Ten-year outcomes of sexual function after radical prostatectomy: results of a prospective longitudinal study

Does Diabetes Have a Negative Impact on Erectile Function Recovery After Radical Prostatectomy?

OBJECTIVE

To quantify the risk of long-term post-radical prostatectomy (RP) erectile dysfunction (ED) in men with diabetes mellitus (DM).

METHODS

We included men who underwent RP and were followed for ≥24 months at our institution; men were excluded if they received androgen deprivation therapy or radiation therapy. Erectile function recovery (EFR) was assessed using the International Index of Erectile Function (IIEF) Erectile Function Domain (EFD) score pre-RP and serially during follow-up. We performed logistic regression analysis to investigate a potential association between erectile function 24 months post-RP.

RESULTS

Of 2261 men included, 8% were diabetic. Men in the diabetic group tended to present with more vascular comorbidities. For men with DM, the median time from diagnosis was 4 years pre-RP, and the median hemoglobin A1c pre-RP was 6.7%. After 24 months post-RP, EFR was significantly lower among the diabetic group. The median EFD was 7. Men with DM had a lower proportion of functional EFR (17%) and a greater proportion of severe ED (57%). In the univariable logistic regression model to analyze DM diagnosis was a significant predictor of functional EFR (OR 0.43, P <.001) and severe ED (OR 1.85, P <.001) 24 months post-RP. Furthermore, this was not observed for a multivariable analysis.

CONCLUSION

Twenty-four months after RP, EFR is compromised in individuals with DM.

Functional Impact of Neuro-Vascular Bundle Preservation in High Risk Prostate Cancer without Compromising Oncological Outcomes: A Propensity-Modelled Analysis

Nerve sparing (NS) is a surgical technique to optimize functional outcomes of radical prostatectomy (RP). However, it is not recommended in high risk (HR) cases because of the risk of a positive surgical margin that may increase the risk of cancer recurrence. In the last two decades there has been a change of perspective to the effect that in well-selected cases NS could be an oncologically safe option with better functional outcomes. Therefore, we aim to compare the functional outcomes and oncological safety of NS during RP in men with HR disease. A total of 1340 patients were included in this analysis, of which 12% (n = 158) underwent non-NSRP and 39% (n = 516) and 50% (n = 666) uni- and bilateral NSRP, respectively. We calculated a propensity score and used inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of Pca patients undergoing non-NSRP and those having uni- and bilateral NSRP, respectively. NS improved functional outcomes; after IPTW, only 3% of patients having non-NSRP reached complete erectile function recovery (without erectile aid) at 24 months, whereas 22% reached erectile function recovery (with erectile aid), while 87% were continent. Unilateral NS increased the probability of functional recovery in all outcomes (OR 1.1 or 1.2, respectively), bilateral NS slightly more so (OR 1.1 to 1.4). NSRP did not impact the risk of any recurrence (HR 0.99, 95%CI 0.73-1.34, p = 0.09), and there was no difference in survival for men who underwent NSRP (HR 0.65, 95%CI 0.39-1.08). There was no difference in cancer-specific survival (0.56, 95%CI 0.29-1.11). Our study found that NSRP significantly improved functional outcomes and can be safely performed in carefully selected patients with HR-PCa without compromising long term oncological outcomes.

Low-intensity pulsed ultrasound ameliorates erectile dysfunction induced by bilateral cavernous nerve injury through enhancing Schwann cell-mediated cavernous nerve regeneration

BACKGROUND

Cavernous nerve injury-induced erectile dysfunction caused by pelvic surgery or trauma is refractory to conventional medications and required an alternative treatment. Low-intensity pulsed ultrasound is a noninvasive mechanical therapy that promotes nerve regeneration.

OBJECTIVES

To investigate the therapeutic effect and potential mechanism of low-intensity pulsed ultrasound in the treatment of neurogenic erectile dysfunction.

MATERIALS AND METHODS

Thirty rats were randomly divided into the sham-operated group, bilateral cavernous nerve injury group, and bilateral cavernous nerve injury + low-intensity pulsed ultrasound group. The erectile function was assessed 3 weeks after daily low-intensity pulsed ultrasound treatment. The penile tissues and cavernous nerve tissues were harvested and subjected to histologic analysis. Primary Schwann cells and explants were extracted from adult rats. The effects of low-intensity pulsed ultrasound on proliferation, migration, and nerve growth factor expression of Schwann cells and axonal elongation were examined in vitro. RNA sequencing and western blot assay were applied to predict and verify the molecular mechanism of low-intensity pulsed ultrasound-induced Schwann cell activation.

RESULTS

Our study showed that low-intensity pulsed ultrasound promoted Schwann cells proliferation, migration, and neurotrophic factor nerve growth factor expression. Meanwhile, low-intensity pulsed ultrasound exhibits a stronger ability to enhance Schwann cells-mediated neurite outgrowth of major pelvic ganglion neurons and major pelvic ganglion/cavernous nerve explants in vitro. In vivo experiments demonstrated that the erectile function of the rats in the bilateral cavernous nerve injury + low-intensity pulsed ultrasound group was significantly higher than those in the bilateral cavernous nerve injury groups. Moreover, the expression levels of smooth muscle and cavernous endothelium also increased significantly in the bilateral cavernous nerve injury + low-intensity pulsed ultrasound group. In addition, we observed the higher density and number of cavernous nerve regenerating axons in the bilateral cavernous nerve injury + low-intensity pulsed ultrasound group, indicating that low-intensity pulsed ultrasound promotes axonal regeneration following cavernous nerve injury in vivo. RNA sequencing analysis and bioinformatic analysis suggested that low-intensity pulsed ultrasound might trigger the activation of the PI3K/Akt pathway. Western blot assay confirmed that low-intensity pulsed ultrasound activated Schwann cells through TrkB/Akt/CREB signaling.

CONCLUSIONS

Low-intensity pulsed ultrasound promoted nerve regeneration and ameliorated erectile function by enhancing Schwann cells proliferation, migration, and neurotrophic factor nerve growth factor expression. The TrkB/Akt/CREB axis is the possible mechanism of low-intensity pulsed ultrasound-mediated Schwann cell activation. Low-intensity pulsed ultrasound-based therapy could be a novel potential treatment strategy for cavernous nerve injury-induced neurogenic erectile dysfunction.

The Italian Society of Andrology and Sexual Medicine (SIAMS), along with ten other Italian Scientific Societies, guidelines on the diagnosis and management of erectile dysfunction

PURPOSE

Erectile dysfunction (ED) is one of the most prevalent male sexual dysfunctions. ED has been in the past mistakenly considered a purely psycho-sexological symptom by patients and doctors. However, an ever-growing body of evidence supporting the role of several organic factors in the pathophysiological mechanisms underlying ED has been recognized.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving several other National Societies to provide an updated guideline on the diagnosis and management of ED. Derived recommendations were based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Several evidence-based statements were released providing the necessary up-to-date guidance in the context of ED with organic and psychosexual comorbidities. Many of them were related to incorrect lifestyle habits suggesting how to associate pharmacotherapies and counseling, in a couple-centered approach. Having the oral therapy with phosphodiesterase type 5 inhibitors as the gold standard along with several other medical and surgical therapies, new therapeutic or controversial options were also discussed.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves the most important Societies related to the field of sexual medicine. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving couple sexual satisfaction and overall general health.

Cavernous Nerve Injury Resulted Erectile Dysfunction and Regeneration

Erectile dysfunction (ED) is an important cause of reduced quality of life for men and their partners. Recent studies have found that cavernous nerve injury (CNI) during prostate cancer surgery and other pelvic surgery results in medically induced CNIED in more than 80% of patients. The efficacy of first- and second-line treatment options for ED is poor. A great deal of research has been devoted to exploring new methods of neuroprotection and nerve regeneration to save erectile function in patients with CNIED, especially in patients with cavernous nerve injury after prostate cancer surgery. In addition, such as neuromodulatory proteins, proimmune ligands, gene therapy, stem cell therapy, and the current cutting-edge low-energy shock wave therapy have shown advantages in basic research and limited clinical studies. In the context of today's modern medicine, these new therapeutic techniques are expected to be new tools in the treatment of cavernous nerve injury erectile dysfunction. This article presents the main causes, mechanisms, and treatment of cavernous nerve injury erectile dysfunction and combines them with new treatment strategies.

Preliminary Development of a Mindfulness-Based Group Therapy to Expand Couples' Sexual Intimacy after Prostate Cancer: A Mixed Methods Approach

Introduction

Sexual health and intimacy are consistently reported among the top unmet supportive care needs of prostate cancer (PC) survivors. With an aging population and advances in PC detection and treatment, the need for better PC sexual health interventions is acute.

Aim

Examine the feasibility of a mindfulness-based therapy group aimed at improving sexual intimacy for couples following PC treatments.

Methods

A 4-session mindfulness-based group intervention was developed for PC survivors (mean age 65.6 yrs) and their partners (mean age 61.4 yrs). A mixed-methods approach was adopted to account for small sample sizes (N = 14 couples). Findings will guide future treatment refinement via participants’ lived experiences.

Main Outcome Measures

Quantitative outcomes assessed pretreatment, immediately after treatment, and 6 months later included relationship adjustment, sexual satisfaction, sexual function, depression, anxiety, and mindfulness. Qualitative outcomes used Grounded Theory Approach following posttreatment exit interviews.

Results

Effect sizes 6 months posttreatment indicated moderate improvements in overall sexual satisfaction and large increases in mindfulness in PC survivors, small decreases in sexual intimacy reported by partners, and small increases in anxiety in PC survivors and partners. Qualitative outcomes revealed 6 themes: (i) PC treatments must view PC as a couple’s disease; (ii) PC treatments must consider the impact of illness on individuals and the couple; (iii) Mindfulness was a valued treatment modality; (iv) Individual factors contribute to outcomes, and therefore, must be considered; (v) Multiple perceived mechanisms for change exist; (vi) Group format is a therapeutic element of the process.

Conclusion

An acceptance-based approach to sexual intimacy needs among PC survivors and their partners is feasible. While this small-scale preliminary study suggests that mindfulness may address some currently unmet needs among this population, randomized clinical trials are needed.

JA Bossio, CS Higano, LA Brotto. Preliminary Development of a Mindfulness-Based Group Therapy to Expand Couples’ Sexual Intimacy after Prostate Cancer: A Mixed Methods Approach. Sex Med 2021;9:100310.

PDE-5i Management of Erectile Dysfunction After Rectal Surgery: A Systematic Review Focusing on Treatment Efficacy

Erectile dysfunction (ED) is one of the main functional complications of surgical resections of the rectum due to rectal cancers or inflammatory bowel disease (IBD). The present systematic review aimed at revising ED management strategies applied after rectal resections and their efficacy in terms of improvement of the International Index of Erectile Function (IIEF) score. A literature search was conducted on Medline, EMBASE, Scopus, and Cochrane databases by two independent reviewers following the PRISMA guidelines. Randomized and nonrandomized controlled trials (RCTs, NRCTs), case-control studies, and case series evaluating medical or surgical therapies for ED diagnosed after rectal surgery for both benign and malignant pathologies were eligible for inclusion.

Out of 1028 articles initially identified, only five met the inclusion criteria: two RCTs comparing oral phosphodiesterase type-5 inhibitor (PDE-5i) versus placebo; one NRCT comparing PDE-5i versus PDE-5i + vacuum erection devices (VEDs) versus control; and two before-after studies on PDE-5i. A total of 253 (82.7%) rectal cancer patients and 53 (17.3%) IBD patients were included. Based on two RCTs, PDE-5i significantly improved IIEF compared to placebo at 3 months (SMD = 1.07; 95% CI [0.65, 1.48]; p < .00001; I² = 39%). Improved IIEF was also reported with PDE-5i + VED at 12 months. There is a paucity of articles in the literature that specifically assess efficacy of ED treatments after rectal surgery. Many alternative treatment strategies to PDE-5is remain to be investigated. Future studies should implement standardized preoperative, postoperative, and follow-up sexual function assessment in patients undergoing rectal resections.

Current management strategy of treating patients with erectile dysfunction after radical prostatectomy: a systematic review and meta-analysis

The aim of this study is to present a summary of current evidence concerning the various treatments in the management of penile rehabilitation after radical prostatectomy (RP) and provide recommendations for future research. Randomized controlled trials (RCTs) were identified from electronic databases including PubMed, the Cochrane Library, Embase, and Web of Science from inception through March 2020 with no limitation to language. Comparable data from each study were combined in a meta-analysis where possible, otherwise data were synthesized narratively. The data analysis was completed by Review Manager version 5.3. A total of 39 RCTs were included in this study. At present, phosphodiesterase type 5 inhibitors (PDE5is) remain the first-line treatment for patients with erectile dysfunction (ED) after RP. Compared with the placebo group, patients in regular PDE5is group (mean difference (MD): 0.76; 95% confidence interval (CI): 1.69-4.44; p < 0.0001) and on demand group (MD: 3.92; 95% CI: 2.95-4.88; p < 0.00001) had a significantly higher mean Erectile Function domain of the International Index of Erectile Function (IIEF-EF) scores within 3 months after RP. As for the proportion of IIEF-EF ≥ 22, patients in regular PDE5is group and on demand PDE5is group had significantly higher proportion than those in placebo group 6 months after RP, and the odds ratios were 1.87 (95% CI: 1.32-2.66; p = 0.0005) and 2.17 (95% CI: 1.20-3.93; p = 0.01), respectively. No significant difference was observed between regular PDE5is group and on demand group regardless of mean IIEF-EF score or the proportion of IIEF-EF ≥ 22. Intracorporeal injection therapy seemed to have similar efficacy to PDE5is. The International Index of Erectile Function-5 items (IIEF-5) scores were significantly higher in vacuum constriction devices group than control group at 6-9 months after RP (MD: 6.70, 95% CI: 2.30-11.10, p = 0.003) with great between-study heterogeneity (p = 0.06, I² = 72%). The other therapeutics including low-intensity extracorporeal shockwave therapy, statin therapy, psychotherapy interventions, and pelvic floor muscle training plus electrical stimulation showed certain improvement on erectile function. We found that the combination therapy showed certain advantages over monotherapy. Currently, PDE5is-based combination therapy remains the mainstream treatment for ED after RP. Intracorporeal injection therapy and vacuum therapy could be served as alternative treatments if PDE5is are ineffective and contraindicated.

Optimal pressure in penile rehabilitation with a vacuum erection device: evidence based on a rat model

Vacuum erection device (VED), used to treat radical prostatectomy (RP)-associated erectile dysfunction, has attracted considerable attention. However, the optimal negative pressure remains to be determined. This investigation explored the optimal pressure for VED therapy in penile rehabilitation. Thirty-six 9-week-old male rats were randomly divided into six groups: control groups (sham group, bilateral cavernous nerve crush [BCNC] group) and VED therapy groups (−200 mmHg group, −300 mmHg group, −400 mmHg group, −500 mmHg group). BCNC group and VED therapy groups underwent BCNC surgery. Intracavernosal pressure (ICP)/mean arterial pressure (MAP) ratio was calculated to assess erectile function. Masson's trichrome (MT) staining, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, immunohistochemistry, and real-time polymerase chain reaction (RT-PCR) were performed to explore cellular and molecular changes of the penis. Compared to the BCNC group, ICP/MAP ratios in all VED treatment groups were improved significantly (all P < 0.05), but there were no statistically significant differences among VED therapy groups. With increased pressure, complications gradually emerged and increased in frequency. Expression of molecular indicators, such as endothelial nitric oxide synthase (eNOS) and alpha-smooth muscle actin (α-SMA), increased after VED therapy, and hypoxia-inducible factor 1α (HIF-1α) and transforming growth factor beta (TGF-β) decreased. In addition, VED therapy improved the outcomes of MT and TUNEL assay. This investigation demonstrated a pressure of −200 mmHg in a rat model is optimal for VED therapy for penile rehabilitation after RP. No further benefits were observed with increased pressure, despite an increase in complications.

Athermal versus ultrasonic nerve-sparing laparoscopic radical prostatectomy: a comparison of functional and oncological outcomes

PURPOSE

Many urologists emphasize the concept of heat-related damage suggesting the avoidance of any energy to perform nerve-sparing radical prostatectomy. At our institution, both athermal and ultrasonic dissection have been used over the last years to perform a nerve-sparing laparoscopic radical prostatectomy (NSLRP). In this study, we compare functional and oncological outcomes of the two procedures.

METHODS

All charts from patients undergoing NSLRP between January 2009 and June 2015 were reviewed. The International Index of Erectile Function (IIEF-5) was recorded preoperatively and 3, 12 and 24 months after surgery; continence was recorded at 3 and 12 months; PSA was recorded at last follow-up. Uni- and multivariate analyses were performed to assess the association of variables with functional and oncological outcomes.

RESULTS

Ultrasonic NSLRP was used for 120 patients, while athermal NSLRP on 111. The impact of the cutting technique on erection recovery was different at 3 months, favoring athermal dissection (p = 0.002); however, significance was lost at 12 (p = 0.09) and 24 (p = 0.14) months. Continence recovery was comparable at 3 (p = 0.1) and 12 (p = 0.2) months; the rate of positive surgical margins and PSA recurrence were also similar (p = 0.2 and p = 0.06, respectively). At univariate analysis, age, Gleason sum, nerve-sparing laterality, and extension (intra- vs interfascial) were associated with overall erection recovery; only age and nerve-sparing laterality were independent predictors. Age and preoperative TRUS prostate volume were associated with continence recovery, both at uni- and multivariate analysis.

CONCLUSIONS

The use of an ultrasonic device compared to athermal dissection during NSLRP does not affect long-term potency, nor continence and early biochemical recurrence.

Sildenafil orodispersible film in the treatment of erectile dysfunction after radical prostatectomy: A single-centre open-label uncontrolled trial

Phosphodiesterase-5 inhibitors are the first-line therapy for erectile dysfunction (ED) after radical prostatectomy (RP). This single-centre open-label uncontrolled study evaluated the efficacy and safety of the new sildenafil orodispersible film (ODF) in ED treatment after RP. Sildenafil 100 mg ODF was administered twice a week for 3 months to patients under 75 years of age, with a Framingham cardiovascular risk score < 20% and a pre-operative International Index of Erectile Function (IIEF)-5 score ≥ 17, who had undergone open RP between 2016 and 2018. Erectile function was assessed pre-operatively, post-operatively and after treatment through the IIEF-5 score, the Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3; adverse events (AE) were also investigated after 3 months. A total of 65 patients with a median (25th-75th percentile) post-operative IIEF-5 score of 8 (7-9) were treated. Nine (13.8%) patients reported AE of mild/moderate grade and discontinued treatment. A significant IIEF-5 score median (25th-75th percentile) increase of 10 (0-12) was found after treatment in the other 56 patients (p < .001). Sildenafil 100 mg ODF was effective in ED after RP in terms of improved IIEF-5 score and improved SEP-Q2 and SEP-Q3 in 67.9% of patients. It could represent a valid alternative for those patients with low compliance to tablet intake.

The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT, POSEIDON, and TAC-HFT Trials

BACKGROUND

Despite limited human data, there is a growing interest in the use of stem cell therapy (SCT) for erectile dysfunction (ED).

AIM

To determine the effect of transendocardial stem cell injection on erectile function on men with cardiomyopathy and ED.

METHODS

We used International Index of Erectile Function (IIEF) scores collected from men enrolled in 3 separate randomized controlled trials: Comparison of Allogeneic vs Autologous Bone Marrow-Derived Mesenchymal Stem Cells Delivered by Transendocardial Injection in Patients With Ischemic Cardiomyopathy (POSEIDON), Transendocardial Mesenchymal Stem Cells and Mononuclear Bone Marrow Cells for Ischemic Cardiomyopathy (TAC-HFT), and Dose Comparison Study of Allogeneic Mesenchymal Stem Cells in Patients With Ischemic Cardiomyopathy (TRIDENT). These trials recruited patients with ischemic cardiomyopathy and ejection fraction less than 50%. Inclusion and exclusion criteria were identical in all 3 trials. The primary intervention in these trials included transendocardial stem cell injection of stem cells or placebo via cardiac catheterization. The follow-up period was 1 year. IIEF data were collected at baseline and at multiple time points in each trial.

OUTCOMES

We investigated erectile function over time based on cell dose, cell source (autologous vs allogenic), cell type (mesenchymal stem cells vs bone marrow mononuclear cells), and comparing men who received SCT with those who received placebo.

RESULTS

A total of 36 men were identified with complete IIEF data. 8 men received placebo injection, and 28 received SCT. The median age was 66.5 years. Comorbidities were similar among all men. Analysis was performed on men with ED, defined by an IIEF-EF score of 24 or less. In the placebo and all-comer SCT group, the median IIEF-EF score was 5 [1-8] and 5 [1-15] at baseline and was 3.5 [3-5.8] and 7 [1-18] at 12 months (P > .05). When analyzed by cell dose, the IIEF-EF score in men who received 200 million cells increased significantly over 12 months (14 [4-23] to 20 [15-24.5], P = .014.) Similarly, an autologous cell source resulted in a similar increase from baseline to 12 months (14 [3.8-23.3] to 20 [12-22], P = .030).

CLINICAL IMPLICATIONS

Erectile function may improve after systemic delivery of SCT in men with ischemic cardiomyopathy and at least mild ED.

STRENGTHS & LIMITATIONS

This post hoc analysis is the first to investigate the effect of SCT on erectile function using randomized, placebo-controlled data. Weaknesses include that ED was not a primary end point, and men were not originally recruited based on erectile function.

CONCLUSION

Future trials on systemic delivery of SCT for ED should focus on high cell dose and autologous cell source, as these seem to provide the best response in men with at least mild ED. Ory J, Saltzman RG, Blachman-Braun R, et al. The Effect of Transendocardial Stem Cell Injection on Erectile Function in Men With Cardiomyopathy: Results From the TRIDENT, POSEIDON, and TAC-HFT Trials. J Sex Med 2020;17:695-701.

Endothelial progenitor cells promote viability and nerve regenerative ability of mesenchymal stem cells through PDGF-BB/PDGFR-β signaling

Denervation-induced erectile dysfunction (ED) is a prevailing health problem. Our previous study revealed that endothelial progenitor cells (EPCs) promoted the effect of mesenchymal stem cells (MSCs) on restoration of denervation-induced ED in rats. However, underling mechanisms are still largely elusive. In this study, EPCs and MSCs were co-cultured and resorted to co-EPCs and co-MSCs. EPCs-derived paracrine factors containing PDGF-BB (platelet-derived growth factor) were detected, and MSCs were pre-treated with PDGF-BB, while co-MSCs were pre-treated with PDGFR inhibitor AG1296. Either viability or nerve regenerative ability of MSCs was evaluated. In addition, inhibition of either PI3K/Akt or MEK/Erk pathway was performed to evaluate the role of PI3K/Akt and MEK/Erk pathway in PDGF-BB-induced viability of MSCs. The results revealed that PDGF-BB significantly increased the proportion of PDGFR-β⁺ MSCs, and promoted both in-vitro and in-vivo viability, as well as nerve regenerative capacity and erectile function restoration of MSCs in rats. Inhibition of PI3K/Akt, MEK/Erk pathway or mTOR led to decrease of PDGF-BB/PDGFR-β induced viability of MSCs. To our knowledge, our study first demonstrates that EPCs promote viability and potential nerve regenerative ability of MSCs through PDGF-BB/PDGFR-β signaling and its downstream PI3K/Akt and MEK/Erk pathways. mTOR acts as a co-mediator in PI3K/Akt and MEK/Erk pathways.

Prostate-specific health-related quality of life and patient-physician communication - A 3.5-year follow-up

OBJECTIVE

The aim of this study is to examine associations between prostate-specific health-related quality of life (HRQOL) and aspects of patient-physician communication in localized prostate cancer treatment.

METHODS

Data of patients with localized prostate cancer were collected at 6-month intervals over a 3.5-year period within a prospective, observational study (HAROW). Data collection comprised D'Amico risk categories, the Charlson Comorbidity Index, patient-physician communication (information, shared decision making, support, devotion), and prostate-specific HRQOL (incontinence aid, urinary symptoms, bowel symptoms, hormonal treatment-related symptoms, sexual functioning, sexual activity). Data of N = 1722 patients undergoing radical prostatectomy were analyzed by longitudinal multilevel analysis.

RESULTS

The mean patient age was 65 years; 31% had a low risk and 38% an intermediate risk of cancer growth and spread; 73% had a Charlson Comorbidity Index of 0. Significant associations were found between prostate-specific HRQOL and shared decision making, support and devotion. Patient information was not significantly associated with aspects of prostate-specific HRQOL.

CONCLUSION

Patient reported long term outcomes are associated with aspects of patient-physician communication in prostate cancer patients. Patients feeling involved by their urologists experience less side effects of (surgical) treatment.

PRACTICE IMPLICATIONS

Special communication training programmes should be developed and implemented for urologists.

Combined Transplantation of Mesenchymal Stem Cells and Endothelial Progenitor Cells Restores Cavernous Nerve Injury-Related Erectile Dysfunction

BACKGROUND

Whether combined transplantation of mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs) is more effective than transplantation of a single cell type in the restoration of erectile function is unknown.

AIM

To investigate the effect of combined transplantation of MSCs and EPCs on restoration of erectile function in rats with cavernous nerve injury (CNI).

METHODS

MSCs were isolated from human bone marrow and EPCs were isolated from human umbilical cord blood. MSCs and EPCs were identified by flow cytometry and in vitro differentiation or immunofluorescence staining. 25 8-week-old male Sprague-Dawley rats were allocated to 1 of 5 groups: sham operation group, bilateral CNI group receiving periprostatic implantation of MSCs plus EPCs, MSCs, EPCs, or phosphate buffered saline (control group). 2 weeks after CNI and treatment, erectile function of rats was measured by electrically stimulating the CN. The penis and major pelvic ganglia were harvested for histologic examinations. RNA and protein levels of neurotrophin factors (vascular endothelial growth factor, nerve growth factor, and brain-derived neurotrophic factor) in mono- or coculture MSCs and EPCs were assessed by real-time polymerase chain reaction and enzyme-linked immunosorbent assay, respectively.

OUTCOMES

Intracavernous pressure and mean arterial pressure were measured to evaluate erectile function. Histologic examinations of the penis and major pelvic ganglia and RNA and protein levels of neurotrophin factors in MSCs and EPCs were performed.

RESULTS

MSCs and EPCs expressed the specified cell markers and exhibited the typical appearance and characteristics. Treatments using MSCs and/or EPCs could increase endothelial and smooth muscle contents of the corpus cavernosum, decrease caspase-3 expression and increase penile neuronal nitric oxide synthase expression, and restore the neural component of the major pelvic ganglia in rats with CNI. Combined transplantation of MSCs and EPCs had a better effect on improving erectile function than single transplantation of MSCs or EPCs. Expression levels of vascular endothelial growth factor and nerve growth factor in coculture MSCs and EPCs were significantly higher than those of primary MSCs or EPCs.

CLINICAL TRANSLATION

Combined transplantation of MSCs and EPCs was more effective in restoring erectile function in CNI-related erectile dysfunction models.

STRENGTHS AND LIMITATIONS

The study, for the 1st time, proved that combined transplantation of MSCs and EPCs was more effective in restoring erectile function in rats with CNI. The rat model might not represent the human condition.

CONCLUSION

Combined periprostatic transplantation of MSCs and EPCs could restore erectile function in rats with CNI more effectively. MSCs might restore CN fibers by secreting neurotrophin factors such as vascular endothelial growth factor and nerve growth factor, and EPCs could enhance the paracrine activity of MSCs. Fang J-f, Huang X-n, Han X-y, et al. Combined Transplantation of Mesenchymal Stem Cells and Endothelial Progenitor Cells Restores Cavernous Nerve Injury-Related Erectile Dysfunction. J Sex Med 2018;15:284-295.

Effects of Biofeedback in Preventing Urinary Incontinence and Erectile Dysfunction after Radical Prostatectomy

In this study, we present a biofeedback method for the strengthening of perineal muscles during the preoperative procedures for radical prostatectomy, and we evaluate this technique as a prevention measure against complications such as urinary incontinence (UI) and erectile dysfunction (ED), which affect prostatectomy patients after surgery. In the experimental protocol, the patients performed specific exercises with the help of a device that provided the patient with visual biofeedback, based on a plot of the anal pressure. For the experimental protocol, we selected 20 male patients, with an average age of 64.0 years, and submitted them to ten therapeutic sessions each. A control group consisting of 32 men with an average age of 66.3 years, who were treated with the same surgical procedure but not with the preoperative procedures, also took part in the experiment. To evaluate UI and ED after the surgery in both control and experimental groups, we used two validated questionnaires-to assess UI, we used the King's Health Questionnaire (KHQ) and, for ED, we used the International Index of Erectile Function (IIEF-5) Questionnaire. We compared the variables associated with UI and ED after the surgery for the control and experimental groups. The occurrence of UI after radical prostatectomy in the control group (100% of the patients) was higher than that for the experimental group (5% of the patients), with p < 0.0001. Likewise, the occurrence of erectile dysfunction after prostatectomy in the control group (48.6% of the patients) was higher than that for the experimental group (5% of the patients), with p < 0.0001. The number of nocturia events also decreased as a consequence of the intervention (p < 0.0001), as did the number of disposable underwear units for urinary incontinence (p < 0.0001). Furthermore, we compared, only for the experimental group, the anal pressure before the biofeedback intervention and after the surgery, and we verified that the anal pressure after surgery was significantly higher (p < 0.0001). The results strongly suggest that the preoperative biofeedback procedure was effective in decreasing urinary incontinence and erectile dysfunction after radical prostatectomy. As future work, we intend to extend this analysis for larger samples and considering a broader age range.

Comparison of Functional Outcome after Extended versus Super-Extended Pelvic Lymph Node Dissection during Radical Prostatectomy in High-Risk Localized Prostate Cancer

Background

Urinary continence and erectile function (EF) are best preserved when meticulous dissection of prostate and nerve sparing technique are used during radical prostatectomy (RP). However, extent of lymph node dissection (LND) may also adversely affect functional results.

Objective

To determine whether performing a super-extended LND (seLND) has a significant effect on recovery of urinary continence and EF after RP.

Design, setting, and participants

All patients who underwent RP from January 2007 until December 2013 were handed questionnaires assessing continence and EF. All patients in whom at least an extended LND (eLND) was performed were selected. This search yielded 526 patients. 172 of these patients had filed out 2 or more questionnaires and were included in our analysis.

Outcome measurements and statistical analysis

All questionnaires were reviewed. We used Kaplan–Meier analyses and multivariate Cox analysis to assess the difference in recovery of continence and EF over time for eLND/seLND. Primary endpoints were full recovery of continence (no loss of urine) and full recovery of EF (successful intercourse possible). Patients who did not reach the endpoint when the last questionnaire was filled out were censored at that time. Median follow-up was 12.43 months for continence, and 18.97 months for EF.

Results and limitations

Patients undergoing seLND have a lower chance of regaining both urinary continence [hazard ratio (HR) 0.59, 95% CI 0.39–0.90, p = 0.026] and EF (HR 0.28, 95% CI 0.13–0.57, p = 0.009). Age at surgery had a significant influence on both continence and EF in multivariate analysis. Major limitation of the study was that no formal preoperative assessment of continence and potency was done.

Conclusion

Extending the LND template beyond the eLND template may cause at least a significant delay in recovery of urinary continence and leads to less recovery of EF.

Does penile rehabilitation have a role in the treatment of erectile dysfunction following radical prostatectomy?

In men undergoing radical treatment for prostate cancer, erectile function is one of the most important health-related quality-of-life outcomes influencing patient choice in treatment. Penile rehabilitation has emerged as a therapeutic measure to prevent erectile dysfunction and expedite return of erectile function after radical prostatectomy. Penile rehabilitation involves a program designed to increase the likelihood of return to baseline-level erectile function, as opposed to treatment, which implies the therapeutic treatment of symptoms, a key component of post–radical prostatectomy management. Several pathological theories form the basis for rehabilitation, and a plethora of treatments are currently in widespread use. However, whilst there is some evidence supporting the concept of penile rehabilitation from animal studies, randomised controlled trials are contradictory in outcomes. Similarly, urological guidelines are conflicted in terms of recommendations. Furthermore, it is clear that in spite of the lack of evidence for the role of penile rehabilitation, many urologists continue to employ some form of rehabilitation in their patients after radical prostatectomy. This is a significant burden to health resources in public-funded health economies, and no effective cost-benefit analysis has been undertaken to support this practice. Thus, further research is warranted to provide both scientific and clinical evidence for this contemporary practice and the development of preventative strategies in treating erectile dysfunction after radical prostatectomy.

Global, Regional and National Burden of Prostate Cancer, 1990 to 2015: Results from the Global Burden of Disease Study 2015

PURPOSE

Data on the incidence, mortality and burden of prostate cancer as well as changing trends are necessary to provide policy makers with the evidence needed to allocate resources appropriately. This study presents estimates of prostate cancer incidence, mortality and burden from 1990 to 2015 by patient age, country and developmental status using the results of the Global Burden of Disease 2015 study.

MATERIALS AND METHODS

Data from vital registration systems and cancer registries were used to generate mortality estimates. Cause specific mortality served as the basis for estimating incidence, prevalence and disability adjusted life years. The global number of incident cases, deaths and disability adjusted life years attributable to prostate cancer are reported as well as age standardized rates.

RESULTS

Incident cases of prostate cancer increased 3.7-fold from 1990 to 2015. The age standardized incidence rate also increased 1.7-fold during the study period and in 2015 it reached 56.71/100,000 person-years (95% uncertainty interval 45.86-78.45). Global estimates of the age standardized death rate decreased slightly to 14.24 deaths (95% uncertainty interval 11.8-17.95) per 100,000 person-years in 2015. The decline in the age standardized death rate was more prominent in high income countries. Disability adjusted life years attributable to prostate cancer increased by 90% during the study period.

CONCLUSIONS

The prostate cancer mortality rate is decreasing in high income countries. However, the incidence and burden of disease are steadily increasing globally, resulting in further challenges in the allocation of limited health care resources. The current study provides comprehensive knowledge of the local burden of disease and help with appropriate allocation of resources for prostate cancer prevention, screening and treatment.

Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis

BACKGROUND

Penile rehabilitation, defined as the use of any drug or device at or after radical prostatectomy to maximize erectile function recovery, is commonly used for post-prostatectomy erectile dysfunction; however, conflicting results based on each study make it difficult to give a recommendation for clinical practice.

AIM

To clarify the effect of oral phosphodiesterase type 5 inhibitors (PDE5is), vacuum erection devices, intracorporeal injection therapy, and the combination of these treatments on penile rehabilitation.

METHODS

A comprehensive publication search was done through the PubMed and Embase databases up to February 8, 2017. The reference lists of the retrieved studies also were investigated. Data were analyzed using STATA 12.0. A fixed- or random-effects model was used to calculate the overall combined odds ratio (OR) or standard mean differences (SMDs). Publication bias was assessed using the Begg and Egger tests.

OUTCOMES

Change in sexual function before and after treatment.

RESULTS

After screening, 11 randomized controlled trials and 5 case-control studies were included. The overall meta-analysis showed that penile rehabilitation with PDE5is, vacuum erection devices, and intracorporeal injection significantly increased the number of patients with erectile function improvement (OR = 2.800, 95% CI = 1.932-4.059, P = .000) and International Index of Erectile Function (IIEF) score (SMD = 5.896, 95% CI = 4.032-7.760, P = .000). In subgroup analysis based on study design, randomized controlled trials and case-control studies showed that penile rehabilitation increased the number of patients with erectile function improvement (randomized controlled trials: OR = 2.154, 95% CI = 1.600-2.895, P = .000; case-control studies: OR = 2.800, 95% CI = 1.932-4.059, P = .000). Subgroup analysis for PDE5i treatment also only demonstrated an increased patient response rate (OR = 2.161, 95% CI = 1.675-2.788, P = .000) and IIEF scores (SMD = 0.922, 95% CI = 0.545-1.300, P = .000). However, after PDE5i washout, there was no improvement of spontaneous erectile function (OR = 1.027, 95% CI = 0.713-1.478, P = .610).

CLINICAL TRANSLATION

This study provides information about the efficacy of penile rehabilitation that can help clinicians decide treatment strategies.

STRENGTHS AND LIMITATIONS

This meta-analysis has higher statistical power than each study. Preoperative patient characteristics, various treatment methods, and different follow-up times might bring bias to pooled effects.

CONCLUSION

Our meta-analysis confirmed that administration of PDE5is, vacuum erection devices, and intracorporeal injection after radical prostatectomy can increase erection function during treatments. However, current evidence does not support that penile rehabilitation with PDE5is can improve recovery of spontaneous erectile function. Further studies with adequate follow-up and larger samples should be conducted to generate a comprehensive conclusion. Liu C, Lopez DS, Chen M, Wang R. Penile Rehabilitation Therapy Following Radical Prostatectomy: A Meta-Analysis. J Sex Med 2017;14:1496-1503.

Effect of androgen deprivation therapy on sexual function and bother in men with prostate cancer: A controlled comparison

OBJECTIVES

The adverse sexual effects of androgen deprivation therapy (ADT) on men with prostate cancer have been well described. Less well known is the relative degree of sexual dysfunction and bother associated with ADT compared to other primary treatment modalities such as radical prostatectomy. We sought to describe the trajectory and relative magnitude of changes in sexual function and bother in men on ADT and to examine demographic and clinical predictors of ADT's adverse sexual effects.

METHODS

Prostate cancer patients treated with ADT (n = 60) completed assessments of sexual function and sexual bother 3 times during a 1-year period after the initiation of ADT. Prostate cancer patients treated with radical prostatectomy only and not receiving ADT (n = 85) and men with no history of cancer (n = 86) matched on age and education completed assessments at similar intervals.

RESULTS

Androgen deprivation therapy recipients reported worsening sexual function and increasing bother over time compared to controls. Effect sizes for the differences in sexual function were large to very large, and for bother were small to very large. Age younger than 83 years predicted relatively poorer sexual function, and age younger than 78 years predicted greater sexual bother at 12 months in men on ADT compared to men not on ADT.

CONCLUSIONS

Most men on ADT for prostate cancer will never return to baseline levels of sexual function. Interventions focused on sexual bother over function and designed to help couples build and maintain satisfying relationship intimacy are likely to more positively affect men's psychological well-being while on ADT than medical or sexual aids targeting sexual dysfunction.

Intracavernous Injections of Bone Marrow Mononucleated Cells for Postradical Prostatectomy Erectile Dysfunction: Final Results of the INSTIN Clinical Trial

We recently reported stage I of a phase 1/2 clinical trial of cell therapy to treat postradical prostatectomy erectile dysfunction (INSTIN, INtra-cavernous STem-cell INjection clinical trial, NCT01089387). In this first stage, four doses of intracavernous autologous bone marrow mononuclear cells (BM-MNCs) were tested in 12 patients. Here, we report the results of stage II, in which six additional patients received the optimal dose identified in stage I (10⁹ BM-MNCs), and the long-term results in the 12 patients included in stage I. The objectives were to assess the safety and efficacy of this new treatment. In stage II, no patients had side effects, and the erectile function improvements were similar to those seen in stage I: after 6 months, significant improvements versus baseline were noted in International Index of Erectile Function-15 intercourse satisfaction (7.8±3.1 vs 2.2±3.4, p=0.033) and erectile function (18±8.3 vs 3.7±4.1, p=0.035) domains. In stage I patients, after a mean follow-up of 62.1±11.7 mo, there were no prostate cancer recurrences, and erectile function scores were somewhat lower compared with the 1-yr time point. These findings suggest that intracavernous BM-MNC injections are safe and improve erectile function. The decline in erectile function over time suggests a need for assessing repeated injections.

PATIENT SUMMARY

We report a phase 1/2 pilot clinical trial of cell therapy consisting in intracavernous injection of bone marrow mononuclear cells to treat postradical prostatectomy erectile dysfunction. Erectile function was improved after 6 mo in the patients given 1×10⁹ cells. No serious side effects (life threatening or requiring hospitalisation) occurred after a mean follow-up of 62.1 mo in the first 12 patients.

Functional outcomes of clinically high-risk prostate cancer patients treated with robot-assisted radical prostatectomy: a multi-institutional analysis

BACKGROUND

To ascertain 3-year urinary continence (UC) and sexual function (SF) recovery following robot-assisted radical prostatectomy (RARP) for clinically high-risk prostate cancer (PCa).

METHODS

Retrospective analyses of a prospectively maintained database for 769 patients with D'Amico high-risk PCa undergoing RARP at two tertiary care centers in the United States and Europe between 2001 and 2014. The association between time since RARP and recovery of UC (defined as 0 pad/one safety liner per day) and SF (defined as sexual health inventory for men (SHIM) score ⩾17) was tested in separate preoperative and post-operative Cox-proportional hazards regression models. Sensitivity analyses were conducted using continence 0 pad per day and erection sufficient for intercourse as end points for UC and SF recovery, respectively.

RESULTS

Mean age of the cohort was 62.3 years, and 62.1% harbored ⩾PT3a disease. Nerve sparing (unilateral or bilateral) RARP was performed in 87.7% of patients. Kaplan-Meier estimates of UC recovery at 12, 24 and 36 months after surgery was 85.2%, 89.1% and 91.2%, respectively, while 33.8, 52.3 and 69.0% of preoperatively potent men (preoperative SHIM ⩾17; n=548; 71.3%) recovered SF. Similar results were noted in sensitivity analyses. Patient age and year of surgery were associated with UC and SF recovery; additionally, preoperative SHIM score, degree of nerve sparing, pT3b-T4 disease and surgical margins were associated with SF recovery over the period of observation.

CONCLUSIONS

Patients with D'Amico high-risk PCa treated with RARP may continue to recover UC and SF beyond 12 months of surgery and show promising outcomes at 3-year follow-up. Appropriate patient selection and counseling may aid in setting realistic expectations for functional recovery post RARP.

Orgasmic Function after Radical Prostatectomy

PURPOSE

We examined postprostatectomy orgasmic function and assessed for potential predictors.

MATERIALS AND METHODS

Between 2005 and 2013, 499 men underwent radical prostatectomy and completed quality of life questionnaires prospectively before surgery and at regular postoperative intervals. We used mixed effects logistic regression models to evaluate average differences in followup measures and interactions with time.

RESULTS

At a median followup of 36 months orgasmic function was worse, stable or improved in 300 (60.1%), 152 (30.5%) and 47 men (9.4%), respectively. Orgasmic function recovery plateaued at 15 to 21 months. High postoperative orgasmic function was positively associated with younger age (50 years or younger vs 51 to 60 OR 3.40, 95% CI 1.56-7.41), nerve sparing (bilateral OR 7.11, 95% CI 2.55-19.77, modified 4.34, 95% CI 1.38-13.58 and unilateral OR 3.93, 95% CI 1.17-13.16), erectile function (OR 4.67, 95% CI 3.32-6.57) and sexual desire (OR 5.51, 95% CI 3.95-7.68) but negatively associated with lower urinary tract symptoms (OR 0.58, 95% CI 0.41-0.82) and urinary incontinence (OR 0.38, 95% CI 0.25-0.56). Although robotic status did not influence orgasmic function in the overall cohort, it was associated with faster recovery on subgroup analysis of 356 patients with long followup. On another subgroup analysis of 235 men with long followup and poor erectile function the association of high preoperative orgasmic function and bilateral nerve sparing with high orgasmic function persisted, suggesting an independent effect on orgasmic function apart from that on erectile function.

CONCLUSIONS

Orgasmic function recovery after radical prostatectomy is a lengthy process. Predictors of orgasmic function include preoperative orgasmic function, age, nerve sparing status, erectile function, sexual desire and urinary control and function.

[Urinary incontinence and sexual dysfunction after treatment of localized prostate cancer: Results from a population aged less than 65years old]

INTRODUCTION

An increasing number of patients with prostate cancer (PC) are diagnosed and treated. The aim of this study was to investigate urinary incontinence (UI) and sexual dysfunction (SD) two years after treatment for localized prostate cancer (PC).

METHODS

This study followed all cases of localized PC diagnosed between 2008 and 2009 in men aged≤65years old and still alive two years after treatment. In total, 437 men were recruited. Data were collected using a standardized questionnaire and by cross-checking with data from the cancer registry. Descriptive and comparative analyses were performed to evaluate persisting UI and SD at 2years.

RESULTS

At two years after treatment, UI was persistent in 48.8%; 41.2% had used urinary protections, and 39.2% had used at least 1 pad/day; 55.2% reported financial difficulties for purchasing protective pads. In total, 22.7% did not consult a specialist for UI. SD was persistent in 82.8%; 30.4% did not consult a specialist for SD. SD had a negative impact on the sex life of patients and their partners. After adjustment for cancer stage, prostatectomy was significantly associated with persisting UI and SD at two years.

CONCLUSION

Two years after treatment, rates of persisting UI and/or SD remain high. Treatment by prostatectomy was significantly associated with an increased risk of persisting adverse effects at two years. The different toxicities between treatments should be presented to patients before initiating therapy in order to encourage the patient to contributed to shared treatment decision-making.

[Functional results and treatment of functional dysfunctions after radical prostatectomy]

OBJECTIVE

To describe the functional results and treatment of functional dysfunctions after radical prostatectomy for localized prostate cancer.

MATERIAL AND METHOD

Bibliography search was performed from the database Medline (National Library of Medicine, Pubmed) selected according to the scientific relevance. The research was focused on continence, potency, les dyserections, couple sexuality, incontinence, treatments of postoperative incontinence, dysrection and trifecta.

RESULTS

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Despite recent developments in surgical techniques, post-radical prostatectomy urinary incontinence (pRP-UI) continues to be one of the most devastating complications, which affects 9-16% of patients. Sphincter injury and bladder dysfunction are the most common causes or pRP-UI. The assessment of severity of pRP-UI that affects the choice of treatment is still not well standardized but should include at least a pad test and self-administered questionnaires. The implantation of an artificial urinary sphincter AMS800 remains the gold standard treatment for patients with moderate to severe pRP-UI. The development of less invasive techniques such as the male sling of Pro-ACT balloons has provided alternative therapeutic options for moderate and slight forms of pRP-UI. Most groups now consider the bulbo-urethral compressive sling as the treatment of choice for patients with non-severe pRP-UI. The most appropriate second-line therapeutic strategy is not clearly determined. Recent therapies such as adjustable artificial urinary sphincters and sling and stem cells injections have been investigated. Maintenance of a satisfying sex life is a major concern of a majority of men facing prostate cancer and its treatments. It is essential to assess the couple's sexuality before treating prostate cancer in order to deliver comprehensive information and consider early therapeutic solutions adapted to the couple's expectations. Active pharmacological erectile rehabilitation (intracavernous injections or phosphodiesterase type 5 inhibitors [PDE5i] on demand, during in the month following surgery) or passive (daily PDE5i after surgery) might improve the quality of erections especially in response to PDE5i. Unimpaired aspects of sexual response (orgasm) may, when the erection is not yet recovered, represent an alternative allowing the couple to preserve intimacy and complicity. Androgen blockade is a major barrier to maintain or return to a satisfying sex. Trifecta is a simple tool to present in one way the results of radical prostatectomy: in case of bilateral neurovascular preservation, Trifecta is 60% whatever the surgical approach.

CONCLUSION

Radical prostatectomy is an elaborate and challenging procedure when carcinological risk balances with functional results. Various treatments of postoperative incontinence and dysrections exist. Functional disorders after surgery have to be treated to ameliorate quality of life of patients.

Surgery and hormonal treatment for prostate cancer and sexual function

Prostate cancer (PC) is one of the most common cancers effecting men today. With earlier detection and improvements in available treatment modalities, there still remains significant morbidity associated with the treatment of PC. Male sexual health and erectile function are greatly impacted by these therapies and remain a concern to PC survivors. This article reviews the current literature on male sexual health following radical prostatectomy (RP) or androgen ablation therapy for PC. Each treatment modality affects male sexual function to an appreciable level, although certain patients have better outcomes if they have preoperative potency, are younger, or have nerve-sparing surgery. There is a delayed recovery up to 2 years seen in erectile function following RP. With androgen deprivation therapy (ADT), attempts can be made at different administration strategies and exercise may possibly play a role in maintaining erectile function. Penile rehabilitation protocols attempt to protect erectile function immediately following therapy through different modalities, although no one approach has been agreed upon.

Nanoparticle Improved Stem Cell Therapy for Erectile Dysfunction in a Rat Model of Cavernous Nerve Injury

PURPOSE

Recently intracavernous injection of stem cells has garnered great interest as a potential treatment of erectile dysfunction. However, most stem cells are washed out immediately after intracavernous injection. The goal of this study was to investigate using NanoShuttle™ magnetic nanoparticles to maintain stem cells in the corpus cavernosum after intracavernous injection, thereby improving stem cell therapy of erectile dysfunction in an animal model.

MATERIALS AND METHODS

Adipose derived stem cells were magnetized with NanoShuttle magnetic nanoparticles to create Nano-adipose derived stem cells. A total of 24 rats underwent bilateral cavernous nerve crush and were randomly assigned to 3 groups, including adipose derived stem cells, Nano-adipose derived stem cells and Nano-adipose derived stem cells plus magnet. Cells were tracked at days 1, 3, 5 and 9 after intracavernous injection. Another 40 rats with bilateral cavernous nerve crush were randomly assigned to 4 groups, including bilateral cavernous nerve crush, bilateral cavernous nerve crush plus adipose derived stem cell intracavernous injection, bilateral cavernous nerve crush plus Nano-adipose derived stem cell intracavernous injection and bilateral cavernous nerve crush plus Nano-adipose derived stem cell intracavernous injection plus magnet. Functional testing and histological analysis were performed 4 weeks after intracavernous injection.

RESULTS

In the in vitro study 1) NanoShuttle magnetic nanoparticles were successfully bound to adipose derived stem cells and 2) Nano-adipose derived stem cells migrated toward the magnet. In the in vivo study 1) cell tracking showed that Nano-adipose derived stem cells were successfully retained in the corpus cavernosum using the magnet for up to 3 days while most adipose derived stem cells were washed out in other groups by day 1 after intracavernous injection, and 2) intracavernous pressure/mean arterial pressure, and αSMA (α-smooth muscle actin) and PECAM-1 (platelet endothelial cell adhesion molecule 1) expression in the Nano-adipose derived stem cell group was significantly higher than in the other groups.

CONCLUSIONS

Magnetization of adipose derived stem cells with NanoShuttle magnetic nanoparticles kept adipose derived stem cells in the corpus cavernosum and improved adipose derived stem cell therapy of erectile dysfunction in an animal model.

Health related quality of life after oesophagectomy: elderly patients refer similar eating and swallowing difficulties than younger patients

Background

Oesophagectomy for cancer could be safe and worthwhile in selected older patients, but less is known about the effect of oesophagectomy on perceived quality of life of such delicate class of cancer patients. The aim of this study was to evaluate the impact of oesophagectomy for cancer in elderly patients in term of health-related quality of life.

Methods

We retrospectively evaluated all consecutive patients who underwent oesophagectomy for cancer at the Surgical Oncology Unit of the Veneto Institute of Oncology between November 2009 and March 2014. Quality of life was evaluated using EORTC C-30 and OES-18 questionnaires at admission, at discharge and 3 months after surgery. Adjusted multivariable linear mixed effect models were estimated to assess mean score differences (MDs) of selected aspects in older (≥70 years) and younger (<70 years) patients.

Results

Among 109 participating patients, 23 (21.1 %) were at least 70 years old and 86 (78.9 %) were younger than 70 years. Global quality of life was clinically similar between older and younger patients over time (MD 4.4). Older patients reported clinically and statistically significantly worse swallowing saliva (MD 17.4, 95 % C.I. 3.6 to 31.2), choking when swallowing (MD 13.8, 95 % C.I. 5.8 to 21.8) and eating difficulties (MD 20.1 95 % C.I. 7.4 to 32.8) than younger patients only at admission.

Conclusions

Early health-related quality of life perception after surgery resulted comparable in older and younger patients. This result may also be due to some predisposition of the elderly to adapt to the new status.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1647-5) contains supplementary material, which is available to authorized users.

Treatment of localized prostate cancer in elderly patients

Prostate cancer is a disease of the elderly. According to National Cancer Institute, more than 56.7% of incident cases are diagnosed and more than 90% of cancer specific deaths occur in men greater than 65 years of age. Despite equivalent oncologic outcomes with treatment, primary local therapy is often deferred in elderly men with high-risk prostate cancer, in part due to concerns that post surgery quality of life (QOL) functional outcomes compare poorly to younger men. Our aim in this editorial is to discuss the functional and oncological outcomes in management of elderly with localized prostate cancer.

Unexpected Long-term Improvements in Urinary and Erectile Function in a Large Cohort of Men with Self-reported Outcomes Following Radical Prostatectomy

BACKGROUND

It is generally assumed that if a man does not regain urinary continence or erectile function within 12 mo of radical prostatectomy (RP), then the chance of subsequent recovery is low.

OBJECTIVE

To determine the probability of achieving good urinary function (UF) or erectile function (EF) up to 48 mo postoperatively in men who reported poor UF or EF at 12 mo after RP.

DESIGN, SETTING, AND PARTICIPANTS

We identified 3187 patients who underwent RP from 2007 through 2013 at a tertiary institution and had extended multidisciplinary follow-up with patient-reported UF and EF scores at ≥12 mo.

INTERVENTION

Open or minimally invasive RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcome was good UF as defined by a urinary score ≥17 (range: 0-21) or good EF as defined by a modified International Index of Erectile Function-6 score ≥22 (range: 1-30). The probability of functional recovery beyond 12 mo was determined by Kaplan-Meier analyses.

RESULTS AND LIMITATIONS

Among patients incontinent at 12 mo, the probability of achieving good UF at 24, 36, and 48 mo was 30%, 49%, and 59%. In patients experiencing erectile dysfunction at 12 mo, the probability of recovering EF at 24, 36, and 48 mo was 22%, 32%, and 40%. On multivariable analyses, 12-mo functional score and age were associated with recovery, but only score was consistently significant.

CONCLUSIONS

Men with incontinence or erectile dysfunction at 12 mo have higher than anticipated rates of subsequent functional improvement. Probability of recovery is strongly influenced by score at 12 mo. Further research should address the impact of ongoing multidisciplinary follow-up care on our observed rates of recovery.

PATIENT SUMMARY

Many prostate cancer patients continue to recover urinary and erectile function after 12 mo. The level of functional recovery by 12 mo is associated with long-term recovery and should be discussed by the physician and patient when deciding on rehabilitative interventions.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies

OBJECTIVES

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients.

RESULTS

The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation.

CONCLUSIONS

The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

Long-term Satisfaction After Open Radical Prostatectomy

OBJECTIVE

To determine the association between baseline factors, post-treatment factors, and long-term satisfaction after radical prostatectomy (RP).

METHODS

Between January 2000 and March 2009, 1425 men who underwent RP by a single surgeon were enrolled in an institutional review board-approved, prospective, longitudinal outcomes study. Baseline characteristics and post-treatment functional and oncologic outcomes were captured through 2013. Patient survey responses from 875 (61.4%) of these men were used to evaluate satisfaction with treatment outcome and treatment decision.

RESULTS

Overall, 88.2% and 91.0% men were satisfied to very satisfied with treatment outcome and treatment decision, respectively. Baseline sexual function was associated with satisfaction with both treatment outcome (adjusted odds ratio [aOR] = 1.40; 95% confidence interval [CI], 1.01-1.93) and treatment decision (aOR = 1.47; 95% CI, 1.08-2.01). Among post-treatment factors, higher University of California, Los Angeles Prostate Cancer Sexual Function (aOR = 2.95; 95% CI, 2.06-4.22), University of California, Los Angeles Prostate Cancer Urinary Function (aOR = 2.38; 95% CI, 1.66-3.40), and lower urinary tract symptom scores (aOR = 1.91; 95% CI, 1.19-3.06) were predictors of satisfaction with outcome. Bother due to incontinence and sexual dysfunction, and perception of cure were independent predictors of both satisfaction with treatment outcome and treatment decision.

CONCLUSION

Nearly 90% of men are satisfied with both their treatment outcome and treatment decision after open RP. Improving long-term satisfaction after RP requires efforts to provide realistic expectations and improve functional outcomes.

Psychosocial perspectives on sexual recovery after prostate cancer treatment

Many therapies for erectile dysfunction (ED) after prostate cancer treatment improve erectile firmness, yet, most couples stop using aids within 1-2 years. Patients and partners who expect immediate and complete success with their first ED treatment can be demoralized when they experience treatment failure, which contributes to reticence to explore other ED aids. Comprehensive patient education should improve sustainability and satisfaction with ED treatments. Pre-emptive and realistic information should be provided to couples about the probability of recovering natural erections. Beginning intervention early and using a couple-based approach is ideal. Recommendations are provided about the timing of ED treatment, the order of aid introduction, and combination therapies. Renegotiation of sexual activity is an essential part of sexual adaptation. From the outset of therapy, couples should be encouraged to broaden their sexual repertoire, incorporate erection-independent sexual activities, and continue to be sexual despite ED and reduced libido.

Coupling of prostate and thyroid cancer diagnoses in the United States

BACKGROUND

Prostate and thyroid cancers represent two of the most overdiagnosed tumors in the US. Hypothesizing that patients diagnosed with one of these malignancies were more likely to be diagnosed with the other, we examined the coupling of diagnoses of prostate and thyroid cancer in a large US administrative dataset.

METHODS

The surveillance, epidemiology, and end results (SEER) database was used to identify men diagnosed with clinically localized prostate cancer (CaP) or thyroid cancer between 1995 and 2010. SEER*stat software was used to estimate multivariable-adjusted standardized incidence ratios (SIRs) and investigate the rates of subsequent malignancy diagnosis. Additional non-urologic cancer sites were added as control groups.

RESULTS

Patients with thyroid cancer were much more likely to be diagnosed with CaP than patients in the SEER control group (SIR 1.28 [95% CI 1.1-1.5]; p < 0.05). Similarly, the observed incidence of thyroid cancer was significantly higher in patients with CaP when compared with SEER controls (SIR 1.30 [95% CI 1.2-1.4]; p < 0.05). When stratified by follow-up interval, the observed thyroid cancer diagnosis rate among men with CaP was significantly higher than expected at 2-11 (SIR 1.83 [95% CI 1.4-2.4]), 12-59 (SIR 1.24 [95% CI 1.0-1.5]), and 60-119 (SIR 1.25 [95% CI 1.0-1.5]) months of follow-up. There was no increased risk of CaP or thyroid cancer diagnosis among patients with non-urologic malignancies.

CONCLUSIONS

There is a significant association of diagnoses with prostate and thyroid cancer in the US. In the absence of a known biological link between these tumors, these data suggest that diagnosis patterns for prostate and thyroid malignancies are linked.