Erectile function after radical prostatectomy: a review

Prostate cancer-related sexual dysfunction - the significance of social relations in men's reconstructions of masculinity

Narrating illness experiences in a culturally acceptable manner is essential for retaining quality of life after the disruptive event of being diagnosed for prostate cancer. Psychological pressures caused by treatment side-effects such as erectile dysfunction require reinterpretation of the meanings and impacts of these side-effects on masculinity. This helps maintain coherence in men's lives. We studied how men employ culturally available discursive strategies (compensation, redefinition, recontextualisation, and normalisation) in reconstructing masculinity and sexuality. Our data consists of 22 interviews of heterosexual Finnish prostate cancer patients who had undergone surgery. The aim was to analyse the ways in which various life situations and social relations shaped and limited the use of these strategies. Discourse analysis revealed that older age, a supportive spouse, children, supportive male friends, and good health - were key elements men used in reconstructing a coherent new self-image and conception of life following cancer treatment. Men with sexually active male friends, men without families, younger men and men with new intimate relationships struggled to develop a new version of their masculinity. Being able to effectively utilise certain aspects of one's life situation in re-constructing masculinity is important in maintaining quality of life despite troublesome treatment side-effects.

Prevalence of post-prostatectomy erectile dysfunction and a review of the recommended therapeutic modalities

Radical prostatectomy (RP) represents one of the most commonly used first-line treatment modalities in men with localized prostate cancer. One of the most feared post-surgical complications is erectile dysfunction (ED), usually caused by direct damage to the cavernous nerves or due to neuropraxia. Penile rehabilitation is an emerging concept that was proposed to stimulate and accelerate recovery of erectile function after RP. The goal is to improve blood flow to the penis, increasing cavernous oxygenation and avoiding fibrosis. The most common used modalities include oral phosphodiesterase type 5 inhibitors (PDE5-I), vacuum erection devices (VEDs), intracorporeal injection (ICI) therapy, medicated urethral system for erections (MUSE), and a combination of these treatments. For those patients with severe ED, ED refractory to medical therapy and/or seeking long term reliable results, the penile prosthesis implant remains an excellent alternative. We conducted a broad review of post-prostatectomy ED prevalence with different techniques and the success rates of the different therapeutic approaches.

Men's experiences after prostatectomy: A meta-synthesis

OBJECTIVE

The purpose of this review was to critically analyze, interpret, and synthesize the literature on men's experiences after prostatectomy.

DESIGN

A meta-synthesis was conducted.

DATA SOURCES

Six databases (PubMed, EMBASE, CINAHL, PsycINFO, AgeLine, and Sociological Abstract) were searched from the earliest year to 2016. From initial searches with main keywords (prostatectomy and qualitative study), 642 abstracts were retrieved. Based on inclusion criteria (English-language published qualitative study focusing on the experience of men after prostatectomy), this meta-synthesis included 15 studies.

REVIEW METHODS

Components of meta-study (meta-data-analysis, meta-method, and meta-theory) were employed to analyze, interpret, and synthesize the results of included studies. Three authors independently appraised the methodological quality of the included studies using a combined appraisal tool (The Critical Appraisal Skills Programme Qualitative Research Checklist and Paterson et al.'s Primary Research Appraisal Tool). The Enhancing Transparency in Reporting the Synthesis of Qualitative Research Statement was used to strengthen the completeness of reporting.

RESULTS

Fifteen studies met inclusion criteria and quality appraisal guidelines, however, most did not identify or relate their findings to theory. Through meta-synthesis, five themes emerged: facing a life-changing situation, experiencing changes and their impact, striving to manage and adjust to changes, coping with masculinity, and anticipating the future.

CONCLUSIONS

After prostatectomy, men experienced physical, psychological, and social changes. Many men are physically and psychologically ill-prepared and suffer from lack of information and support. Health care providers need to be sensitive to men's needs including perceptions of masculinity, realize the importance of support as an essential component of men's adaptation post-prostatectomy, and provide comprehensive and individualized patient-centered interventions. Future studies need to use rigorous research methods, clearly identify methodological approaches, and consider employing or developing theory.

Efficacy of vacuum erectile devices (VEDs) after radical prostatectomy: the initial Irish experience of a dedicated VED clinic

Controversy exists regarding optimal penile rehabilitation program following radical prostatectomy (RP). Vacuum erectile devices (VEDs) have become an important component of penile rehabilitation protocols. The aim of this study was to assess the efficacy and patient satisfaction of a dedicated VED clinic. A voluntary telephone questionnaire was performed of all patients who attended a VED clinic to date in two university teaching hospitals. Patient demographics, histopathological characteristics and functional status (International Index of Erectile Function (IIEF) scores) were obtained from a retrospective review of a prospectively maintained database. Sixty-five men attended the dedicated VED clinic in the two university teaching hospitals. Forty-men (76.3%) men purchased a VED following the dedicated clinic. There was significant differences noted between the mean preoperative and the 3-month postoperative IIEF scores (22.08±3.16 vs 11.3±3.08, P=0.0001) and between the 3-month postoperative IIEF score and the post-VED use IIEF score (11.3±3.08 vs 16.74±2.62, P=0.0001). Despite VED use, there was a significant reduction in erectile function from presurgery status (22.08±3.16 vs 16.74±2.62, P=0.0001). All patients reported that the dedicated VED was helpful and would recommend it to other patients. Our study demonstrates that, despite a reduction in erectile function after RP, successful erections are attainable with a VED. There is potential and need for the development of a standard penile rehabilitation program and treatment of ED after RP internationally.

Core principles of sexual health treatments in cancer for men

PURPOSE OF REVIEW

The considerable prevalence of sexual health problems in men after cancer treatment coupled with the severity of impact and challenges to successful intervention make sexual dysfunction one of the most substantial health-related quality of life burdens in all of cancer survivorship. Surgeries, radiation therapies, and nontreatment (e.g., active surveillance) variously result in physical disfigurement, pain, and disruptions in physiological, psychological, and relational functioning. Although biomedical and psychological interventions have independently shown benefit, long-term, effective treatment for sexual dysfunction remains elusive.

RECENT FINDINGS

Recognizing the complex nature of men's sexual health in an oncology setting, there is a trend toward the adoption of a biopsychosocial orientation that emphasizes the active participation of the partner, and a broad-spectrum medical, psychological, and social approach. Intervention research to date provides good insight into the potential active ingredients of successful sexual rehabilitation programming.

SUMMARY

Combining a biopsychosocial approach with these active intervention elements forecasts an optimistic future for men's sexual rehabilitation programming within oncology. However, significant gaps remain in our understanding of patient experience and appropriate sexual health intervention for gay men and men of diverse race and culture.

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.

Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer

AIM

To develop a management strategy (rehabilitation programme) for erectile dysfunction (ED) after radiotherapy (RT) or androgen deprivation therapy (ADT) for prostate cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management in this patient group together with a survey of 28 experts in the management of treatment-induced ED from across the UK were conducted.

RESULTS

Data from 19 articles and completed questionnaires were collated. The findings discussed in this article confirm that RT/ADT for prostate cancer can significantly impair erectile function. While many men achieve erections through PDE5-I use, others need combined management incorporating exercise and lifestyle modifications, psychosexual counselling and other erectile aids. This article offers a comprehensive treatment algorithm to manage patients with ED associated with RT/ADT.

CONCLUSION

Based on published research literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for ED after RT/ADT. In addition to implementing the algorithm, understanding the rationale for the type and timing of ED management strategies is crucial for clinicians, men and their partners.

Phenotypic modulation of corpus cavernosum smooth muscle cells in a rat model of cavernous neurectomy

Background

Patients undergoing radical prostatectomy (RP) are at high risk for erectile dysfunction (ED) due to potential cavernous nerve (CN) damage during surgery. Penile hypoxia after RP is thought to significantly contribute to ED pathogenesis.

Aim

We previously showed that corpora cavernosum smooth muscle cells (CCSMCs) undergo phenotypic modulation under hypoxic conditions in vitro. Here, we studied such changes in an in vivo post-RP ED model by investigating CCSMCs in bilateral cavernous neurectomy (BCN) rats.

Methods

Sprague-Dawley rats underwent sham (n = 12) or BCN (n = 12) surgery. After 12 weeks, they were injected with apomorphine to determine erectile function. The penile tissues were harvested and assessed for fibrosis using Masson trichrome staining and for molecular markers of phenotypic modulation using immunohistochemistry and western blotting. CCSMC morphological structure was evaluated by hematoxylin-eosin (H&E) staining and transmission electron microscopy (TEM).

Results

Erectile function was significantly lower in BCN rats than in sham rats. BCN increased hypoxia-inducible factor-1α and collagen protein expression in corpora cavernous tissue. H&E staining and TEM showed that CCSMCs in BCN rats underwent hypertrophy and showed rough endoplasmic reticulum formation. The expression of CCSMC phenotypic markers, such as smooth muscle α-actin, smooth muscle myosin heavy chain, and desmin, was markedly lower, whereas vimentin protein expression was significantly higher in BCN rats than in control rats.

Conclusions

CCSMCs undergo phenotype modulation in rats with cavernous neurectomy. The results have unveiled physiological transformations that occur at the cellular and molecular levels and have helped characterize CN injury–induced ED.

Prostate cancer support groups: Canada-based specialists' perspectives

To understand prostate cancer (PCa) specialists' views about prostate cancer support groups (PCSGs), a volunteer sample of Canada-based PCa specialists (n = 150), including urologists (n = 100), radiation oncologists (n = 40), and medical oncologists (n = 10) were surveyed. The 56-item questionnaire used in this study included six sets of attitudinal items to measure prostate cancer specialists' beliefs about positive and negative influences of PCSGs, reasons for attending PCSGs, the attributes of effective PCSGs, and the value of face-to-face and web-based PCSGs. In addition, an open-ended question was included to invite additional input from participants. Results showed that PCSGs were positively valued, particularly for information sharing, education and psychosocial support. Inclusivity, privacy, and accessibility were identified as potential barriers, and recommendations were made for better marketing PCSGs to increase engagement. Findings suggest prostate cancer specialists highly valued the role and potential benefits of face-to-face PCSGs. Information provision and an educational role were perceived as key benefits. Some concerns were expressed about the ability of web-based PCSGs to effectively engage and educate men who experience prostate cancer.

Development of UK recommendations on treatment for post-surgical erectile dysfunction

AIM

To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context.

METHODS

PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted.

RESULTS

Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies.

CONCLUSION

Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

Erectile dysfunction as a complication after treatment of prostate cancer

Introduction:

Treatment of localized prostate cancer refers to two basic modes which are the radical retro pubic prostatectomy and external radiotherapy. However, according to most authors, radical prostatectomy is the gold standard for long-term survival. Objective: To determine the occurrence of erectile dysfunction after radical operative treatment and irradiation therapy.

Material and methods:

In this paper we have examined the occurrence of erectile dysfunction after conducted treatment for localized prostate cancer. In this paper we have examined 84 of 138 patients who underwent radical retro pubic prostatectomy at the Urology Clinic in the period from January 2009 to December 2010 and 26 patients who underwent radical external radiotherapy in the same period, because of localized prostate cancer. Results: The average age of surgical patients was 65 years, the youngest patient was 49 years and the oldest 81 years. From the 84 patients which underwent surgery, neurovascular preservation of nerve bundles was done in 36 (42.8%) patients from which bilateral in 28 patients (77.7%) and unilateral in 8 patients (22.2%). Average age of patients who underwent irradiation therapy was 68 years.

Conclusion:

Erectile dysfunction occurs in greater proportion after radical retro pubic prostatectomy compared to radiation treatment, and the preservation of both neurovascular bundles reduces this difference.

Comparative cost-effectiveness of robot-assisted and standard laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of men with localised prostate cancer: a health technology assessment from the perspective of the UK National Health Service

BACKGROUND

Robot-assisted laparoscopic prostatectomy is increasingly used compared with a standard laparoscopic technique, but it remains uncertain whether potential benefits offset higher costs.

OBJECTIVE

To determine the cost-effectiveness of robotic prostatectomy.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a care pathway description and model-based cost-utility analysis. We studied men with localised prostate cancer able to undergo either robotic or laparoscopic prostatectomy for cure. We used data from a meta-analysis, other published literature, and costs from the UK National Health Service and commercial sources.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Care received by men for 10 yr following radical prostatectomy was modelled. Clinical events, their effect on quality of life, and associated costs were synthesised assuming 200 procedures were performed annually.

RESULTS AND LIMITATIONS

Over 10 yr, robotic prostatectomy was on average (95% confidence interval [CI]) £1412 (€1595) (£1304 [€1473] to £1516 [€1713]) more costly than laparoscopic prostatectomy but more effective with mean (95% CI) gain in quality-adjusted life-years (QALYs) of 0.08 (0.01-0.15). The incremental cost-effectiveness ratio (ICER) was £18 329 (€20 708) with an 80% probability that robotic prostatectomy was cost effective at a threshold of £30 000 (€33 894)/QALY. The ICER was sensitive to the throughput of cases and the relative positive margin rate favouring robotic prostatectomy.

CONCLUSIONS

Higher costs of robotic prostatectomy may be offset by modest health gain resulting from lower risk of early harms and positive margin, provided >150 cases are performed each year. Considerable uncertainty persists in the absence of directly comparative randomised data.

Optimizing postoperative sexual function after radical prostatectomy

Erectile dysfunction (ED) is one of the complications associated with pelvic surgery. The significance of ED as a complication following pelvic surgery, especially radical prostatectomy (RP), lies in the negative impact that it has on patients' sexual and overall life. In the literature, rates of ED following RP range from 25% to 100%. Such variety is associated with pelvic dissection and conservation of neurovascular structures. Another important factor impacting on postoperative ED is the preoperative erectile function of the patient. Advances in the knowledge of pelvic anatomy and pathological mechanisms led to a refinement of pelvic surgical techniques, with attention to the main structures that if damaged compromise erectile function. These improvements resulted in lower postoperative ED rates and better erectile recovery, especially in patients undergoing RP. Furthermore, surgery alone is not sufficient to prevent this complication, and thus, several medical strategies have been tested with the aim of maximizing erectile function recovery. Indeed it seems that prevention of postoperative ED must be addressed by a multimodal approach. The aim of this review is to give a picture of recent knowledge, novel techniques and therapeutic approaches in order to reach the best combination of treatments to reduce the rate of ED after pelvic surgery.

Effects of early pelvic-floor muscle exercise for sexual dysfunction in radical prostatectomy recipients

BACKGROUND

Sexual dysfunction is common after radical prostatectomy (RP). Although pelvic-floor muscle exercise (PFME) has been recommended for sexual dysfunction, the optimal time for starting exercises after this surgery and the effects of exercise still need to be examined.

OBJECTIVES

The present study was intended to explore the prevalence of sexual dysfunction and to assess the efficacy of PFME in sexual dysfunction following RP.

METHODS

Participants were randomly distributed into an experimental group (n = 35) or a control group (n = 27). The experimental group took part in PFME as part of regular daily activities after catheter removal post-RP. The control group was taught the exercise in the third month after RP. We followed up the participants at 1, 3, 6, 9, and 12 months.

RESULTS

All of the patients experienced a severe degree of sexual dysfunction after receiving RP. A t test showed a significant difference in the sexual function mean score between the experimental and control groups at 6 and 12 months. A mixed-model analysis indicated that, after a controlled surgical approach, there was a significant difference in group effect. The experimental group's sexual function was better than the control group's sexual function.

CONCLUSION

This study demonstrates that early PFME is an effective intervention for sexual dysfunction in prostatectomy patients. The results can help healthcare providers to include this intervention in patients' discharge plans.

IMPLICATIONS FOR PRACTICE

Patient sexual dysfunction after an RP is common. Nurses should evaluate and manage patients' sexual dysfunction and promote the early return of patients' potency.

Assessing couples' preferences for postoperative sexual rehabilitation before radical prostatectomy

OBJECTIVES

To evaluate the readiness of couples to engage in a sexual rehabilitation programme (SRP) before radical prostatectomy (RP) and to identify barriers to participation in an SRP after RP. To identify couples' current levels of sexual function and intimacy.

PATIENTS AND METHODS

Patients completed the International Index of Erectile Function (IIEF) and their partners completed the Female Sexual Function Index (FSFI) to measure sexual function. Couples completed the Miller Social Intimacy Scale (MSIS) to measure intimacy in relationships. All participants were seen by a sexual health clinician after completing the measures to discuss barriers to participation in an SRP, and to receive an education session.

RESULTS

Study participants comprised 143 patients and 104 partners. Patients <60 years old had significantly higher sexual function (P < 0.002) compared with those patients aged 60 years and older. Partners' sexual function scores were suggestive of need for further medical evaluation. Partners' participation was cited by patients as important to them enrolling in an SRP. Couples' intimacy levels were strongly correlated (P < 0.0001).

CONCLUSIONS

Results suggest that less than 50% of patients are interested in receiving information about the impact of RP on sexual function before surgery. Female sexual function should be assessed as part of any SRP because they may require medical treatment if they are to support rehabilitation efforts for their spouses. Baseline assessment of a couple's sexual function and willingness to participate in an SRP should be performed preoperatively.

Treatment decision regret and related factors following radical prostatectomy

BACKGROUND

Issues such as physical and psychological distress impact the quality of life of patients after a radical prostatectomy (RP). It is important to understand the regret that patients often report following a RP and the factors that influence their regret.

OBJECTIVE

The objective of the present study was to understand the regret that patients report following a RP and the influencing factors for their regret.

METHODS

Patients who had a diagnosis of prostate cancer and who underwent a RP between 2004 and 2010 were recruited for this study. The data gathered included a regret scale; the University of California, Los Angeles, Prostate Cancer Index; and demographic and disease-related information.

RESULTS

A total of 100 patients participated in our study. Of those who participated, 31% regretted that they had received an RP. Stepwise regression showed that the following 5 variables were predictors of patient regret after an RP: whether the patient would choose to have an RP again, understanding the treatment and complications, bothersome adverse sexual effects, age, and bothersome adverse bowel effects.

CONCLUSION

We found that 31% of the participants reported experiencing regret after receiving an RP. Our data suggest that urologists and nurses should carefully portray the risks and benefits of RPs during preoperative counseling to minimize patient regret and maximize patient satisfaction.

IMPLICATIONS FOR PRACTICE

Patient regret after an RP is common. Urological nurses should therefore counsel patients regarding the impacts of complications associated with RPs and seek appropriate nursing interventions to reduce patient regret following an RP.

Multipotent stromal cell therapy for cavernous nerve injury-induced erectile dysfunction

INTRODUCTION

Erectile dysfunction (ED) following radical prostatectomy (RP) is a result of inadvertent damage to the cavernous nerves that run close to the prostate capsula. The mechanisms behind the development of post-RP ED are increasingly recognized and include cavernosal fibrosis and cavernosal smooth muscle apoptosis, resulting from cavernous nerve degeneration due to neuropraxia. In recent years, cell-based therapies have received increasing attention regarding their potential for recovery of erectile function following cavernous nerve injury (CNI). Multipotent stromal cells (MSCs) are an attractive cell source for this application based on their regenerative potential and their clinical applicability.

AIM

To review available evidence on the efficacy and mechanisms of action of MSC application for the treatment of ED, with an emphasis on ED following CNI.

METHODS

A nonsystematic review was conducted on the available English literature between 1966 and 2011 on the search engines SciVerse-sciencedirect, SciVerse-scopus, Google Scholar, and PubMed.

RESULTS

MSCs from both bone marrow and adipose tissue have shown beneficial effects in a variety of animal models for ED. While MSC application in chronic disease models such as diabetes, aging, and hyperlipidemia may result in cell engraftment and possibly MSC differentiation, this observation has not been made in the acute CNI rat model. In the latter setting, MSC effects seem to be established by cell recruitment toward the major pelvic ganglion and local paracrine interaction with the host neural tissue.

CONCLUSIONS

While the type of model may influence the mechanisms of action of this MSC-based therapy, MSCs generally display efficacy in various animal models for ED. Before translation to the clinic is established, various hurdles need to be overcome.

Penile prostheses

Penile prosthesis implantation is recognized as a valid option to obtain an artificial erection satisfactory for sexual intercourse in those patients in which a pharmacological approach is contraindicated or ineffective. Penile prostheses are subbject to continuous development and they are achieving ever better mechanical reliability and safety. The devices are divided into two general types: semirigid (malleable and mechanical) and inflatables. The AMS® (American Medical Systems) and Coloplast Ltd® produce the majority of inflatable and semirigid devices.Malleable and mechanical prostheses have the disadvantage that the penis is always erect although it can be orientated in different ways, while the advantages are ease of use and the need for a simpler surgical procedure compared with inflatable prostheses. Three-component prostheses are more sophisticated than semirigid devices. The advantages of these devices are that the prosthesis feels softer than semirigid or two-piece devices when deflated, with a better cosmetic result, and it ensures a more natural erection than others kinds of prosthesis. The disadvantages are the possibility of malfunction and the need for a more complicated surgical technique. Implantation of a penile prosthesis can be performed in a short surgical time under locoregional anaesthesia, and for this reason hospitalization is usually brief and the patient can be discharged 2 days after the operation if complications are not evident. Patient and partner satisfaction reflect the quality and the effectiveness of this treatment. Even though the results are positive in the vast majority of patients, the possibility of several complications makes penile prosthesis implantation a delicate kind of surgery. Complications can happen when the operation is carried out, in the peri-operative and in the postoperative period, and include infections, erosions of the prosthesis and mechanical failure in case of inflatable prosthesis. Penile prostheses available on the market have improved the success of this kind of surgery, thanks to the introduction of new materials and designs.

Increased expression of nestin in the major pelvic ganglion following cavernous nerve injury

In an effort to identify neuronal repair mechanisms of the major pelvic ganglion (MPG), we evaluated changes in the expression of nestin, an intermediate filament protein and neural stem cell marker following cavernous nerve crush injury (CNI). We utilized two groups of Sprague Dawley rats: (i) sham and (ii) bilateral CNI. Erectile responses to cavernous nerve stimulation (CNS) were determined at 48 h in a subset of rats. The MPG was isolated and removed at 48 h after CNI, and nestin immunolocalization, protein levels and RNA expression were evaluated. At 48 h, erectile responses to CNS in CNI rats were substantially reduced (P<0.05; ∼70% decrease in intracavernous pressure/mean arterial pressure) compared with sham surgery controls. This coincided with a dramatic 10-fold increase (P<0.05) in nestin messenger RNA expression and protein levels in the MPG of rats with CNI. Immunoflourescence microscopy demonstrated that nestin upregulation after CNI occurred within the ganglion cell bodies and nerve fibers of the MPG. In conclusion, CNI induces nestin in the MPG. These data suggest that nestin may be involved in the regenerative process of the cavernous nerve following crush injury.

[Clinical symptoms of hypogonadism after radical prostatectomy]

This study checked whether the prevalence of hypogonadal symptoms [measured using the Aging Males' Symptoms Scale (AMSS)] after radical prostatectomy can give information about the prevalence of hypogonadism in this group of patients. Distribution of the level of complaints (no, mild, moderate or severe) on the AMSS after radical prostatectomy (n=576) was analyzed in all patients (G) and stratified by the point in time of data collection [surgery to AMSS less (K1) and more than 1 year (K2)].The total score shows more patients with mild and moderate symptoms in G, K1, and K2 compared with the control (G 57.6 and 23.4%, K1 59.1 and 22.4%, K2 40 and 35.6% vs 36.5 and 11.2%). In the somatic score G and K1 show 2.4% (G) and 1.7% (K1) less patients with no and 1.5% (G) and 0.9% (K1) less patients with little complaints compared with the control; 2.6% (G) and 1.8% (K1) more patients state moderate and 1.2% (G) and 0.8% (K1) more severe complaints. K2 shows fewer patients with no and mild (22.2 and 31.1% vs 33.3 and 39.3%) and more with moderate and severe complaints (33.3 and 13.3% vs 21.0 and 6.4%) compared with the control. In the psychological score patients in G and K1 state less mild complaints (G 33.9%, K1 32.8% vs 41.8%), more patients state no complaints (G 45.8%, K1 47.3% vs 43.6%) as well as moderate and severe complaints (G 12.8%, K1 12.8% vs 10.9% and G 7.5%, K1 7.2% vs 3.7 %) compared with the control. K2 shows more complaints of all levels compared with the control (mild 46.7 vs 41.8%, moderate 13.3 vs 10.9%, and severe 11.1 vs 3.7%). In the sexual score all groups of patients show significantly more severe complaints (G 89.6%, K1 89.5%, K2 91.1% vs 6.1%).Multiple factors influenced by surgery and diagnosis of cancer which are independent of hormonal effects make distribution of hypogonadal symptoms on the AMSS not suitable to give information about the prevalence of hypogonadism after radical prostatectomy. An analysis of serum testosterone seems to be essential.

Patients' desire to preserve sexual activity and final decision for a nerve-sparing approach: results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

INTRODUCTION

Preservation of sexual function after surgery represents a major issue for patients undergoing radical prostatectomy (RP).

AIM

To investigate determinants of patients' desire to preserve sexual activity before RP and surgeons' final decision to perform a nerve-sparing RP (NSRP).

METHODS

  Overall, 2,408 prostate cancer patients, candidates to RP, from 136 urologic departments across the Italian territory were evaluated in a multicenter prospective observational study. All patients underwent RP, according to single-center indications and procedures.

MAIN OUTCOME MEASURES

Age, body mass index, previous benign prostatic hyperplasia history, preoperative tumor characteristics, quality of life through the Short Form Health Survey (SF-12), and the University of California Los Angeles Prostate Cancer Index (UCLA-PCI), erectile function through the International Index of Erectile Function (IIEF-5), desire to preserve sexual activity, NS operative outcomes, and surgical margins status were recorded.

RESULTS

Overall, 1,667 were interested to preserve sexual activity. Age, physical component summary of SF12 (PCS-12), sexual function score of UCLA-PCI, and IIEF-5 score were the main determinants of such interest. Only 1,246 patients were suitable for a NSRP according to guidelines. Surgeons performed a non-NSRP (NNSRP) in 1,234 patients, a unilateral NSRP in 318 and a bilateral NSRP in 856. Age, bioptical Gleason score, percentage of positive cores, PCS-12, and patient's desire to preserve sexual activity were the main determinants of final decision for a NSRP. Surgeons performed a NSRP in 424 not suitable and in 121 not interested patients. Positive surgical margins in not suitable patients submitted to NSRP were not higher if compared to that obtained after NNSRP in the same subgroup. Limits include lack of oncological and functional follow-up.

CONCLUSIONS

Most patients are interested to preserve sexual activity. Discrepancies exist among patients' preferences, guidelines' indications, and surgeon's final decision.

Activated RhoA/Rho kinase impairs erectile function after cavernous nerve injury in rats

PURPOSE

RhoA and rho kinase serve as key regulators of penile vascular homeostasis. The role of RhoA/rho kinase signaling in the penis after cavernous nerve injury has not been fully investigated. We characterized the molecular expression profiles of RhoA/rho kinase signaling that occur in the penis after cavernous nerve injury. We hypothesized that erectile dysfunction after bilateral cavernous nerve injury is accompanied by up-regulation of RhoA/rho kinase activity in the rat penis.

MATERIAL AND METHODS

We used 2 groups, including sham operation and bilateral cavernous nerve injury. At 14 days after nerve injury each group underwent cavernous nerve stimulation to determine erectile function at baseline and after intracavernous injection of the rho kinase inhibitor Y-27632 (Tocris Bioscience, Ellisville, Missouri). Penes were assessed at baseline for protein expression of neuronal nitric oxide synthase, RhoA, and rho kinase 1 and 2 by Western blot, immunoreactivity of neuronal nitric oxide synthase, rho kinase 1 and 2, RhoA-guanosine triphosphatase and rho kinase activity.

RESULTS

Erectile function was decreased in nerve injured rats. Neuronal nitric oxide synthase protein was significantly decreased while RhoA and rho kinase 2 protein levels were significantly increased in rat penes with nerve injury. Rho kinase 1 protein expression was equivalent. Rho kinase immunoreactivity was qualitatively increased in the corporeal smooth muscle of nerve injured rats. RhoA-guanosine triphosphatase and rho kinase activity was significantly increased in injured rat penes compared to that in sham operated penes. Intracavernous injection of Y-27632 caused a significantly greater increase in intracavernous pressure in nerve injured rats compared to that in sham operated rats, suggesting increased rho kinase activity.

CONCLUSIONS

Data suggest that RhoA/rho kinase up-regulation in response to cavernous nerve injury contributes to penile vasculature dysfunction after cavernous nerve injury. Thus, the RhoA/rho kinase pathway may be a suitable target for treating post-radical prostatectomy erectile dysfunction.

Sex life after 65: how does erectile dysfunction affect ageing and elderly men?

INTRODUCTION

We report the findings pertinent to the ageing and elderly participants of a population-based study of erectile dysfunction (ED).

METHOD

We examined the sociodemographic characteristics, self-reported morbidities and responses to the 5-item International Index of Erectile Function (IIEF-5) of participants aged > or = 65 years and > or = 80 years.

RESULTS

Most (73%) participants were married or had partners. Among the participants aged > or = 65 years, the prevalence of ED (IIEF-5 scores <22) was 67% and of severe ED (IIEF-5 scores <8) 48%. About 32% were sexually active, and 11% had regular sexual intercourse. Cardiovascular disease (CVD) was reported in 37% and diabetes mellitus (DM) in 13%, with odds of ED at 3.91 and 4.68, respectively. Among those aged > or = 80 years, the prevalence of ED was 68% and of severe ED 57%. About 12% were sexually active, and 3% had regular sexual intercourse. CVD was reported in 44% and DM in 11%, with corresponding odds of ED at 2.55 and 2.90.

CONCLUSIONS

Most ageing and elderly men are in a relationship and many are sexually active. ED is prevalent and severe. Morbidities are common and significantly associated with ED, impairing the sex lives of affected men.

Health Promotion and Illness Demotion at Prostate Cancer Support Groups

Although health promotion programs can positively influence health practices, men typically react to symptoms, rather than maintain their health, and are more likely to deny than discuss illness-related issues. Prostate cancer support groups (PCSGs) provide an intriguing exception to these practices, in that men routinely discuss ordinarily private illness experiences and engage with self-health. This article draws on individual interview data from 52 men, and participant observations conducted at the meetings of 15 groups in British Columbia, Canada to provide insights to how groups simultaneously facilitate health promotion and illness demotion. The study findings reveal how an environment conducive to men’s talk was established to normalize prostate cancer and promote the individual and collective health of group members. From a gendered perspective, men both disrupted and embodied dominant ideals of masculinity in how they engaged with their health at PCSGs.

Importance of baseline potency rate assessment of men diagnosed with clinically localized prostate cancer prior to radical prostatectomy

INTRODUCTION

Erectile dysfunction (ED) is a common, and multifactorial medical problem with significant impact on quality of life. Knowledge about baseline potency is highly important in men undergoing treatment for prostate cancer (PCa) as it might influence judgments about impact of treatment and thereby treatment decisions.

AIMS

To analyze the baseline potency rate of men with clinically localized PCa prior to radical prostatectomy (RP). Furthermore, it was of interest to identify comorbid factors of preoperative ED.

MAIN OUTCOME MEASURE

Prevalence of preoperative ED and association between comorbidities and ED in men prior to RP in bi- and multivariable logistic regression analyses.

METHODS

Retrospective analysis of a large single center cohort of 1,330 evaluable PCa patients who were preoperatively assessed with the abridged 5-item version of the International Index of Erectile Function (IIEF) also described as Sexual Health Inventory for Men. Baseline potency and comorbidity rates, and their distribution were described. The risk of baseline ED associated with age, body mass index (BMI), the presence of hyperlipoproteinemia (HLP), non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and depression were analyzed in bi- and multivariable logistic regression analyses.

RESULTS

Using the IIEF-5 cutoff value of 21, 48% demonstrated some degree of ED. Severe, moderate, mild to moderate, mild, and no ED was observed in 9.2, 4.0, 10.2, 24.7, and 52% respectively. In univariable analyses, ED significantly increased according to increasing age, BMI, presence of HLP, hypertension, NIDDM, and depression (P <or= 0.045). In multivariable analysis, age, BMI, NIDDM, and depression represented independent risk factors of baseline ED (all P <or= 0.005).

CONCLUSIONS

It is important to note that one in two men diagnosed with a clinically localized PCa experiences some degree of baseline ED of which 23.4% are moderate to severe prior to local therapy. Age, BMI, NIDDM, and presence of depression represent important independent risk factors of baseline ED.

Randomized, double-blind, placebo-controlled study of postoperative nightly sildenafil citrate for the prevention of erectile dysfunction after bilateral nerve-sparing radical prostatectomy

Four weeks after bilateral nerve-sparing radical retropubic prostatectomy, men with normal erectile function before surgery were randomized to double-blind sildenafil (50 or 100 mg) or placebo nightly for 36 weeks, followed by an 8-week drug-free period before assessment of erectile function. Enrollment was prematurely ceased and only 76 men completed because, assuming a placebo response rate similar to the published literature (for example, 34% in meta-analysis), the 25% response at blinded interim review suggested a lack of treatment effect. On the contrary, spontaneous erectile function (a combined score of >or=8 for questions 3 and 4 of the International Index of Erectile Function and a positive response to 'Were erections good enough for satisfactory sexual activity?') occurred in only 4% of the placebo group (n=1 of 25) versus 27% (n=14 of 51, P=0.0156, Fisher's exact test) of the sildenafil group. Nightly sildenafil administration for 36 weeks after surgery markedly increased the return of normal spontaneous erections.

Does management of erectile dysfunction after radical prostatectomy meet patients' expectations? Results of a national survey (REPAIR) by the French Urological Association

INTRODUCTION

Little stress has been placed on patients' satisfaction with regard to management of erectile dysfunction (ED) after radical prostatectomy (RP) and on how physicians' and patients' views may differ in this respect.

AIM

To assess the extent to which urologists' perceptions of their patients' expectations and the actual needs expressed by these patients coincide with regard to ED and its management.

METHODS

Those French urologists who provisionally accepted to participate in the survey (760/1,272; 59.7%) received a physician survey instrument, 10 patient data forms to be completed during the first 10 consultations of patients who had undergone RP less than 12 months previously, and 10 copies of a questionnaire for patients to complete. MAIN OUTCOME MEASURES; Patient-reported sexual activity, satisfaction with sexual activity (Male Sexual Health Questionnaire), and treatment expectations; urologists' subjective assessment of the importance given by their patients to ED; the timing they propose for starting ED treatment.

RESULTS

Overall, 535/1,272 urologists (42%) returned the physician survey instrument (45.6 +/- 8.7 years, 28-67) and 2,644 patients completed the patient questionnaire (64.0 +/- 6.1 years, 44-79). The percentage of patients having intercourse pre RP was highly age-dependent (89% at 55-59 years; 56% at > or = 70 years); 70-75% of patients claimed to be satisfied with their pre-RP sexual activity. Post RP, 27-53% of patients (depending upon length of follow-up), who were sexually active pre RP, had intercourse. Only 18% (< 5 months' follow-up) or 28% (> 5 months' follow-up) were satisfied. Over half (53%)--and especially the younger patients--expected early ED treatment (1 or 3 months post RP). Agreement between patients' expectations and urologists beliefs on timing of ED treatment was poor. At the 1- or 2-month visits, 73% of patients were already finding ED frustrating.

CONCLUSIONS

Erectile dysfunction is an important issue for patients who have undergone RP. Urologists tend to underestimate patients' distress and desire for early treatment.

The early use of transurethral alprostadil after radical prostatectomy potentially facilitates an earlier return of erectile function and successful sexual activity

OBJECTIVE

To assess whether early introduction of the Medicated Urethral System for Erection (MUSE(TM), Vivus Inc., Mountain View, CA, USA) after radical prostatectomy (RP) results in a shorter recovery time for the return to functional erections and successful sexual activity.

PATIENTS AND METHODS

In a prospective study of 91 sexually active men who had a nerve-sparing RP for prostate cancer, 56 were treated with MUSE (125 or 250 microg three times per week for 6 months) while the remaining 35 had no erectogenic aids, except as necessary when attempting sexual activity. Self-administration of MUSE was initiated approximately 3 weeks after RP. Treatment efficacy was analysed by the patient's response to the Sexual Health Inventory for Men (SHIM) questionnaire.

RESULTS

The mean patient age was approximately 59 years and the median follow-up 6 months; the compliance rate was 68%. Patients reported a significant improvement in all domains of the SHIM questionnaire after using MUSE. At the end of 6 months 74% of the patients who remained on MUSE were able to have successful vaginal intercourse. Of patients who completed the 6-month course of MUSE, half were able to have successful vaginal intercourse by the end of treatment. Most of these patients reported the recovery of spontaneous erections and required no additional erectogenic aids for successful intercourse. They had a mean SHIM score of 18.9. All 56 patients who received MUSE reported mild penile aching or urethral burning, and of these, 32% discontinued treatment. In the untreated control group, 37% regained erections sufficient for vaginal intercourse at the 6-month follow-up, with a mean SHIM score of 15.8. Of the control patients who recovered penile function, 71% were dissatisfied with the quality of their erections and sought adjuvant therapy.

CONCLUSIONS

Initiating MUSE shortly after RP is safe and tolerable, and appears to shorten the recovery time to reagin erectile function.

How urologists manage erectile dysfunction after radical prostatectomy: a national survey (REPAIR) by the French urological association

INTRODUCTION

There is little sound information on how urologists manage erectile dysfunction (ED) arising after radical prostatectomy (RP) in a real-world situation.

AIM

To perform a national survey of how French urologists manage ED after RP in routine practice.

MAIN OUTCOME MEASURES

Choice of first-line treatment, type of treatment (rehabilitation of erectile function vs. treatment on demand for intercourse), and timing and duration of treatment.

METHODS

All French urologists were invited to take part in a survey; 59.7% accepted provisionally (760/1,272). They received the survey questionnaire and 10 patient data forms to be completed during the visits of the first 10 patients with fewer than 12 months follow-up post-RP. These were returned to an independent third party for analysis.

RESULTS

The final response rate was 535/1,272 (42%). Before performing RP, 80% of the urologists assessed sexual activity and 76% erectile function; 9% did neither. Thirty-eight percent reported that they systematically proposed ED treatment to their patients post-RP ("routine prescribers"). The remainder was treated on occasion, either at the patients' request (49%) or at their own discretion (13%). Routine prescribers tended to be younger and had performed more RPs in the preceding year. Most urologists (88%) always used the same first-line treatment: regular intracavernosal injections (ICIs) for rehabilitation, 39%; ICI on demand for intercourse, 30%; phosphodiesterase type 5 (PDE5) inhibitors on demand, 16%, or regular PDE5 inhibitors for rehabilitation, 8%; alternating ICI and PDE5 inhibitors, 7%; vacuum device, <1%. ED treatment was initiated within 3 months of RP by 72% of the urologists (92% of routine prescribers). The percentage of urologists recommending ED treatment for 6 months was 20%, 38% for 1 year, and 33% for 2 years.

CONCLUSION

ED was commonplace after RP. French urologists reported a proactive attitude to ED treatment, many favoring pharmacologic rehabilitation therapy. ICI was their first-line treatment of choice.

FK506 and sildenafil promote erectile function recovery after cavernous nerve injury through antioxidative mechanisms

INTRODUCTION

Immunophilin ligands and phosphodiesterase type 5 (PDE5) inhibitors are touted to promote erectile function recovery after cavernous nerve (CN) injury. However, the mechanisms for their effects remain unclear.

AIM

To compare the erection recovery effects of the immunophilin ligand FK506 and the PDE5 inhibitor sildenafil after CN injury and determine whether they involve antioxidative and/or antiapoptotic mechanisms.

METHODS

Initial experiments established conditions of our CN injury model in adult male Sprague-Dawley rats. Subsequently, we evaluated treatment effects 14 days after: (i) unilateral CN injury (UNI) + saline (vehicle control); (ii) UNI + FK506 (5 mg/kg once daily, subcutaneous x 5 days); (iii) UNI + sildenafil (20 mg/kg every 8 hours, subcutaneous x 7 days); (iv) UNI + FK506/sildenafil; and (v) sham surgery.

MAIN OUTCOME MEASURES

Intracavernous pressure (ICP) measurement after CN electrical stimulation to assess erectile function and Western blot analysis of expressions of glutathione peroxidase (GPX; antioxidant enzyme), nitrotyrosine (NT; oxidative stress marker), and phosphorylated and total Akt (antiapoptotic factor) in penes.

RESULTS

In the UNI model, GPX expression was increased at Days 1 and 7, while p-Akt expression decreased at Day 1 and returned to baseline at Day 7. GPX expression was significantly higher in the UNI + FK506 group compared with the saline-treated group (P < 0.05). ICP increased in all treatment groups compared with that of the saline-treated group (P < 0.05). NT levels were increased after saline treatment (P < 0.05) but not after FK506 and sildenafil treatment, alone or in combination. GPX was localized to nerves coursing through the penis and to smooth muscle and endothelium of the dorsal vein and arteries.

CONCLUSIONS

Both FK506 and sildenafil protect erectile function after CN injury by decreasing oxidative stress-associated tissue damage. FK506 may act through increased GPX activity. Further research is required to elucidate mechanisms associated with the beneficial effect of sildenafil.

Results of unilateral genitofemoral nerve grafts with contralateral nerve sparing during radical prostatectomy

OBJECTIVES

To evaluate the success of erectile function preservation and recovery in a select group of patients with extensive disease unilaterally on biopsy who were candidates for unilateral nerve sparing and contralateral genitofemoral interposition nerve-grafting radical prostatectomy (RP). Because of its low donor site morbidity, the genitofemoral nerve is an appealing donor source for cavernous nerve grafting during RP. Although evidence has shown that sural interposition nerve grafts during RP preserve erectile function, the evidence for genitofemoral nerve grafts is limited.

METHODS

Nerve-sparing RP was performed according to the technique of Walsh on 22 patients with prostate cancer. At follow-up, the patients completed an 11-item self-report questionnaire that included the erectile function (EF) domain of the International Index of Erectile Function.

RESULTS

The mean patient age was 62 years (range 48 to 76). The mean follow-up time was 23 months (range 9 to 37). Of the 22 patients, 3 reported no erectile dysfunction (ED) (EF score 26 to 30), 3 reported mild ED (EF score 22 to 25), 1 reported moderate ED (EF score 11 to 16), and 15 reported severe ED (EF score less than 11). Eight men continued to experience mild chronic thigh or scrotal numbness after the genitofemoral nerve graft procedure.

CONCLUSIONS

The benefits of unilateral nerve grafting with the genitofemoral nerve remain uncertain. A prospective randomized trial is warranted before the widespread adoption of unilateral nerve grafting.