Erectile Function Recovery After Nerve-Sparing Radical Prostatectomy for Prostate Cancer: Is Back to Baseline Status Enough for Patient Satisfaction?

Sexual satisfaction in prostate cancer: a multi-group comparison study of treated patients, patients under active surveillance, patients with negative biopsy, and controls

PURPOSE

Erectile function changes after prostate cancer (PCa) treatment are well documented, but less understood is the relative impact of prostate biopsy and active surveillance on sexual well-being. It is unknown whether potential negative impacts are exclusive to patients who have been treated for PCa, or whether the diagnosis itself or the experience of biopsy may also impact sexual well-being. Sexual satisfaction is an important yet understudied indicator of sexual well-being in this population. This study examines sexual satisfaction and its predictors across several comparison groups to explore relative impact.

METHODS

At baseline and 12 months, questionnaire data was collected in four samples: (1) following PCa treatment, (2) active surveillance, (3) negative prostate biopsy result, and (4) controls receiving no biopsy or treatment. Predictors assessed included group, erectile function, communication style, and partner involvement.

RESULTS

Sexual satisfaction declined in the active treatment group, no changes were observed in active surveillance or non-PCa control, and improvements were observed in the biopsy group. Predictors of sexual satisfaction over and above erectile function included restrictive communication (i.e. protective buffering) and perceived partner involvement. For higher levels of erectile function, a higher perceived degree of partner involvement was protective of sexual satisfaction.

CONCLUSION

Sexual satisfaction is an important indicator of sexual well-being and is negatively impacted following PCa treatment, but not active surveillance or prostate biopsy.

IMPLICATIONS FOR CANCER SURVIVORS

Communication and partner involvement are potentially modifiable factors to be considered for intervention and may promote sexual satisfaction following PCa treatment. Patients experiencing negative biopsy, who note lower sexual satisfaction may experience improved satisfaction with time, and those under active surveillance who worry about sexual satisfaction may find reassurance from these results.

Anxiety, depression, urinary continence, and sexuality in patients undergoing radical prostatectomy: preliminary findings

OBJECTIVES

Evaluate the relationship between psychological distress, namely anxiety and depression, with urinary continence and recovery of erectile function in patients undergoing radical prostatectomy (RP).

METHODS

We retrospectively analyzed data from 33 consecutive patients who underwent RP in a single tertiary-referral academy between 01/2018 to 01/2019. We used the International Index of Erectile Function (IIEF-15), the Sexual Complaints Screener for Men (SCS-M), and the Hospital Anxiety and Depression Scale (HADS), validated questionnaires for the assessment of sexual function, anxiety, and depression experiences, respectively. These questionnaires were administered at the pre-surgical visit, after surgery, and at intermediate follow-ups (three, six, and twelve months).

RESULTS

The analysis of the questionnaires completed during follow-up shows that erectile function is the most affected, with 90% erectile dysfunction (ED) at three months after surgery. In terms of emotional states, anxiety prevails in the first months following surgery and is statistically significantly associated with incontinence (p = 0.02). Depressive symptoms, on the other hand, appear later and prevail over anxiety at six months after surgery, although not statistically significant.

CONCLUSIONS

In the early post-surgical phase anxiety and ED are the most frequently detected components, while depressive experiences and decreased desire, typical of later stages, have not yet fully emerged.

Evaluation of sexual function after robot-assisted radical prostatectomy: A farewell to IIEF questionnaire

Longevity with localized prostate cancer (PCa) has been achieved, and the contribution of robot-assisted radical prostatectomy (RARP) to cancer control is evident. The next step to investigate in the treatment of localized PCa is improvement of the quality of life (QOL) after RARP. Erectile dysfunction has been considered a major surgical complication, and patient satisfaction after RARP has not improved despite the development of nerve preservation and penile rehabilitation. To comprehensively understand sexual dysfunction after RARP, we must investigate other complications with regard to sexual health, including low sexual desire, disturbed orgasmic function (i.e., anejaculation, orgasm intensity, painful orgasm, and climacturia), shortening of penile length, penile curvature (Peyronie's disease) and unique psychological alterations after the diagnosis of PCa, which are neglected side effects after prostatectomy. In this context, routine evaluation of erectile function by the International Index of Erectile Function only is not sufficient to understand patients' difficulties. A questionnaire is just one way of enabling patients to evaluate their pre- and postoperative concerns; listening to patients face-to-face is warranted to detect symptoms. Understanding the relationship between symptoms and preserved nerve localization can ultimately provide an individualized nerve-sparing procedure and improve patient satisfaction after RARP. In combination with psychological counseling, including the partner and medical treatment, such as testosterone replacement, it is time to reconsider ways to improve sexual dysfunction after RARP.

Functional outcome after radical prostatectomy in 1313 patients: A single-center study

OBJECTIVES

To assess the impact of urinary continence and erectile function on the quality of life in men undergoing radical prostatectomy (RP) for prostate cancer (PC), we analyzed the preoperative and 1-year postoperative outcomes of five functional domains and their influencing factors.

PATIENTS AND METHODS

In this prospective study, all patients undergoing open or robot-assisted RP between Febuary 2017 and March 2020 in a single academic center were included. Patient-reported outcomes were assessed pre- and 12 months postoperatively using the Expanded Prostate Index Composite (EPIC-26) survey, evaluating continence, irritative/obstructive micturition, gastrointestinal symptoms, sexuality, and overall vitality. We examined the impact of RP on sexual function and urinary continence using multivariable logistic regression models, accounting for patient and tumor characteristics.

RESULTS

Overall, 1313 consecutive patients gave consent for study participation and completed both surveys. The median age was 66 years (IQR: 60-70). The majority of patients (n = 601, 46%) had an intermediate risk PC. Robotic RP was performed in 71.6% and nerve-sparing technique in 81% of the cases. The median pre- versus postoperative scores were the following: urinary continence 100 (IQR: 91.8-100) versus 85.5 (64.8-100), irritative micturition 87.5 (IQR: 75-100) versus 93.8 (IQR: 87.5-100), gastrointestinal symptoms the same with 100 (IQR: 95.8-100), vitality 95 (IQR: 80-100) versus 90 (IQR: 75-100), and erectile function 65.3 (IQR: 38.8-87.5) versus 22.2 (IQR: 12.5-48.7), respectively. Age (p < 0.001), risk classification (p = 0.002), and nerve-sparing surgery (p = 0.016) were associated with good sexual function (EPIC-26 score ≥60), while only age (p = 0.001) was statistically significantly associated with good urinary continence (EPIC-26 score ≥80).

CONCLUSION

Non-modifiable factors such as age and PC risk classification impact urinary continence and sexual function after RP. Nevertheless, urologic surgeons should further focus on improving nerve-sparing techniques, the only modifiable variable, to reduce the surgery's negative impact on urinary continence and sexual function.

Prevalence of erectile dysfunction in male survivors of cancer: a systematic review and meta-analysis of cross-sectional studies

Background

Prevalence of erectile dysfunction (ED) in male survivors of cancer across cancer types has not been systematically analysed.

Aim

To estimate the prevalence of ED in all types of cancer and identify characteristics associated with ED in survivors of cancer.

Design and setting

Systematic review and meta-analysis (MA) of cross-sectional studies.

Method

MEDLINE, CINAHL, PsycINFO, and EMBASE were searched, targeting reports published from inception to 1 February 2020. All retrospective or prospective studies reporting prevalence of ED in male patients with cancer and using a validated tool for detection of ED were included. A random-effects MA model was used to pool prevalence of ED as absolute estimates at three different stages, that is, ‘healthy’, ‘at diagnosis’, and ‘after treatment’. A univariate MA regression including the three-level group variable as the only independent variable was used to assess the difference in ED prevalence across the three groups. Further MAs were conducted for studies involving patients at diagnosis and after treatment, and statistical inferences were made with setting for multiple testing controlling for a false discovery rate (FDR) <0.05.

Results

In total, 1301 studies were assessed for inclusion. Of these, 141 were potentially eligible and subsequently scrutinised in full text. Finally, 43 studies were included with a total of 13 148 participants. Overall, pooled data of the included studies showed an ED prevalence of 40.72% (95% confidence interval [CI] = 31.80 to 50.29) in patients with cancer, with prevalences of 28.60% (95% CI = 12.10 to 53.83) at time of diagnosis and 42.70% (95% CI = 32.97 to 53.03) after treatment, with significant difference between these two stages and across cancer locations, controlling for an FDR <0.05.

Conclusion

Erectile dysfunction was particularly high in male survivors of cancer and was associated with cancer treatment, cancer site, and age.

On the Relationship Between Erectile Function and Sexual Distress in Men with Prostate Cancer

Erectile difficulties are common after prostate cancer (PCa) treatment and are associated with sexual distress. However, the relationship between erectile function and sexual distress has yet to be carefully examined. This study had three goals: (1) examine the relationship between erectile function and sexual distress; (2) determine groups of men based on erectile function and sexual distress; and (3) examine the psychosexual characteristics of these groups. A cross section of 233 sexually active men after PCa treatment (age M = 64.90 years, SD = 7.50) completed an online survey containing demographic, health, and sexuality and relationship questionnaires. The relationship between erectile function and sexual distress was curvilinear. Four groups of men were found: good erectile function and low sexual distress, poor erectile function and high sexual distress, but also good erectile function yet high sexual distress, and poor erectile function and low sexual distress. Regardless of erectile function, men with greater sexual distress were more depressed, reported additional sexual concerns, placed less value on sex, were less sexually satisfied, and used protective buffering communication more frequently. They were also less likely to be satisfied with their adaptation to sexual changes and less likely to have found a solution to those changes. The relationship between erectile function and sexual distress is complex, characterized by a wide array of responses to erectile function (high and low distress) and multiple correlates of sexual distress. These results broaden the concept of sexual recovery after PCa treatment, which may assist clinicians and researchers to better address sexual problems after PCa treatment.

A prediction model relating the extent of intraoperative fascia preservation to erectile dysfunction after nerve-sparing robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is performed in patients with prostate cancer. Unfortunately, 10-46% of patients may still suffer from limited erectile function (EF) after RARP. This study aimed to develop a prediction model based on the extent of fascia preservation (FP) and postoperative EF after RARP. A previously developed FP score quantizing the extent and regions of nerve-preservation was determined in a cohort of 1241 patients who underwent RARP. The predictive value of the FP score for post-prostatectomy EF (following the international index erectile function (IIEF) score, EF domain) was analyzed. To increase the predictive value of the scoring system, the FP regions were related to postoperative EF, nerve distribution and co-morbidity factors. Finally, a prediction model for EF was developed based on the studied cohort. When corrected for the preoperative IIEF-EF, the FP score was shown to be a significant denominator for IIEF (p = 2.5 × 10^- 15) with an R² of 35%. Variable selection performed using the Akaike information criterion led to a final prediction model for postoperative IIEF after nerve-preservation based on the FP score. Furthermore, patient's age, preoperative IIEF score, CCIS and use of clips for nerve sparing were significantly associated with postoperative IIEF-EF. More anterior fascia preservation was correlated with better EF outcome and age was a strong independent predictor of EF outcome. In older men, the relative benefit of more extensive fascia preservation was at least similar to younger men, despite a lower baseline IIEF-EF score. Quantitative nerve-sparing FP scoring could be related to the postoperative IIEF-EF and integrated into a multivariate prediction model, which includes with age, use of surgical clips, the Charlson Comorbidity Index Score (CCIS), and preoperative IIEF-EF. When further validated the prediction model could provide patients and care-givers a qualitative estimation of EF outcome after RARP.

Decrease in Intercourse Satisfaction in Men Who Recover Erections After Radical Prostatectomy

INTRODUCTION

Recovery of erections after radical prostatectomy (RP) is assumed to lead to recovery in sexual satisfaction. Although data suggest a relationship between sexual function and sexual satisfaction, it is unclear whether presurgical levels of sexual satisfaction are attained for men who "recover" erections post-RP.

AIM

The goal of this analysis is to determine whether the recovery of erectile function restores presurgical levels of sexual satisfaction.

METHODS

We assessed 229 men pre-RP and 24-months post-RP. At both time points, participants completed the Erectile Function Domain (EFD) and the Intercourse Satisfaction Domain (ISD) of the International Index of Erectile Function (IIEF). Erectile function recovery at 24 months was defined as (1) (EFD≥24) or (2) EFD back to baseline (BTB). One hundred sixty-six men with penetration hardness erections (PHEs) at baseline (EFD >24) were included in the analyses. Repeated measure t-tests were used to compare changes in ISD scores and effect size (Cohen's d) was calculated to determine the clinical significance of these changes. Multivariable analyses (MVA) were used to test the relationship between EFD and ISD.

RESULTS

The mean age of men was 58 (SD = 7) years. The mean EFD score at baseline was 29 (SD = 2), which declined significantly to 20 (SD = 10) at 24 months. ISD also decreased significantly between baseline and 24 months (12 to 8.3, P < .001, d = 0.87), even among men with PHEs at 24 months (12.3 to 11.3, P < .001, d = 0.50) and men who achieved BTB erections at 24 months (12.4 to 11.7, P = .02, d = 0.35). For men with PHEs at 24 months, MVAs identified baseline ISD (beta = 0.46) and 24-month EFD (beta = 0.23) as the only significant predictors of 24-month ISD. However, among men who achieved BTB erections at 24 months, baseline ISD (beta = 0.49) was the only significant predictor of 24-month ISD.

CLINICAL IMPLICATIONS

These findings underscore the importance of the integration of psychological support and medical care to best meet the needs of patients. Furthermore, these results can be used to facilitate pre-RP communication and counseling with patients to improve understanding and manage post-RP expectations.

STRENGTHS & LIMITATIONS

The study methodology, specifically the use of BTB as a means of defining erectile function and the longitudinal, prospective study design are relative strengths. Despite the longitudinal design, the study did not include a control group of healthy, age-matched men.

CONCLUSION

Results highlight the enduring impact of sexual dysfunction, namely erectile dysfunction, on intercourse satisfaction following RP and suggest that restoration of function in and of itself does not ensure the restoration of satisfaction. Terrier JE, Masterson M, Mulhall JP, et al. Decrease in intercourse satisfaction in men who recover erections after radical prostatectomy. J Sex Med 2018;15:1133-1139.

nNOS-positive minor-branches of the dorsal penile nerves is associated with erectile function in the bilateral cavernous injury model of rats

The changes in neuronal nitric oxide synthases (nNOS) in the dorsal penile nerves (DPNs) are consistent with cavernous nerve (CN) injury in rat models. However, the anatomical relationship and morphological changes between the minor branches of the DPNs and the CNs after injury have never been clearly explored. There were forty 12 week old male Sprague-Dawley rats receiving bilateral cavernous nerve injury (BCNI). Erectile function of intracavernous pressure and mean arterial pressure were measured. The histology and ultrastructure with H&E stain, Masson's trichrome stain and immunohistochemical stains were applied on the examination of CNs and DPNs. We demonstrated communicating nerve branches between the DPNs and the CNs in rats. The greatest damage and lowest erectile function were seen in the 14^th day and partially recovered in the 28^th day after BCNI. The nNOS positive DPN minor branches' number was significantly correlated with erectile function. The sub-analysis of the number of nNOS positive DPN minor branches also matched with the time course of the erectile function after BCNI. We suggest the regeneration of the DPNs minor branches would ameliorate the erectile function in BCNI rats.

DAPK and CIP2A are involved in GAS6/AXL-mediated Schwann cell proliferation in a rat model of bilateral cavernous nerve injury

Purpose

Impotence is one of the major complications occurring in prostate cancer patients after radical prostectomy (RP). Self-repair of the injured nerve has been observed in animal models and in patients after RP. However, the downstream signalling is not well documented. Here, we found that the DAPK/CIP2A complex is involved in GAS6/AXL-related Schwann cell proliferation.

Materials and Methods

The 3 groups were a sham group, a 14-day post-bilateral cavernous nerve injury (BCNI) group and a 28-day post-BCNI group. Erectile function was assessed and immunohistochemistry was performed. The rat Schwann cell RSC96 line was chosen for gene knockdown, cell viability, western blot, immunofluorescence and co-immunoprecipitation assays.

Results

The intracavernosal pressure was low on the 14^th day after BCNI and partially increased by the 28^th day. GAS6 and p-AXL expression gradually increased in the cavernous nerve after BCNI. RSC96 cells incubated with a GAS6 ligand showed increased levels of p-ERK1/2 and p-AKT. Moreover, DAPK and CIP2A.p-AXL and p-DAPK and CIP2A complexes were identified by both immunoblotting and co-immunoprecipitation.

Conclusion

The DAPK/CIP2A complex is involved in GAS6/AXL-related Schwann cell proliferation. CIP2A inhibits PP2A activity, which results in p-DAPK(S308) maintenance and promotes Schwann cell proliferation. CIP2A is a potential target for the treatment of nerve injury after RP.

Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy

INTRODUCTION

The International Index of Erectile Function (IIEF) is the gold standard validated instrument for defining erectile function (EF) and its response to treatment. The EF domain (EFD) contains six questions and is a sensitive and specific measurement of treatment-related changes in EF. The EFD score has been widely used as a primary assessment end point for clinical trials of EF recovery after radical prostatectomy (RP). Various EFD scores have been used to define functional erections. Recently, an EFD score of at least 22 has been used as a threshold in major post-RP penile rehabilitation studies.

AIM

To define the EFD score that optimally defines "functional" erections after RP.

METHODS

We assessed men 24 months after RP using the IIEF and specifically analyzed the scores of the EFD and intercourse satisfaction domain (ISD).

MAIN OUTCOME MEASURES

We used two questions on satisfaction (score = 0-5) and enjoyment (score = 0-5) from the ISD to classify IS (score = 0-10). We tested the following intercourse satisfaction classifications: ISD score equal to 10, ISD score of at least 8, and a score of at least 4 for the ISD questions on satisfaction and enjoyment. We used the classification that produced the largest area under the curve (AUC) using a receiver operating characteristic (ROC) curve. Then, we used a three-step process to determine the optimal EFD score cutoff using sensitivity and specificity analysis.

RESULTS

One hundred seventy-eight men had an average age at RP of 58 ± 7 years and a 24-month EFD score of 20 ± 9. Sixty-four percent had complete nerve-sparing surgery, 35% had partial nerve-sparing surgery, and 1% had the nerves fully resected. Thirty-three percent had laparoscopic RP and 67% had open RP. The ROC curves produced AUCs of 0.80 (ISD score = 10), 0.85 (ISD score ≥ 8), and 0.86 (ISD scores for satisfaction and enjoyment ≥ 4; P < .001 for all comparisons). Using the IS criterion of ISD scores for satisfaction and enjoyment of at least 4 (largest AUC), the sensitivity and specificity values were 0.89 and 0.66 for an ESD score equal to 22, 0.78 and 0.71 for a score equal to 23, 0.78 and 0.80 for a score equal to 24, 0.77 and 0.82 for a score equal to 25, and 0.73 and 0.85 for a score equal to 26. The scores of 24 and 25 met the criteria outlined in the first two steps of analysis. The score of 24 was selected as the cutoff using face valid judgment and the previous literature.

CONCLUSION

These data support an EFD score of 24 as a valid cutoff defining "functional" erection in men with erectile dysfunction after RP. These data are important for clinicians in counseling patients and to researchers to define inclusion criteria and treatment end points for trials of erectile dysfunction after RP. Terrier JE, Muhall JP, Nelson CJ. Exploring the Optimal Erectile Function Domain Score Cutoff That Defines Sexual Satisfaction After Radical Prostatectomy. J Sex Med 2017;14:804-809.

Erectile function recovery in men treated with phosphodiesterase type 5 inhibitor administration after bilateral nerve-sparing radical prostatectomy: a systematic review of placebo-controlled randomized trials with trial sequential analysis

The impact of phosphodiesterase type 5 inhibitor (PDE5I) treatment modality (on-demand vs. daily), PDE5I half-life and time from surgery to PDE5I prescription on the achievement of drug-assisted erectile function (EF) recovery is uncertain. We systematically reviewed published randomized clinical trials (RCTs). We performed meta-analyses of data on 2317 men treated with PDE5Is after nerve-sparing radical prostatectomy (NSRP). A PubMed and SCOPUS search was performed for trials published from 1 January 1969 to 30 June 2016. PDE5Is are effective in achieving drug-assisted recovery of erectile function (EF). From a statistical standpoint, these studies were subjected to Trial Sequential Analysis to determine whether the pooled data were adequately powered to verify the study outcomes. On-demand treatment with PDE5Is was significantly better than daily treatment in recovering drug-assisted EF. This effect was maintained even when the drugs were stratified according with half-life. Although not based on head-to-head trials, Avanafil used on-demand was the most effective PDE5I in recovering drug-assisted EF. Whereas tadalafil was equally effective when used both on-demand and daily, vardenafil significantly improved drug-assisted EF recovery only when used on-demand. The start of PDE5I treatment six months or more after surgery compared to treatment started earlier did not negatively affect the rate of drug-assisted EF recovery or the possibility to have successful intercourse based on the Sexual Encounter Profile question-3 (SEP-3). Current trials do not support the hypothesis that PDE5I use recovers drug-unassisted EF, although chronic low-dose tadalafil administration may help to preserve erectile tissue integrity. Potential shortcomings in the trials design may partially explain these disappointing results and several questions concerning the recovery of drug-unassisted EF remain unanswered. Thus, there is a need for well-designed new RCTs requiring changes in the timing of PDE5I administration as well as in the dose and the treatment duration.