results demonstrate that the presence of LUTS is associated with an increased chance of ED and sexual dissatisfaction in Brazilian men and reinforce the importance of a comprehensive assessment of these conditions. Gomes CM, Averbeck MA, Koyama M, et al. Association Among Lower Urinary Tract Symptoms, Erectile Function, and Sexual Satisfaction: Results from the Brazil LUTS Study. Sex Med 2019;8:45-56.

Analysis of Spatial Dose-Volume Relationships and Decline in Sexual Function Following Permanent Brachytherapy for Prostate Cancer

OBJECTIVE

To explore relationships between dose to periprostatic anatomic structures and erectile dysfunction (ED) outcomes in an institutional cohort treated with prostate brachytherapy.

METHODS

The Sexual Health Inventory for Men (SHIM) instrument was administered for stage cT1-T2 prostate cancer patients treated with Pd-103 brachytherapy over a 10-year interval. Dose volume histograms for regional organs at risk and periprostatic regions were calculated with and without expansions to account for contouring uncertainty. Regression tree analysis clustered patients into ED risk groups.

RESULTS

We identified 115 men treated with definitive prostate brachytherapy who had 2 years of complete follow-up. On univariate analysis, the subapical region (SAR) caudal to prostate was the only defined region with dose volume histograms parameters significant for potency outcomes. Regression tree analysis separated patients into low ED risk (mean 2-year SHIM 20.03), medium ED risk (15.02), and high ED risk (5.54) groups. Among patients with good baseline function (SHIM ≥ 17), a dose ≥72.75 Gy to 20% of the SAR with 1 cm expansion was most predictive for 2-year potency outcome. On multivariate analysis, regression tree risk group remained significant for predicting potency outcomes even after adjustment for baseline SHIM and age.

CONCLUSION

Dose to the SAR immediately caudal to prostate was predictive for potency outcomes in patients with good baseline function. Minimization of dose to this region may improve potency outcomes following prostate brachytherapy.

Quality of Life, Psychological Functioning, and Treatment Satisfaction of Men Who Have Undergone Penile Prosthesis Surgery Following Robot-Assisted Radical Prostatectomy

BACKGROUND

Penile prosthesis surgery is last-line treatment to regaining erectile function after radical prostatectomy (RP) for localized prostate cancer.

AIMS

To assess quality of life, psychological functioning, and treatment satisfaction of men who underwent penile implantation after RP; the psychosocial correlates of treatment satisfaction and sexual function after surgery; and the relation between patients' and partners' ratings of treatment satisfaction.

METHODS

98 consecutive patients who underwent penile implantation after RP from 2010 and 2015 and their partners were invited to complete a series of measures at a single time point. Of these, 71 patients and 43 partners completed measures assessing sexual function, psychological functioning, and treatment satisfaction. Proportions of patients who demonstrated good sexual function and satisfaction with treatment and clinical levels of anxiety and depression were calculated. Hierarchical regression analyses were conducted to determine psychosocial factors associated with patient treatment satisfaction and sexual function and patient-partner differences in treatment satisfaction.

OUTCOMES

Patients completed the Expanded Prostate Cancer Index Composite Short Form (EPIC-26), Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), Prostate Cancer-Related Quality of Life Scale, Self-Esteem and Relationship Questionnaire (SEAR), Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Partners completed the GAD-7, PHQ-9, EDITS (partner version), and SEAR.

RESULTS

94% of men reported satisfaction with treatment (EDITS score > 50). 77% of men reported good sexual function (EPIC-26 score > 60). Lower depression scores were associated with higher sexual confidence and sexual intimacy, and these were correlated with better treatment satisfaction and sexual function. Patients experienced higher sexual relationship satisfaction (median score = 90.6) than their partners (median score = 81.2), but there was no difference in treatment satisfaction between groups. Higher patient treatment satisfaction was more likely to be reported for couples whose depression scores were more similar.

CLINICAL IMPLICATIONS

It is important to provide preoperative penile implant counseling and encourage patients to seek postoperative counseling if needed.

STRENGTHS AND LIMITATIONS

This is one of the first Australian-based studies comprehensively assessing treatment satisfaction and psychosocial health of men after penile prosthesis surgery after RP. This was a retrospective cross-sectional study, so there is a possibility of recall bias, and causal associations could not be determined.

CONCLUSION

Men in this Australian series who underwent penile prosthesis surgery after RP generally reported good sexual function and treatment satisfaction. Nevertheless, patient and partner mental health influenced their reported experience of the treatment. Pillay B, Moon D, Love C, et al. Quality of Life, Psychological Functioning, and Treatment Satisfaction of Men Who Have Undergone Penile Prosthesis Surgery Following Robot-Assisted Radical Prostatectomy. J Sex Med 2017;14:1612-1620.

Interpreting Patient Reported Urinary and Sexual Function Outcomes across Multiple Validated Instruments

PURPOSE

Comparing patient reported outcomes such as urinary and erectile function across institutions is critical for prostate cancer research and quality assurance. Such comparisons are complicated due to the use of different questionnaires. We aimed to develop a method to convert scores among 4 commonly used instruments.

MATERIALS AND METHODS

Patient reported data on urinary and sexual function were collected on 1,284 men with localized prostate cancer using the EPIC-26 (Expanded Prostate Index Composite), PCI (UCLA Prostate Cancer Index), SHIM (Sexual Health Inventory for Men) and I-PSS (International Prostate Symptom Scale) questionnaires. We investigated several methods to convert scores among questionnaires.

RESULTS

Conversion between EPIC and PCI urinary and sexual function subscales was best achieved using only the subset of questions asked on both questionnaires. For the conversion between EPIC or PCI erectile function scores and SHIM scores, we defined thresholds of poor, intermediate and good function as EPIC/PCI 0 to 40 and SHIM 1 to 7, EPIC/PCI 41 to 59 and SHIM 8 to 16, and EPIC/PCI 60 to 100 and SHIM 17 to 25, respectively. Urinary continence scores highly correlated for PCI and EPIC (r = 0.94). No comparison was possible for I-PSS with EPIC and PCI due to differences in the domains addressed by these questionnaires.

CONCLUSIONS

We have introduced methods to convert scores among the EPIC, PCI and SHIM questionnaires. While these conversion methods may introduce minor imprecision, to our knowledge they represent the best available tools to combine and compare patient reported outcomes that are assessed using different instruments in men undergoing radical prostatectomy or active surveillance.

Patient-reported outcomes in the ProtecT randomized trial of clinically localized prostate cancer treatments: study design, and baseline urinary, bowel and sexual function and quality of life

Objectives

To present the baseline patient‐reported outcome measures (PROMs) in the Prostate Testing for Cancer and Treatment (ProtecT) randomized trial comparing active monitoring, radical prostatectomy and external‐beam conformal radiotherapy for localized prostate cancer and to compare results with other populations.

Materials and Methods

A total of 1643 randomized men, aged 50–69 years and diagnosed with clinically localized disease identified by prostate‐specific antigen (PSA) testing, in nine UK cities in the period 1999–2009 were included. Validated PROMs for disease‐specific (urinary, bowel and sexual function) and condition‐specific impact on quality of life (Expanded Prostate Index Composite [EPIC], 2005 onwards; International Consultation on Incontinence Questionnaire‐Urinary Incontinence [ICIQ‐UI], 2001 onwards; the International Continence Society short‐form male survey [ICSmaleSF]; anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), generic mental and physical health (12‐item short‐form health survey [SF‐12]; EuroQol quality‐of‐life survey, the EQ‐5D‐3L) were assessed at prostate biopsy clinics before randomization. Descriptive statistics are presented by treatment allocation and by men's age at biopsy and PSA testing time points for selected measures.

Results

A total of 1438 participants completed biopsy questionnaires (88%) and 77–88% of these were analysed for individual PROMs. Fewer than 1% of participants were using pads daily (5/754). Storage lower urinary tract symptoms were frequent (e.g. nocturia 22%, 312/1423). Bowel symptoms were rare, except for loose stools (16%, 118/754). One third of participants reported erectile dysfunction (241/735) and for 16% (118/731) this was a moderate or large problem. Depression was infrequent (80/1399, 6%) but 20% of participants (278/1403) reported anxiety. Sexual function and bother were markedly worse in older men (65–70 years), whilst urinary bother and physical health were somewhat worse than in younger men (49–54 years, all P < 0.001). Bowel health, urinary function and depression were unaltered by age, whilst mental health and anxiety were better in older men (P < 0.001). Only minor differences existed in mental or physical health, anxiety and depression between PSA testing and biopsy assessments.

Conclusion

The ProtecT trial baseline PROMs response rates were high. Symptom frequencies and generic quality of life were similar to those observed in populations screened for prostate cancer and control subjects without cancer.

Exploring the feasibility and acceptability of couple-based psychosexual support following prostate cancer surgery: study protocol for a pilot randomised controlled trial

BACKGROUND

Men who undergo surgery for prostate cancer frequently experience significant side-effects including urinary and sexual dysfunction. These difficulties can lead to anxiety, depression and reduced quality of life. Many partners also experience psychological distress. An additional impact can be on the couple relationship, with changes to intimacy, and unmet psychosexual supportive needs in relation to sexual recovery and rehabilitation. The aim of this exploratory randomised controlled trial pilot study is to determine the feasibility and acceptability of a novel family-relational-psychosexual intervention to support intimacy and reduce distress among couples following prostate cancer surgery and to estimate the efficacy of this intervention.

METHODS/DESIGN

The intervention will comprise six sessions of psychosexual and relationship support delivered by experienced couple-support practitioners. Specialist training in delivering the intervention will be provided to practitioners and they will be guided by a detailed treatment manual based on systemic principles. Sixty-eight couples will be randomised to receive either the intervention or standard care (comprising usual follow-up hospital appointments). A pre-test, post-test design will be used to test the feasibility of the intervention (baseline, end of intervention and six-month follow-up) and its acceptability to couples and healthcare professionals (qualitative interviews). Both individual and relational outcome measures will assess sexual functioning, anxiety and depression, couple relationship, use of health services and erectile dysfunction medication/technologies. An economic analysis will estimate population costs of the intervention, compared to usual care, using simple modelling to evaluate the affordability of the intervention.

DISCUSSION

Given the increasing incidence and survival of post-operative men with prostate cancer, it is timely and appropriate to determine the feasibility of a definitive trial through a pilot randomised controlled trial of a family-relational-psychosexual intervention for couples. The study will provide evidence about the components of a couple-based intervention, its acceptability to patients and healthcare professionals, and its influence on sexual and relational functioning. Data from this study will be used to calculate sample sizes required for any definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01842438.Registration date: 24 April 2013; Randomisation of first patient: 13 May 2013.

Potency preservation following stereotactic body radiation therapy for prostate cancer

BACKGROUND

Erectile dysfunction after prostate radiation therapy remains an ongoing challenge and critical quality of life issue. Given the higher dose of radiation per fraction using stereotactic body radiation therapy (SBRT) there is concern that post-SBRT impotency would be higher than conventional radiation therapy approaches. This study sought to evaluate potency preservation and sexual function following SBRT for prostate cancer.

METHODS

Between February 2008 and March 2011, 216 men with clinically localized prostate cancer were treated definitively with SBRT monotherapy at Georgetown University Hospital. Potency was defined as the ability to have an erection firm enough for intercourse with or without sexual aids while sexual activity was defined as the ability to have an erection firm enough for masturbation and foreplay. Patients who received androgen deprivation therapy (ADT) were excluded from this study. Ninety-seven hormone-naïve men were identified as being potent at the initiation of therapy and were included in this review. All patients were treated to 35-36.25 Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). Prostate specific antigen (PSA) and total testosterone levels were obtained pre-treatment, every 3 months for the first year and every 6 months for the subsequent year. Sexual function was assessed with the Sexual Health Inventory for Men (SHIM), the Expanded Prostate Index Composite (EPIC)-26 and Utilization of Sexual Medication/Device questionnaires at baseline and all follow-up visits.

RESULTS

Ninety-seven men (43 low-, 50 intermediate- and 4 high-risk) at a median age of 68 years (range, 48-82 years) received SBRT. The median pre-treatment PSA was 5.9 ng/ml and the minimum follow-up was 24 months. The median pre-treatment total serum testosterone level was 11.4 nmol/L (range, 4.4-27.9 nmol/L). The median baseline SHIM was 22 and 36% of patients utilized sexual aids prior to treatment. Although potency rates declined following treatment: 100% (baseline); 68% (6 months); 62% (12 months); 57% (18 months) and 54.4% (24 months), 78% of previously potent patients had erections sufficient for sexual activity at 24 months post-treatment. Overall sexual aid utilization increased from 36% at baseline to 49% at 24 months. Average EPIC sexual scores showed a slow decline over the first two years following treatment: 77.6 (baseline); 68.7 (6 months); 63.2 (12 months); 61.9 (18 months); 59.3 (24 months). All sexual functions including orgasm declined with time. Prior to treatment, 13.4% of men felt their sexual function was a moderate to big problem which increased to 26.7% two years post treatment. Post-treatment testosterone levels gradually decreased with a median value at two year follow-up of 10.7 nmol/L. However, the average EPIC hormonal scores did not illustrate a statistically significant difference two years post-treatment. Review of the radiation doses to the penile bulb in this study, a potential marker of post-treatment sexual function, revealed that the dose was relatively low and at these low doses the percentage of the penile bulb receiving 29.5 Gy did not correlate with the development of ED.

CONCLUSIONS

Men undergoing SBRT monotherapy for prostate cancer report sexual outcomes comparable to those reported for conventional radiation modalities within the first 24 months after treatment. Longer follow-up is required to confirm the durability of these findings.

Measuring and predicting prostate cancer related quality of life changes using EPIC for clinical practice

PURPOSE

We expanded the clinical usefulness of EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) by evaluating its responsiveness to health related quality of life changes, defining the minimally important differences for an individual patient change in each domain and applying it to a sexual outcome prediction model.

MATERIALS AND METHODS

In 1,201 subjects from a previously described multicenter longitudinal cohort we modeled the EPIC-CP domain scores of each treatment group before treatment, and at short-term and long-term followup. We considered a posttreatment domain score change from pretreatment of 0.5 SD or greater clinically significant and p ≤ 0.01 statistically significant. We determined the domain minimally important differences using the pooled 0.5 SD of the 2, 6, 12 and 24-month posttreatment changes from pretreatment values. We then recalibrated an EPIC-CP based nomogram model predicting 2-year post-prostatectomy functional erection from that developed using EPIC-26.

RESULTS

For each health related quality of life domain EPIC-CP was sensitive to similar posttreatment health related quality of life changes with time, as was observed using EPIC-26. The EPIC-CP minimally important differences in changes in the urinary incontinence, urinary irritation/obstruction, bowel, sexual and vitality/hormonal domains were 1.0, 1.3, 1.2, 1.6 and 1.0, respectively. The EPIC-CP based sexual prediction model performed well (AUC 0.76). It showed robust agreement with its EPIC-26 based counterpart with 10% or less predicted probability differences between models in 95% of individuals and a mean ± SD difference of 0.0 ± 0.05 across all individuals.

CONCLUSIONS

EPIC-CP is responsive to health related quality of life changes during convalescence and it can be used to predict 2-year post-prostatectomy sexual outcomes. It can facilitate shared medical decision making and patient centered care.

Short-term functional outcomes and complications associated with transperineal template prostate mapping biopsy

OBJECTIVE

To assess the complications and erectile and urinary functional outcomes of transperineal template mapping biopsy (TTMB) of the prostate.

METHODS

We retrospectively reviewed the records of 84 patients undergoing TTMB at our institution and recorded complications and functional outcomes. Erectile and urinary functions were measured at baseline, 2 weeks, and 6 ± 2 weeks after TTMB using the International Index of Erectile Function short version (IIEF-5) and International Prostate Symptom Score questionnaires. Erectile and urinary function parameters were compared between baseline and 2 and 6 weeks after TTMB in a paired fashion. A subanalysis of erectile function was performed in preoperatively potent men (IIEF-5 >17).

RESULTS

Sixteen patients (19%) experienced complications. The most common events were transient urinary retention (6%), prostatitis (4%) and local events, including perineal hematoma, bruising, or perineal pain (5%). One patient with hematuria required intervention. IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 20 (interquartile range [IQR], 16-23), 18 (IQR, 12-22), and 18 (IQR, 12-22), respectively (P = .096 and P = .034). Among preoperatively potent men, IIEF-5 scores at baseline, 2 weeks, and 6 weeks were 22 (IQR, 20-24), 21 (IQR, 18-24), and 22 (IQR, 18-24), respectively (P = .011 and P = .018). International Prostate Symptom Scores were 6 (IQR, 3.5-11) at baseline, rose to 10 (IQR, 4.8-15) at 2 weeks (P = .012), and returned to 7 (IQR, 3.5-13) at 6 weeks (P = .628).

CONCLUSION

TTMB has a favorable morbidity profile, with mostly mild and transient complications. Urinary retention occurred in 6%, and only 1 patient required intervention with bladder irrigation. Despite a statistically significant decline in erectile function from baseline, the median change in IIEF-5 score was 1 point. Urinary symptoms worsened initially but returned to baseline within 6 weeks.

Sexual bother and function after radical prostatectomy: predictors of sexual bother recovery in men despite persistent post-operative sexual dysfunction

Changes in sexual bother (SB) following radical prostatectomy (RP) negatively affect health-related quality of life (HRQoL) of prostate cancer survivors. However, post-operative SB tends to be neglected whereas sexual function (SF) is thoroughly assessed in clinical practice and few studies have focused on and evaluated patients' SB. We retrospectively reviewed 2 345 consecutive patients who underwent RP between 2001 and 2009 at a single institution. SF and SB were assessed using Expanded Prostate Cancer Index Composite (EPIC) questionnaires. We stratified our cohort by SB recovery and post-operative SF status, including a subset of men who recovered SB despite persistent post-RP sexual dysfunction. Multivariable logistic regression analyses were conducted to identify factors for men who have SB recovery. Of 319 eligible patients, 133 (41.7%) recovered their SB at a mean of 20 months after RP. Among the 133 men who demonstrated SB recovery, 109 had post-operative sexual dysfunction. Patients with SB recovery despite post-RP sexual dysfunction were more likely to be old (p = 0.004), to have higher clinical T stage (p < 0.001), to have more non-nerve-sparing RP (p < 0.001), to have lower pre-operative EPIC-SF/SB scores (p < 0.001), to have more extracapsular extension (p = 0.031) and to be PDE5i non-users after surgery (p < 0.001). In multivariable analysis, predictors for this subset were lower comorbidity (OR 0.62, p = 0.043), higher clinical cancer stage (OR 2.35, p = 0.026), worse pre-operative SF (OR 0.98, p = 0.010), SB (OR 0.98, p < 0.010) and no PDE5i use (OR 0.37, p = 0.002); age was not related (OR 0.99, p = 0.555). As SB can influence patients' overall HRQoL, expectations of SB recovery should be provided to patients in the same way that SF recovery is presented. This study may help clinicians to discuss SB with patients and assess their potential for SB recovery following RP.

Erectile function, incontinence, and other quality of life outcomes following proton therapy for prostate cancer in men 60 years old and younger

BACKGROUND

This study sought to evaluate patient-reported health-related quality of life following proton therapy for prostate cancer in men ≤ 60 years old.

METHODS

Between August 2006 and January 2010, 262 hormone-naive men ≤ 60 years old were treated with definitive proton therapy for prostate cancer. Before treatment and every 6 months after treatment, patients filled out the Expanded Prostate Index Composite (EPIC) and the International Index of Erectile Function (IIEF) questionnaires. Potency was defined as successful sexual intercourse in the prior month or an EPIC sexual summary (SS) score ≥ 60.

RESULTS

Median follow-up was 24 months; 90% of men completed follow-up EPIC forms within the last year. For EPIC urinary, bowel, and hormone subscales, the average decline from baseline to 2 years was ≤5 points, except for bowel function (5.2 points). SS scores declined 12.6 points after 2 years. Potency rates declined by 11% from baseline at 2 years, but 94% of men were potent with a baseline IIEF > 21, body mass index < 30, and no history of diabetes. At 2 years after treatment, only 1.8% of men required a pad for urge incontinence. On multivariate analysis, factors associated with a significant decline in SS score were mean penile bulb dose ≥40 cobalt Gy equivalents (P = .012) and radiation dose ≥ 80 cobalt Gy equivalents (P = .017); only diabetes was significantly associated with impotence (P = .015).

CONCLUSIONS

Young men undergoing proton therapy for treatment of prostate cancer have excellent outcomes with respect to erectile dysfunction, urinary incontinence, and other health-related quality of life parameters during the first 2 years after treatment. Longer follow-up is needed to confirm these findings.

Association between preoperative erectile dysfunction and prostate cancer features--an analysis from the Duke Prostate Center Database

INTRODUCTION

Erectile dysfunction (ED) is related to several co-morbidities including obesity, metabolic syndrome, cigarette smoking, and low testosterone, all of which have been reported to be associated with adverse prostate cancer features.

AIM

To examine whether preoperative ED has a relationship with adverse prostate cancer features in patients who underwent radical prostatectomy (RP).

METHODS

We analyzed data from our institution on 676 patients who underwent RP between 2001 and 2010. Crude and adjusted logistic regression models were used to investigate the association between preoperative ED and several pathological parameters. The log-rank test and multivariate proportional hazards model were conducted to determine the association of preoperative ED with biochemical recurrence (BCR).

MAIN OUTCOME MEASURES

The expanded prostate cancer index composite (EPIC) instrument was used to evaluate preoperative erectile function (EF). Preoperative normal EF was defined as EPIC-SF ≥ 60 points while ED was defined as preoperative EPIC-SF lower than 60 points.

RESULTS

Preoperatively, a total of 343 (50.7%) men had normal EF and 333 (49.3%) men had ED. After adjusting for covariates, preoperative ED was identified a risk factor for positive extracapsular extension (OR 1.57; P = 0.029) and high percentage of tumor involvement (OR 1.56; P = 0.047). In a Kaplan-Meier curve, a trend was identified that patients with ED had higher incidence of BCR than men with normal EF (P = 0.091). Moreover, using a multivariate Cox model, higher preoperative EF was negatively associated with BCR (HR 0.99; P = 0.014).

CONCLUSIONS

These results suggest that the likelihood for adverse pathological outcomes as well as BCR following prostatectomy is higher among men with preoperative ED, though these results require validation in larger datasets. The present study indicates that preoperative ED might be a surrogate for adverse prostate cancer outcomes following RP.

Prediction of erectile function following treatment for prostate cancer

CONTEXT

Sexual function is the health-related quality of life (HRQOL) domain most commonly impaired after prostate cancer treatment; however, validated tools to enable personalized prediction of erectile dysfunction after prostate cancer treatment are lacking.

OBJECTIVE

To predict long-term erectile function following prostate cancer treatment based on individual patient and treatment characteristics.

DESIGN

Pretreatment patient characteristics, sexual HRQOL, and treatment details measured in a longitudinal academic multicenter cohort (Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment; enrolled from 2003 through 2006), were used to develop models predicting erectile function 2 years after treatment. A community-based cohort (community-based Cancer of the Prostate Strategic Urologic Research Endeavor [CaPSURE]; enrolled 1995 through 2007) externally validated model performance. Patients in US academic and community-based practices whose HRQOL was measured pretreatment (N = 1201) underwent follow-up after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer. Sexual outcomes among men completing 2 years' follow-up (n = 1027) were used to develop models predicting erectile function that were externally validated among 1913 patients in a community-based cohort.

MAIN OUTCOME MEASURES

Patient-reported functional erections suitable for intercourse 2 years following prostate cancer treatment.

RESULTS

Two years after prostate cancer treatment, 368 (37% [95% CI, 34%-40%]) of all patients and 335 (48% [95% CI, 45%-52%]) of those with functional erections prior to treatment reported functional erections; 531 (53% [95% CI, 50%-56%]) of patients without penile prostheses reported use of medications or other devices for erectile dysfunction. Pretreatment sexual HRQOL score, age, serum prostate-specific antigen level, race/ethnicity, body mass index, and intended treatment details were associated with functional erections 2 years after treatment. Multivariable logistic regression models predicting erectile function estimated 2-year function probabilities from as low as 10% or less to as high as 70% or greater depending on the individual's pretreatment patient characteristics and treatment details. The models performed well in predicting erections in external validation among CaPSURE cohort patients (areas under the receiver operating characteristic curve, 0.77 [95% CI, 0.74-0.80] for prostatectomy; 0.87 [95% CI, 0.80-0.94] for external radiotherapy; and 0.90 [95% CI, 0.85-0.95] for brachytherapy).

CONCLUSION

Stratification by pretreatment patient characteristics and treatment details enables prediction of erectile function 2 years after prostatectomy, external radiotherapy, or brachytherapy for prostate cancer.

Sexual quality of life for localized prostate cancer: a cross-cultural study between Japanese and American men

Introduction

Race and ethnicity are important factors in health-related quality of life (QOL) because of racial differences in preferences for, and trust in, health systems. Such factors are likely to affect QOL and patient satisfaction with care.

Results

Using a self-reported questionnaire, Japanese men with prostate cancer reported lower sexual function scores at baseline. In detail, Japanese men were more likely than American men to report poor sexual desire, poor erection ability, poor overall ability to function sexually, poor ability to attain orgasm, poor quality of erections, infrequency of erections, infrequency of morning erections, and intercourse in the previous 4 weeks. However, Japanese men were less likely than American men to be concerned about their sexual function. Two years after surgery, American patients were more likely than Japanese patients to regain their baseline sexual function. The use of phosphodiesterase-5 (PDE-5) inhibitors has been widely publicized as the solution to erectile dysfunction after prostate cancer treatment. Although PDE-5 inhibitors have been available in Japan since 1999, it is striking that Japanese men with localized prostate cancer are much less likely (only 10%) to use PDE-5 inhibitors than American men.

Conclusion

Japanese patients with localized prostate cancer report worse sexual function but are less concerned about their reduced function. In the absence of a biological explanation for such differences, however, we suspect that cultural differences may explain the differences between QOL survey results from Japanese or American men with prostate cancer.

Altered male physiologic function after surgery for prostate cancer: couple perspective

PURPOSE

Both the diagnosis of prostate cancer (PCa) and the physiologic outcomes of surgical treatment impact the male's psychological sphere. However, current research advocates a refocusing of outcomes directed to the PCa "couple". Herein we acquire insight into perspective and concordance regarding male physiological function from the standpoint of a couple recovering from PCa surgery.

MATERIALS AND METHODS

Couples whereby the male partner had undergone primary surgical treatment for PCa were mailed a Retrospective Sexual Survey (RSS) packet consisting of male and female partner questionnaires. RSS questions surveyed physiological changes in libido, foreplay, erection and arousal, orgasm and ejaculation in addition to perceived psychological impact. Patients' and partners' scores were evaluated to determine the concordance of both individual items as well as domain sums.

RESULTS

Twenty-eight couples completed the questionnaires. Only about 40% of men and women were happy with their levels of sexual interest with 82% concordance. Urine loss during orgasm was reported by 43% of men; the majority of participants were bothered by it. Ejaculation changes were observed by 96% of men (concordance 96%) with most reporting anejaculation. A change in orgasm experience was noted by 86% of men (and 36% of their female partners, p < 0.0001). Despite the change, the majority of men and women reported being satisfied with their ability to climax.

CONCLUSION

Our results indicate that patients and their female partners may interpret differently the same physiological outcomes of PCa surgery. This information could be useful to better counsel the PCa couple and help patients and partners adjust after surgery.

Clinical interpretation of the Expanded Prostate Cancer Index Composite-Short Form sexual summary score

PURPOSE

The Expanded Prostate Cancer Index Composite is a validated health related quality of life instrument that is commonly administered after prostate cancer treatment. We classified Expanded Prostate Cancer Index Composite-Short Form sexual summary scores into clinically meaningful groups.

MATERIALS AND METHODS

A development cohort of 561 patients undergoing radical prostatectomy was used to define sexual summary groups by correlation with their responses on the Sexual Health Inventory for Men. A separate validation cohort of 430 patients was used to compare Expanded Prostate Cancer Index Composite-Long Form sexual bother scores among these sexual summary groups.

RESULTS

A sexual summary group score of 0 to 33, 34 to 45, 46 to 60, 61 to 75 and greater than 75 correlated with Sexual Health Inventory for Men groups of severe--1 to 7, moderate--8 to 11, mild/moderate--12 to 16, mild--17 to 21 and no erectile dysfunction--22 to 25, respectively. In the validation group mean sexual bother scores in each of the 5 sexual summary groups were significantly different from each other after controlling for patient age, stage, hormone treatment, marital status and nerve sparing (p <0.0001).

CONCLUSIONS

Expanded Prostate Cancer Index Composite-Short Form sexual summary scores can be categorized into 5 groups for which excellent correlation is found with similar validated groups based on the Sexual Health Inventory for Men. Also, sexual bother scores are significantly different among the groups, showing that they represent discrete, clinically relevant cutoffs. This will help patients and physicians interpret Expanded Prostate Cancer Index Composite scores and help define potency for comparison among various prostate cancer treatments.