Risk of erectile dysfunction after modern radiotherapy for intact prostate cancer

Urethra-Sparing Prostate Cancer Stereotactic Body Radiation Therapy: Sexual Function and Radiation Dose to the Penile Bulb, the Crura, and the Internal Pudendal Arteries From a Randomized Phase 2 Trial

PURPOSE

Erectile dysfunction (ED) is a common side effect after prostate cancer stereotactic body radiation therapy (SBRT). We aimed to assess the correlation between the dose to the penile bulb (PB), internal pudendal arteries (IPA), and crura with the development of ED after ultrahypofractionation as part of a phase 2 clinical trial of urethra-sparing prostate SBRT.

METHODS AND MATERIALS

Among the 170 patients with localized prostate cancer from 9 centers included in the trial, 90 men with Common Terminology Criteria for Adverse Events version 4.03 grade 0 to 1 ED (ED-) at baseline treated with 36.25 Gy in 5 fractions were selected for the present analysis. Doses delivered to the PB, crura, and IPA were analyzed and correlated with grade 2 to 3 ED (ED+) development. The effect on quality of life, assessed by the European Organisation for Research and Treatment of Cancer (EORTC QLQ-PR25) questionnaire, was reported.

RESULTS

After a median follow-up of 6.5 years, 43% (n = 39) of the patients developed ED+, and 57% (n = 51) remained ED-. The dose delivered to the crura was significantly higher in ED+ patients than in ED- patients (7.7 vs 3.6 Gy [P = .014] for the Dmean and 18.5 vs 7.2 Gy [P = .015] for the D2%, respectively). No statistically significant difference between ED+ and ED- patients was observed for the dose delivered to the PB and IPA. The median ED+-free survival was worse in patients receiving a crura Dmean ≥ 4.7 versus < 4.7 Gy (51.5% vs 71.7%, P = .005) and a crura D2% > 12 versus ≤ 12 Gy (54.9% vs 68.9%, P = .015). No ED+-free survival differences were observed for doses delivered to the PB and IPA. Decline in EORTC QLQ-PR25 sexual functioning was significantly more pronounced in patients with higher doses to the crura.

CONCLUSIONS

By keeping a Dmean and D2% to crura below 4.7 and 12 Gy, respectively, the risk of developing ED+ after prostate SBRT may be significantly reduced.

Major adverse cardiovascular events related to phosphodiesterase 5 inhibitors: analysis of real-life data from Eudra-Vigilance database

BACKGROUND

Phosphodiesterase 5 inhibitors (PDE5i) are the standard medical treatment for erectile dysfunction. Aim of our study was to evaluate the rate of major adverse cardiovascular events (MACE) reported during PDE5i treatment based on Eudra-Vigilance (EV) reports.

METHODS

EV database is the system for managing and analyzing data on suspected adverse reactions to medicines which have been authorized or being studied in clinical trials in the European Economic Area. MACE are defined as non-fatal stroke, non-fatal myocardial infarction, non-fatal congestive heart failure, revascularization after aorto-coronary graft bypass and cardiovascular death. We recorded the number of MACE for sildenafil, tadalafil, vardenafil, avanafil per category and severity until 1st July 2023. Pooled Relative Risk (PRR) was used to compare data between drugs.

RESULTS

Overall, 951 MACE events were reported. Most of them were observed in younger patients <65 years old (452/951 events, 48%). Overall, 377/8939 (4%) MACE events were observed for sildenafil, 221/5213 (4%) for tadalafil, 50/1029 (4%) for vardenafil and no events for avanafil. No significative differences were reported comparing sildenafil and tadalafil (PRR 0.71-0.99, IQR 0.61-1.35, P>0.05), neither sildenafil vs. vardenafil (PRR 0.68-0.79, IQR 0.43-1.55, P>0.05), neither tadalafil vs. vardenafil (PRR 0.77-0.95, IQR 0.64-1.30. P>0.05) even when compared for age. Comparison between different classes of age showed MACE were more frequent in patients younger than 65 years old taking sildenafil and tadalafil when compared to patients older than 85 years old (PRR 0.02-0.11. IQR 0.01-0.40. P<0.01) and when compared to patients in 65-85 class of age (PRR 0.02-0.12, IQR 0.01-0.95, P<0.01).

CONCLUSIONS

Real life data is consistent with MACE related to PDE5i. PDE5is are infrequently (<5%) associated with MACE. However, risk seems higher in younger patients, particularly for sildenafil (452/951 events, 48%). Clinicians should consider these data when prescribing PDE5i especially in young patients.

[Relationship between doses to anatomical structures and erectile dysfunction after radiotherapy for prostate cancer: A systematic review]

PURPOSE

During prostatic radiotherapy, damage to several anatomical structures could be the cause of erectile dysfunction: corpora cavernosa, internal pudendal arteries, penile bulb, and neurovascular bundles. Numerous studies have analysed the correlations between the dose received by these structures and erectile function. The objective of this article is to make a systematic review on current knowledge.

MATERIALS AND METHODS

A systematic review was performed in the Medline database using the search engine PubMed. Keywords for the search included: erectile dysfunction, penile bulb, corpora cavernosa, cavernosum, neurovascular bundles, radiation therapy, cancer, prostate cancer. The selected articles must study a correlation between erectile dysfunction and the dose received by anatomical structures. A total of 152 articles were identified. Of these 152 articles, 45 fulfilled the defined selection criteria.

RESULTS

For corpora cavernosa, seven studies were identified, only two studies demonstrated a significant correlation between the dose received by corpora cavernosa and the occurrence of erectile dysfunction. For penile bulb, only 15 of 23 studies showed a correlation. A mean dose on the penile bulb greater than 20Gy was found to be predictive of erectile dysfunction. None of the eight trials concerning neurovascular bundles succeeded to show a correlation between dose and erectile dysfunction. Only one study evaluated the relationship between the dose received by internal pudendal arteries and erectile dysfunction but was found to be negative. However, vessels-sparing studies showed good results on erectile function preservation without compromising the target volume.

CONCLUSION

We currently have little data to show a correlation between erectile dysfunction and sexual structures. It would be necessary to have additional prospective studies evaluating the impact of an optimization on these sexual structures on erectile dysfunction.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Erectile dysfunction following hydrogel injection and hypofractionated radiotherapy for prostate cancer: Our experience in 56 cases

INTRODUCTION

The incidence of erectile dysfunction (ED) in men with organ-confined prostate cancer (PCa) submitted to hypofractionated radiotherapy (HRT) has been prospectively evaluated.

MATERIALS AND METHODS

From April 2018 to September 2020, 56 patients (median age 70 years) with cT1c PCa were treated by HRT directed to the prostate and seminal vesicle. Median PSA was 8.3 ng/ml; 20 patients (35.7%) vs. 28 (50%) vs. 8 (22.3%) had a PCa Grade Group 1 vs. 2 vs. 3, respectively. All patients underwent hydrogel injection of Space OAR and intraprostatic fiducials before HRT. The prescription dose was 60 Gy in 20 fractions 5 days/week over 4 weeks. During the follow up, PSA, genitourinary (GU) and gastrointestinal (GI) toxicities were evaluated. The sexual function was evaluated by International Index of Erectile Function - 5 (IIEF-5) before, 6 and 18 months from HRT; 32/56 (57.1%) men referred a normal sexual activity before HRT (median IIEF-5 score: 22).

RESULTS

Median PSA level at median follow up of 18 months was 0.92 ng/ml and none used adjuvant therapy. One man (1.8%) referred a tardive grade 1 GU complication. At a median follow up of 6 and 18 months, 20/32 (62.5%) kept pretreatment sexual potency (median IIEF-5 score: 21). The 12/32 men who worsened the sexual function following HRT had a median age higher than patients without ED (78 vs. 67 years).

CONCLUSIONS

The use of hydrogel injection and intraprostatic fiducials followed by HRT allowed to kept pretreatment sexual potency in 62.5% of the cases.

A flavonoid derivative of icariside II (YS-10) improves erectile dysfunction in radiation-injured rats via oxidative stress pathway

Background

We explored the preventive effect and mechanism of YS-10, a novel synthesized flavonoid derivative based on the structure of icariside II (ICA II), on a rat model of radiation-induced erectile-dysfunction (Ri-ED).

Methods

Eighteen 10-week-old male Sprague-Dawley (SD) rats were randomly divided into 3 groups. Six rats were used as the control group (Control), and the remaining 12 were given a single X-ray irradiation of 20 Gy in the prostate and then randomly divided into the radiation injury group (Ri-ED group) and YS-10 treatment group (Ri-ED+YS-10, 2.5 mg/kg/day). After 4 weeks of drug administration and a 2-week drug washout period in the YS-10 treatment group, the erectile function of the animals was evaluated, and the tissues were collected for histopathological analysis and detection of oxidative stress indicators.

Results

After radiation injury, the ratio of maximum intracavernosal pressure (ICP) to mean arterial pressure (MAP), the number of neuronal nitric oxide synthase (n-NOS) positive nerve fibers in the penis cavernosa, endothelial cell content, and n-NOS and endothelial nitric oxide synthase (e-NOS) proteins in the Ri-ED group were significantly lower than those in control group. Compared with the control group, the Ri-ED group had lower superoxide dismutase (SOD) levels and higher malondialdehyde (MDA) levels. Compared with the Ri-ED group, the YS-10 group had a significant increase in the ratio of ICP/MAP in the corpus cavernosum (0.59±0.06 vs. 0.43±0.06, P<0.01), the number of n-NOS positive nerve fibers, and the content of endothelial cells. The protein content of n-NOS and e-NOS in the corpus cavernosum increased and could significantly reduce the level of MDA (2.67±0.27 vs. 3.25±0.21, P<0.05).

Conclusions

As a novel ICA II derivative, YS-10 could significantly improve the erectile dysfunction and pathological damage in rats caused by radiation injury, and its mechanism may be related to the improvement of radiation-induced oxidative stress.

The role for MRI-guided transurethral ultrasound ablation in the continuum of prostate cancer care

Prostate cancer continues to have a negative impact on the duration and quality of life for males and their families. MRI is transforming the pathway of prostate cancer detection, diagnosis, staging, and surveillance, backed by multiple Level 1 studies and robust reporting standards. This evolving paradigm of MRI-directed care is now being expanded to include in-bore MRI-guided prostate tissue ablation techniques, which reduce the burden of genitourinary complications associated with standard-of-care treatments, without sacrificing cancer control. The workflow for MRI-guided transurethral ultrasound ablation relies on intraprocedural MRI guidance for treatment planning, automated and physician-monitored treatment delivery, and post-treatment assessment at both immediate and long-term time points. Our early experience has identified several procedure refinements, and aligns with early evidence from prospective clinical studies using transurethral ultrasound ablation for treatment of patients with either primary or recurrent disease. Driven by quantitative real-time imaging, MRI-guided ablative interventions provide rich datasets for developing technical refinements and predictive models that will progressively improve patient outcomes as these novel techniques become part of a new standard-of-care.

Effect of Brachytherapy vs. External Beam Radiotherapy on Sexual Function in Patients With Clinically Localized Prostate Cancer: A Meta-Analysis

Purpose: The aim of this study was to compare the effect of brachytherapy (BT) versus external beam radiotherapy (EBRT) on sexual function in patients with localized prostate cancer (PCa).

Methods: Data were retrieved from the PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang Database until March 4, 2021. Analysis was performed by using RevMan 5.4.1. The main clinical outcomes were the Prostate Cancer Symptom Indices (PCSI) scale and the Expanded Prostate Cancer Index Composite (EPIC) scale scores for sexual function. A meta-analysis was performed to calculate standardized mean differences (SMDs) and their 95% CI. This study has undergone PROSPERO registration (No. CDR42021245438).

Results: Among the 962 studies retrieved, eight prospective cohort studies met the inclusion criteria, covering a total of 2,340 patients, including 1,138 treated with BT alone and 1,202 treated with EBRT alone. The results demonstrated that BT was to some extent advantageous over EBRT in overall sexual function scores in patients with localized PCa during the immediate post-treatment period (SMD = −0.09, 95% CI: −0.18 to −0.01, p = 0.03), but this difference was not detectable at 3 months (SMD = −0.07, 95% CI: −0.18–0.05, and p = 0.25), 12 months (SMD = −0.01, 95% CI: −0.21–0.20, and p = 0.96), and 24 months (SMD = −0.09, 95% CI: −0.20–0.01, and p = 0.09) after treatment.

Conclusion: Our analysis showed that BT showed a short-term advantage over EBRT in terms of sexual function in patients with localized PCa, but this difference diminished over time, though the conclusion needs to be further verified by a longer-term follow-up study.

Pathological Significance of Macrophages in Erectile Dysfunction Including Peyronie's Disease

Erectile function is regulated by complex mechanisms centered on vascular- and nerve-related systems. Hence, dysregulation of these systems leads to erectile dysfunction (ED), which causes mental distress and decreases the quality of life of patients and their partners. At the molecular level, many factors, such as fibrosis, lipid metabolism abnormalities, the immune system, and stem cells, play crucial roles in the etiology and development of ED. Although phosphodiesterase type 5 (PDE5) inhibitors are currently the standard treatment agents for patients with ED, they are effective only in a subgroup of patients. Therefore, further insight into the pathological mechanism underlying ED is needed to discuss ED treatment strategies. In this review, we focused on the biological and pathological significance of macrophages in ED because the interaction of macrophages with ED-related mechanisms have not been well explored, despite their important roles in vasculogenic and neurogenic diseases. Furthermore, we examined the pathological significance of macrophages in Peyronie’s disease (PD), a cause of ED characterized by penile deformation (visible curvature) during erection and pain. Although microinjury and the subsequent abnormal healing process of the tunica albuginea are known to be important processes in this disease, the detailed etiology and pathophysiology of PD are not fully understood. This is the first review on the pathological role of macrophages in PD.

European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction

CONTEXT

The present summary of the European Association of Urology (EAU) guidelines is based on the latest guidelines on male sexual health published in March 2021, with a last comprehensive update in January 2021.

OBJECTIVE

To present a summary of the 2021 version of the EAU guidelines on sexual and reproductive health.

EVIDENCE ACQUISITION

A literature review was performed up to January 2021. The guidelines were updated, and a strength rating for each recommendation was included based on either a systematic review of the evidence or a consensus opinion from the expert panel.

EVIDENCE SYNTHESIS

Late-onset hypogonadism is a clinical condition in the ageing male combining low levels of circulating testosterone and specific symptoms associated with impaired hormone production and/or action. A comprehensive diagnostic and therapeutic work-up, along with screening recommendations and contraindications, is provided. Erectile dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Along with a detailed basic and advanced diagnostic approach, a novel decision-making algorithm for treating ED in order to better tailor therapy to individual patients is provided. The EAU guidelines have adopted the definition of premature ejaculation (PE), which has been developed by the International Society for Sexual Medicine. After the subtype of PE has been defined, patient's expectations should be discussed thoroughly and pharmacotherapy must be considered as the first-line treatment for patients with lifelong PE, whereas treating the underlying cause must be the initial goal for patients with acquired PE. Haemospermia is defined as the appearance of blood in the ejaculate. Several reasons of haemospermia have been acknowledged; the primary goal over the management work-up is to exclude malignant conditions and treat any other underlying cause.

CONCLUSIONS

The 2021 guidelines on sexual and reproductive health summarise the most recent findings, and advise in terms of diagnosis and treatment of male hypogonadism and sexual dysfunction for their use in clinical practice. These guidelines reflect the multidisciplinary nature of their management.

PATIENT SUMMARY

Updated European Association of Urology guidelines on sexual and reproductive health are presented, addressing the diagnosis and treatment of the most prevalent conditions in men. Patients must be fully informed of all relevant diagnostic and therapeutic options and, together with their treating physicians, decide on optimal personalised management strategies.