Responsiveness of the University of California-Los Angeles Prostate Cancer Index

Climacturia and Penile Length Shortening: Adverse Outcomes following Robot-Assisted Radical Prostatectomy

Purpose: While erectile dysfunction and urinary incontinence are commonly cited side effects following radical prostatectomy (RP), climacturia and penile length shortening are less explored. The present study seeks to explore the incidence, risk factors, and predictors of recovery associated with climacturia and penile length shortening following robot-assisted radical prostatectomy (RARP). Patients and Methods: From September 2018 to January 2020, 800 patients underwent RARP for primary treatment of localized prostate cancer. A survey was sent to patients following 1-year follow-up assessing outcomes of continence, erectile dysfunction, climacturia, and penile length shortening. Descriptive statistics were utilized to describe incidence and risk factors and logistic regression modeling was used to identify predictors associated with recovery. Results: Of the 800 patients surveyed, 339 (42%) and 369 (46%) patients responded, with 127/339 (37.5%) and 216/369 (58.5%) endorsing climacturia and penile length shortening. In univariate analysis, a lack of bilateral nerve sparing was associated with climacturia; high body mass index (BMI), high prostate weight, lack of nerve-sparing, and high pathologic stage was associated with penile length shortening. In logistic regression modeling, BMI, prostate weight, and p-stage were all significantly correlated with penile length shortening. Recovery from climacturia was associated with a preoperative International Index of Erectile Function-5 score >21. When patients were asked to rank the importance of these outcomes compared to erectile dysfunction and incontinence, <5% of patients ranked either climacturia or penile length shortening as a high priority following RP. Conclusion: While incidence of climacturia and penile length shortening following RP is significant, impact on patient- and partner-related quality of life are low in comparison to risks of erectile dysfunction and urinary incontinence.

The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis

BACKGROUND

Erectile dysfunction (ED) after treatment for prostate cancer with radiotherapy (RT) is well known, and pooled estimates of ED after RT will provide more accurate patient education.

AIM

To systematically evaluate the natural history of ED in men with previous erectile function after prostate RT and to determine clinical factors associated with ED.

METHODS

We performed a review of the PubMed and Medline, Embase, Cochrane Library, and Web of Science databases in April 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports included a measurement of ED before and after prostate RT. Two hundred seventy-eight abstracts were screened and 105 publications met the criteria for inclusion. Only men with known erectile function before RT were included in the analysis.

OUTCOME

ED after RT of the prostate.

RESULTS

In total, 17,057 men underwent brachytherapy (65%), 8,166 men underwent external-beam RT (31%), and 1,046 men underwent both (4%). Seven common instruments were used to measure ED, including 23 different cutoffs for ED. The Sexual Health Inventory for Men (SHIM) was used in 31 studies (30%). Pooled estimates of SHIM-confirmed ED (score <10-17) suggested the prevalence of ED after RT is 34% of men (95% CI = 0.29-0.39) at 1 year and 57% (95% CI = 0.53-0.61) at 5.5 years. Compared with brachytherapy, studies of the two types of radiation increased the proportion of new-onset ED found by 12.3% of studies (95% CI = 2.3-22.4). For every 10% who were lost to follow-up, the proportion of ED reported increased by 2.3% (95% CI = 0.03-4.7).

CLINICAL IMPLICATIONS

ED is common regardless of RT modality and increases during each year of follow-up. Using the SHIM, ED is found in approximately 50% patients at 5 years.

STRENGTHS AND LIMITATIONS

The strengths of this systematic review include strict inclusion criteria of studies that measured baseline erectile function, no evidence for large effect size bias, and a large number of studies, which allow for modeling techniques. However, all data included in this analysis were observational, which leaves the possibility that residual confounding factors increase the rates of ED.

CONCLUSION

Definitions and measurements of ED after RT vary considerably in published series and could account for variability in the prevalence of reported ED. Loss to follow-up in studies could bias the results to overestimate ED. Gaither TW, Awad MA, Osterberg EC, et al. The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis. J Sex Med 2017;14:1071-1078.

Quality of Life and Sexual Health in the Aging of PCa Survivors

Prostate cancer (PCa) is the most common malignancy in elderly men. The progressive ageing of the world male population will further increase the need for tailored assessment and treatment of PCa patients. The determinant role of androgens and sexual hormones for PCa growth and progression has been established. However, several trials on androgens and PCa are recently focused on urinary continence, quality of life, and sexual function, suggesting a new point of view on the whole endocrinological aspect of PCa. During aging, metabolic syndrome, including diabetes, hypertension, dyslipidemia, and central obesity, can be associated with a chronic, low-grade inflammation of the prostate and with changes in the sex steroid pathways. These factors may affect both the carcinogenesis processes and treatment outcomes of PCa. Any treatment for PCa can have a long-lasting negative impact on quality of life and sexual health, which should be assessed by validated self-reported questionnaires. In particular, sexual health, urinary continence, and bowel function can be worsened after prostatectomy, radiotherapy, or hormone treatment, mostly in the elderly population. In the present review we summarized the current knowledge on the role of hormones, metabolic features, and primary treatments for PCa on the quality of life and sexual health of elderly Pca survivors.

Age and baseline quality of life at radical prostatectomy--who has the most to lose?

PURPOSE

Although younger men have better health related quality of life scores after radical prostatectomy, many have higher baseline function with more to lose than older men. We examined the impact of age on sexual and urinary function and bother during the first 2 years after radical prostatectomy.

MATERIALS AND METHODS

Participants enrolled in CaPSURE™ reported sexual and urinary scores before and after radical prostatectomy using UCLA-PCI. Repeated measures mixed models were used to compare the change in health related quality of life with time between men who were younger (age 60 years or less) and older (age greater than 60 years). Logistic regression models were used to assess associations between age and clinically meaningful health related quality of life decreases (worsening). Models were adjusted for clinical characteristics.

RESULTS

Of 1,806 patients younger men reported higher sexual and urinary function scores at each time point and higher sexual function decrease rates at 1 year than older men (81% vs 75%, p<0.01). Younger men also had higher sexual bother decrease rates 1 year (74% vs 61%, p<0.01) and 2 years (62% vs 56%, p=0.02) after radical prostatectomy. On multivariate analysis age was associated with changes in sexual function and bother from baseline through 2 years (each p<0.01). Younger men had higher adjusted odds of sexual function decreases at 1 year (OR 1.15/5 years, 95% CI 1.01-1.30, p=0.03) but not at 2 years. Younger age was associated with lower odds of worsening sexual bother at 2 years (OR 0.79/5 years, 95% CI 0.67-0.94, p<0.01). Urinary function and bother decrease rates were similar by age. Secondary analyses of the age/health related quality of life interaction showed that men were at greater risk for health related quality of life decreases if baseline scores were above average regardless of age.

CONCLUSIONS

Younger men reported higher sexual and urinary function overall, and experienced greater decreases in sexual function immediately after radical prostatectomy than older men. While the 2 groups experienced similar relative sexual function decreases at 2 years, younger men had worse interim decreases at 1 year. Providers should consider these findings when discussing treatment timing, particularly with younger men diagnosed with early stage, low grade disease.

Measuring health-related quality of life in men with prostate cancer: A systematic review of the most used questionnaires and their validity

OBJECTIVES

To identify and study the psychometric properties of the most used health-related quality-of-life (HRQoL) instruments in men with prostate cancer.

METHODS

We performed a literature search using PubMed and EMBASE to identify all studies on prostate cancer using a HRQoL instrument. The most often used HRQoL instruments were investigated in detail by 2 independent reviewers. Data were extracted regarding the characteristics and psychometric values of the instruments, i.e., content validity, internal consistency, criterion validity, construct validity, reproducibility, responsiveness, floor and ceiling effects, and interpretability. Good psychometric outcomes indicate a high methodological quality of the instrument.

RESULTS

Our systematic search revealed 13,812 potential relevant articles, of which 2,258 appeared relevant after screening the titles and reading the abstracts. We studied the psychometric properties of the 20 most often used HRQoL instruments, the first 3 of which were the Expanded Prostate Index Composite, University of California-Los Angeles Prostate Cancer Index, and Short Form-36 (SF-36). Content validity, internal consistency (α>0.70), criterion validity, construct validity, and reproducibility were good in 60%, 90%, 10%, 35%, and 65% of the 20 instruments, respectively. Responsiveness was not reported for 12 of 20 instruments (60%). Floor and ceiling effects and the interpretability of the questionnaires were only reported in 3 (15%) and 6 (30%) instruments.

CONCLUSIONS

Considering the psychometric properties, we advise to use the SF-12 as a generic instrument, the Cancer Rehabilitation Evaluation System-SF or the Functional Assessment of Cancer Therapy-General as cancer-specific HRQoL instruments, and the University of California-Los Angeles Prostate Cancer Index, the QUFW94, or the Functional Assessment of Cancer Therapy-Prostate as prostate cancer-specific instruments.

Functional outcomes in African-Americans after robot-assisted radical prostatectomy

BACKGROUND AND PURPOSE

Previous studies have demonstrated differences in surgical outcomes after radical prostatectomy based on ethnicity. We compared sexual and urinary outcomes in African-American (AA) patients 6 and 12 months after robot-assisted radical prostatectomy (RARP) with those of non-AA patients.

PATIENTS AND METHODS

We reviewed our RARP database at our institution for patients with at least 12 months of follow-up. Erectile function was defined using the University of California, Los Angeles Prostate Cancer Index as erections "firm enough for masturbation and foreplay" or "firm enough for intercourse," while urinary continence was defined as being "pad free." Only patients who were potent and pad free preoperatively were included in the analysis. Multivariate logistic regression was used to compare postoperative potency and urinary pad-free status between AA and non-AA patients while controlling for pertinent demographic, clinical, and pathologic variables.

RESULTS

In the urinary continence analysis, 140 AA patients and 576 non-AA patients were included, compared with 105 AAs and 500 non-AA patients who were included in the analysis of sexual function. At 12 months postoperatively, a smaller proportion of AA patients were potent compared with non-AA patients (60% vs 76.4%, P=0.001). Similarly, we found a lower incidence of pad-free status for AA patients at 12 months postoperatively (55.7% vs 69.8%, P=0.039). Similar functional results were found at 6 months postoperatively for both analysis groups.

CONCLUSION

AA men appear to have worse urinary and sexual outcomes at 12 months after RARP compared with non-AA patients. At 6 months, there is no statistically significant difference. Further, longer-term studies are needed to validate these results.

Does physiotherapist-guided pelvic floor muscle training increase the quality of life in patients after radical prostatectomy? A randomized clinical study

OBJECTIVE

The aim of this study was to study the effect of postoperative physiotherapist-guided pelvic floor muscle training (PFMT) on health-related quality of life (HRQoL) parameters in patients treated with radical prostatectomy (RP).

MATERIAL AND METHODS

A prospective randomized controlled trial was conducted at St. Olavs Hospital, Trondheim University Hospital, Norway. Eighty-five men were randomized into two intervention groups (A and B). patients in group A (n = 42) were offered physiotherapist-guided PFMT (in groups or by DVD) once weekly throughout the first 12 months after RP, while those in group B (n = 43) trained on their own. HRQoL data were assessed using the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the Short Form-12 (SF-12) health survey. The physical component summary (PCS) and mental component summary (MCS) scores of the SF-12 plus the urinary, sexual and bowel function and bother of the UCLA-PCI make up the eight quality of life outcomes used in this study. Data were obtained preoperatively (baseline), 6 weeks, and 3, 6 and 12 months postoperatively.

RESULTS

Eighty patients completed at least one follow-up assessment, 38 in group A and 42 in group B, giving a dropout rate of 5.9%. The overall response rates were 96% at baseline, 83% at 6 weeks, 90% at 3 months, 88% at 6 months and 68% at 12 months. No statistically significant difference in HRQoL was found between groups A and B.

CONCLUSIONS

Even though physiotherapist-guided training of the pelvic floor muscles after RP improved postoperative urinary incontinence significantly compared to those patients receiving standard care/training, this was not reflected in better outcome in HRQoL parameters.

Among potent men post radical prostatectomy, does the need for phosphodiesterase inhibitors have an impact on sexual bother scores?

Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Although phosphodiesterase inhibitor use post radical prostatectomy improves potency, little is known about its affects on sexual bother. We found no difference in sexual bother scores between patients who use and do not use phosphodiesterase inhibitors. This suggests that the current definition of potency, inclusive of medication use, is valid with respect to sexual bother.

OBJECTIVE

To determine whether the current definition of potency, inclusive of phosphodiesterase inhibitor (PDEi) use, is valid with respect to sexual bother (SB). This will be assessed by characterizing the effect of PDEi use on SB scores in men who are potent post radical prostatectomy.

PATIENTS AND METHODS

The study population consisted of patients who were potent both before and after radical prostatectomy, with at least 2 years of follow-up. Disease-specific quality of life data were evaluated by the University of California, Los Angeles, Prostate Cancer Index (PCI) survey. The relationships between changes in sexual function (SF) and SB and use of PDEi over time were evaluated by mixed model analysis controlling for age, clinical risk group, marital status, and time of PCI assessment.

RESULTS

Of the 246 patients who met the study criteria, 39% reported PDEi use at some point after treatment. PDEi use was not associated with improved SF (P= 0.81). Furthermore, PDEi use was not associated with a change in SB (P= 0.36). Both SF and SB were significantly associated with time of assessment and age, and SF and SB each improved over time. In addition, SB was significantly associated with marital status.

CONCLUSIONS

In this analysis, there was no difference in SF scores between men who were potent with or without the use of PDEi. Furthermore, there was no difference in SB scores between men who were potent with or without the use of PDEi. This suggests that the current, inclusive, definition of potency is valid with respect to SB.

The role of self-efficacy in quality of life for disadvantaged men with prostate cancer

PURPOSE

Self-efficacy is associated with increased participation in treatment decision making and improved health related quality of life. We examined the influence of perceived efficacy in patient-physician interactions on health related quality of life among low income, uninsured men with prostate cancer during a 2-year period.

MATERIALS AND METHODS

We analyzed data derived on participants enrolled in a state funded program providing free prostate cancer treatment and care to indigent men. We used validated instruments to measure patient self-efficacy (confidence in interacting with physicians), and the general and prostate specific health related quality of life outcomes of urinary, sexual and bowel bother, symptom distress, psychological well-being and vitality. We performed repeated measures analysis with general linear mixed modeling to estimate the association of sociodemographic and clinical covariates with health related quality of life.

RESULTS

Our cohort included a total of 472 observations in 99 men. Self-efficacy had a measurable effect on subjective measurements of general and disease specific health related quality of life. Men with the lowest self-efficacy had inferior mean health related quality of life scores across all outcomes. Low self-efficacy was significantly associated with worse bowel bother and general symptom distress during the 2-year study period. Similar health related quality of life outcomes trajectories were observed across self-efficacy categories.

CONCLUSIONS

Of disadvantaged men with clinically localized prostate cancer those with the lowest self-efficacy in physician interactions fared worst across all measured domains of health related quality of life. Interventions to improve patient-physician communication in this population may provide physicians with a supplemental method by which to address health perceptions, mitigate symptom experience and improve health outcomes.

Low-dose rate brachytherapy for men with localized prostate cancer

BACKGROUND

Localized prostate cancer is a slow growing tumor for many years for the majority of affected men. Low-dose rate brachytherapy (LDR-BT) is short-distance radiotherapy using low-energy radioactive sources. LDR-BT has been recommended for men with low risk localized prostate cancer.

OBJECTIVES

To assess the benefit and harm of LDR-BT compared to radical prostatectomy (RP), external beam radiotherapy (EBRT), and no primary therapy (NPT) in men with localized prostatic cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1950), and EMBASE (from 1980) were searched in June 2010 as well as online trials registers and reference lists of reviews.

SELECTION CRITERIA

Randomized, controlled trials comparing LDR-BT versus RP, EBRT, and NPT in men with clinically localized prostate cancer.

DATA COLLECTION AND ANALYSIS

Data on study methods, participants, treatment regimens, observation period and outcomes were recorded by two reviewers independently.

MAIN RESULTS

We identified only one RCT (N = 200; mean follow up 68 months). This trial compared LDR-BT and RP. The risk of bias was deemed high. Primary outcomes (overall survival, cause-specific mortality, or metastatic-free survival) were not reported. Biochemical recurrence-free survival at 5 years follow up was not significantly different between LDR-BT (78/85 (91.8%)) and RP (81/89 (91.0%)); P = 0.875; relative risk 0.92 (95% CI: 0.35 to 2.42).For severe adverse events reported at 6 months follow up, results favored LDR-BT for urinary incontinence (LDR-BT 0/85 (0.0%) versus RP 16/89 (18.0%); P < 0.001; relative risk 0) and favored RP for urinary irritation (LDR-BT 68/85 (80.0%) versus RP 4/89 (4.5%); P < 0.001; relative risk 17.80, 95% CI 6.79 to 46.66). The occurrence of urinary stricture did not significantly differ between the treatment groups (LDR-BT 2/85 (2.4%) versus RP 6/89 (6.7%); P = 0.221; relative risk 0.35, 95% CI: 0.07 to 1.68). Long-term information was not available.We did not identify significant differences of mean scores between treatment groups for patient-reported outcomes function and bother as well as generic health-related quality of life.

AUTHORS' CONCLUSIONS

Low-dose rate brachytherapy did not reduce biochemical recurrence-free survival versus radical prostatectomy at 5 years. For short-term severe adverse events, low-dose rate brachytherapy was significantly more favorable for urinary incontinence, but radical prostatectomy was significantly more favorable for urinary irritation. Evidence is based on one RCT with high risk of bias.