1
|
Shah FI, MacLeod F, Walker LM. Patient Reported Sexual Adaptation Following Prostate Cancer Treatment: An Analysis of Related Variables and Sexual Outcomes Associated with Sexual Adaptation Styles. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2377-2395. [PMID: 38609584 DOI: 10.1007/s10508-024-02855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 04/14/2024]
Abstract
Sexual concerns after prostate cancer (PCa) treatment are high. Flexible coping is a crucial element to maintaining sexual activity after PCa and improves adaptation outcomes. We aimed to identify potential sexual adaptation styles reported by men following PCa treatment, and to assess relationships among associated variables and outcomes. Individuals (n = 223) with PCa treatment history (e.g., radical prostatectomy [n = 165, 74.0%], external beam radiation [n = 83, 37.2%], hormone/androgen deprivation therapy [n = 83, 37.2%]), completed an online survey assessing sexual variables and processes of sexual adaptation. Using a combination of inductive and deductive coding, open-ended responses were thematically analyzed and grouped into sexual adaptation styles. Factors potentially associated with sexual adaptation styles (e.g., age, perceived partner involvement, co-morbidities, relationship duration, time since PCa treatment, desire for physical affection, depression, relationship adjustment) were tested using multinomial logistic regression. Outcomes of sexual well-being (sexual distress, sexual bother, sexual satisfaction) and relationship adjustment were compared against each sexual adaptation style using a multivariate analysis of variance. Sexual activity status and satisfaction with the adaptation process was assessed across the sexual adaptation styles using a chi-square analysis and post-hoc tests. Two distinct categories were identified: those who had Adapted (n = 185) and those who had Not Adapted (n = 38). Four sexual adaptation styles emerged in the adapted category: Relationship Renegotiation (n = 53) and Sexual Renegotiation (n = 47), which were couples-focused styles, and Acceptance/Resignation (n = 34) and Masturbation/Erection (n = 48), which were individual-focused styles. Participants who could not be categorized as one style, but rather met several, were identified as Mixed (n = 3). Higher rates of depression, lower relationship adjustment, lack of sexual activity, and greater dissatisfaction with the adaptation process were observed for Not Adapted participants. Participants engaged in any type of adaptation style fared better than those who had Not Adapted. Couples-focused styles tended to emphasize renegotiation, including a changed perspective on the expression of the relationship. Perceived direct engagement of the partner facilitated adaptation and emphasized engagement with flexible coping, either through redefining priorities or ways of being sexual. Individual-focused styles emphasized pre-cancer erectile function, and either aimed to return to capacity for penetrative sexual activity or accepted its inaccessibility and largely an abandonment of partnered sexual activity.
Collapse
Affiliation(s)
- Fatima I Shah
- Department of Oncology, University of Calgary, Calgary, AB, T2N 4N2, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Fiona MacLeod
- Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Calgary, AB, Canada
| | - Lauren M Walker
- Department of Oncology, University of Calgary, Calgary, AB, T2N 4N2, Canada.
- Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Calgary, AB, Canada.
- Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, AB, Canada.
- Department of Psychology, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
2
|
Visscher J, Hiwase M, Bonevski B, O'Callaghan M. The association of smoking with urinary and sexual function recovery following radical prostatectomy for localized prostate cancer: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis 2024; 27:222-229. [PMID: 37500786 DOI: 10.1038/s41391-023-00701-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Urinary and sexual dysfunction after radical prostatectomy remains a major cause of morbidity, despite widespread availability of pharmacological and rehabilitative treatments. Smoking is a modifiable risk factor known to correlate with erectile and urinary dysfunction and we hypothesise that smoking cessation may improve post-prostatectomy urinary and sexual function recovery. Our objective is to systematically evaluate literature describing the association of smoking status with urinary and sexual function in men following radical prostatectomy. METHODS In total, 310 unique records were identified through a systematic search of the MEDLINE, EMBASE, Scopus, Web of Science, CINAHL and CENTRAL databases up to February 2023. Nine studies reported smoking status and post radical prostatectomy urinary and sexual function outcomes in men with localized prostate cancer. Risk of bias was assessed and meta-analysis included six studies. RESULTS Smokers had inferior erectile function after prostatectomy compared to non-smokers (OR 0.73, [95% CI 0.56-0.95]) during follow-up, while urinary incontinence was not statistically different between groups (OR 1.20, [95% CI 0.75-1.91]). Smoking cessation improved the EPIC-26 sexual domain score with 6.6 points on average [p = 0.03] to a clinically significant maximum of 12.5 points at 18-24 months. CONCLUSIONS Smoking is associated with impaired sexual function recovery after radical prostatectomy and quitting may improve sexual function >18 months. Current evidence shows no such association for urinary outcomes. Further studies are needed to corroborate findings.
Collapse
Affiliation(s)
- Jordi Visscher
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - Mrunal Hiwase
- Department of Surgery, Central Adelaide Health Network, Adelaide, SA, Australia
| | - Billie Bonevski
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael O'Callaghan
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Medical Centre, Urology Unit, Adelaide, SA, Australia
| |
Collapse
|
3
|
Long term erectile function results of radical perineal prostatectomy. Rev Int Androl 2022; 20:152-157. [PMID: 35331662 DOI: 10.1016/j.androl.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 10/18/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Although many patients are being treated by radical prostatectomy (RP), there is still insufficient information about the changes in long-term erectile function after RP. Our aim is to examine long term, up to 5 year erectile function status of patients after Radical Perineal Prostatectomy (RPP). MATERIALS AND METHODS One hundred and thirty-two patients, who underwent bilateral nerve-sparing Radical Perineal Prostatectomy (RPP) in between January 2012 and January 2017, with preoperative age≤70, prostate volume<80g, transrectal ultrasound (TRUS) guided biopsy Gleason score (GS)<7, prostate specific antigen (PSA) value<10ng/mL, and cT stage≤2 (N0, M0) were included into this study. Exclusion criteria were previous cardiovascular diseases, serious chronic renal and/or hepatic insufficiency, neurological diseases, uncontrolled diabetes mellitus, and severe lung diseases. Patients who received additional treatment (hormonal and/or radiotherapy) after RPP were also excluded from the study group. Erectile function was evaluated before surgery and at postoperative 3rd, 12th, and 60th months. Patients with an "International Index of Erectile Function (IIEF) - 5" score of ≥21 and patients whose IIEF-5 scores were between 16 and 20 but responded as "yes" to the "Sexual Encounter Profile (SEP) - 2" and "SEP-3" questions were accepted as having normal erectile function. RESULTS Out of the 132 patients, 96 (72.7%) of the patients were found to be potent in the first postoperative year. A total of 118 patients were evaluated at the end of 5 years. Eighty seven (73.7%) patients had normal erectile function according to our criteria. DISCUSSION According to the results of our study, short term and long term erectile function outcomes of patients undergoing RPP were favorable and there was no statistically significant difference between short and long term results.
Collapse
|
4
|
Intracavernous Injection of Platelet-Rich Plasma Therapy Enhances Erectile Function and Decreases the Mortality Rate in Streptozotocin-Induced Diabetic Rats. Int J Mol Sci 2022; 23:ijms23063017. [PMID: 35328437 PMCID: PMC8948834 DOI: 10.3390/ijms23063017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 12/24/2022] Open
Abstract
Erectile dysfunction (ED) is an agonizing complication of diabetes mellitus (DM) and it is challenging to treat ED in DM patients. Platelet-rich plasma (PRP) is a unique therapeutic strategy comprising intrinsic growth factors. An attempt was made to explore the potentiality of the PRP treatment in DM-induced ED rats in various groups (control, DM-non-ED, DM-ED, and DM-ED treated with PRP). Streptozotocin (STZ) was used to induce DM in rats. The blood glucose levels of the DM rats were maintained at >300 mg/dl. In the 18-week experiment, survival rate, body weight, intracavernous pressure (ICP) variations, and arterial blood pressure were analyzed. The tissue restoration results were validated by histological, immunofluorescence, and transmission electron microscopic analysis. PRP treatment of DM-ED rats significantly increased all parameters of erectile function compared to pre-treatment of PRP and DM-ED treated with vehicle. The histological results revealed that PRP treatment substantially enhanced the regeneration of myelinated nerves and decreased the atrophy of corporal smooth muscle. Notably, the PRP treatment immensely enhanced the survival rate in post-surgery DM-ED rats. These results indicated certain benefits of PRP treatment in delaying damage and preventing post-surgery complications in DM patients. Hence, PRP treatment is a novel multifactorial strategy for DM-ED patients.
Collapse
|
5
|
Focal prostate cancer therapy in the era of multiparametric MRI: a review of options and outcomes. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-022-00501-0. [PMID: 35246609 DOI: 10.1038/s41391-022-00501-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/10/2022] [Accepted: 01/19/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of prostate cancer focal therapy is to achieve oncologic control while reducing the rate of adverse events associated with whole-gland treatments. Numerous focal therapy modalities are currently available with early data demonstrating highly variable rates of cancer control and preservation of sexual/urinary function. METHODS All English language clinical trial publications evaluating various focal therapies for localized prostate cancer were reviewed. The literature search was limited to studies from the modern era of MRI-guided treatment, as MRI is hypothesized to improve tumor localization and targeting. Primary outcomes were post-treatment cancer-free rates, in-field/out-of-field recurrence rates, and rates of conversion to radical therapy. Secondary outcomes were related to functional status and adverse events. RESULTS Numerous focal therapies were identified with clinical data including high-intensity focused ultrasound, transurethral ultrasound ablation, focal laser ablation, focal cryotherapy, irreversible electroporation, and photodynamic therapy. Recurrence rates among all technologies were low to moderate (0-51%) and rates of freedom from radical treatment were highly variable (46-98%). Rates of erectile dysfunction and incontinence generally ranged from 0 to 44% and 0 to 12%, respectively, with variability between focal therapy modalities. Caution should be exercised when comparing studies as outcomes are strongly associated with patient selection. No individual focal therapy is currently recommended by society guidelines. Randomized controlled trials are ongoing in search of a standard of care. CONCLUSION For localized MRI-visible prostate cancer, early clinical trial data demonstrate that focal therapy can provide good to moderate cancer control while having preferable side effect profiles compared to whole-gland treatments. While current studies do not make head-to-head comparisons between technologies, early data suggest a potential for these technologies to provide adequate cancer control in a well-selected patient population. The oncologic outcomes of some focal therapies appear promising; however, longer-term follow-up data are needed to assess the durability of early outcomes.
Collapse
|
6
|
Miyata Y, Matsuo T, Nakamura Y, Mitsunari K, Ohba K, Sakai H. Pathological Significance of Macrophages in Erectile Dysfunction Including Peyronie's Disease. Biomedicines 2021; 9:biomedicines9111658. [PMID: 34829887 PMCID: PMC8615952 DOI: 10.3390/biomedicines9111658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Tomohiro Matsuo
- Correspondence: ; Tel.: +81-95-819-7340; Fax: +81-95-819-7343
| | | | | | | | | |
Collapse
|
7
|
Hard Times: Prostate Cancer Patients' Experiences with Erectile Aids. J Sex Med 2021; 18:1775-1787. [PMID: 37057492 DOI: 10.1016/j.jsxm.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/25/2021] [Accepted: 07/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Prostate cancer (PCa) treatments commonly lead to erectile difficulties. While the mainstay treatment is erectile aids (EAs) to promote erectile recovery, some men never use these treatments and those whose do use EAs often abandon them in the long-term. AIM The goal of this study was to examine PCa patients' experiences with EAs, to elucidate relationships between experiences with EAs on psychological and sexual well-being, and to explore benefits and drawbacks to EA use. METHODS A self-report survey including validated questionnaires was administered to examine PCa patients' use and perceptions of helpfulness of EAs, and to characterize associations between use, perceived helpfulness, and psychological and sexual well-being. The survey was followed by an open-ended prompt to explore participants' experiences with EAs. OUTCOMES We surveyed 260 North American men, up to 25 years after receiving treatment for PCa. Three groups of patients were observed, including those who used EAs and perceived them to be helpful, those who used EAs and perceived them to be unhelpful, as well as a smaller group of patients who never used EAs. RESULTS Around 80% of the sample were using or had used EAs. Despite the high frequency of use, not all men found EAs helpful. Men who used EAs and found them unhelpful reported poorer psychological and sexual well-being compared to men who didn't use aids or who used EAs but found them helpful. Results indicated both benefits and drawbacks to the use of EAs. Benefits related largely to the efficacy of the aid in promoting erections. A wide range of drawbacks were also reported. CLINICAL IMPLICATIONS Given the negative sexual and psychological impacts associated with using EAs and finding them unhelpful, we suggest that researchers and health care providers should take care to proactively address potential challenges that are common with EA use, and also to consider the risks of failed attempts with EAs. STRENGTHS & LIMITATIONS By using both scaled and open-ended questions, a more nuanced picture of the relative benefits and limitations of EA use within the PCa population is presented. As responses were not mandatory, a subset of participants provided comments about the use of EAs. Additionally, the sample was quite homogenous, with mostly white, American and well-educated participants, so it therefore lacks generalizability to other populations. CONCLUSION This paper illustrates several challenges to EA use, while providing insight into reasons for abandonment of use of EAs. Walker LM, Sears CS, Santos-Iglesias P, et al. Hard Times: Prostate Cancer Patients' Experiences with Erectile Aids. J Sex Med 2021;18:1775-1787.
Collapse
|
8
|
Wu J, Chen Z, Zhong F, Yang W, Ouyang X, Ma X, Zheng S, Wei H. Transplantation of Human Gingiva-Derived Mesenchymal Stem Cells Ameliorates Neurotic Erectile Dysfunction in a Rat Model. Front Bioeng Biotechnol 2021; 9:630076. [PMID: 34235136 PMCID: PMC8255925 DOI: 10.3389/fbioe.2021.630076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/22/2021] [Indexed: 12/23/2022] Open
Abstract
Cavernous nerve injury (CNI) is the main cause of erectile dysfunction (ED) following pelvic surgery. Our previous studies have demonstrated that transplantation of different sources of mesenchymal stem cells (MSCs) was able to alleviate ED induced by CNI in rat models. However, little is known about the therapeutic effects of human gingiva-derived MSCs (hGMSCs) in CNI ED rats. Herein, we injected the hGMSCs around the bilateral major pelvic ganglia (MPG) in a rat model of CNI and evaluated their efficacy. The results showed that treatment of hGMSCs could significantly promote the recovery of erectile function, enhance smooth muscle and endothelial content, restore neuronal nitric oxide synthase (nNOS) expression, and attenuate cell apoptosis in penile tissue. Moreover, penile fibrosis was significantly alleviated after hGMSC administration. In addition, potential mechanism exploration indicated that hGMSCs might exert its functions via skewed macrophage polarity from M1 toward M2 anti-inflammatory phenotype. In conclusion, this study found that transplantation of hGMSCs significantly improved CNI-related ED, which might provide new clues to evaluate their pre-clinical application.
Collapse
Affiliation(s)
- Juekun Wu
- Department of Thyroid and Breast Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zehong Chen
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Fuyan Zhong
- Central Laboratory, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wende Yang
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xi Ouyang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaolei Ma
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Songguo Zheng
- Department of Internal Medicine, Ohio State University College of Medicine and Wexner Medical Center, Columbus, OH, United States
| | - Hongbo Wei
- Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
9
|
Heß J. [Penile rehabilitation after nerve-sparing radical prostatectomy : A comparison of strategies]. Urologe A 2021; 60:1199-1201. [PMID: 34089084 DOI: 10.1007/s00120-021-01554-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Jochen Heß
- Klinik für Urologie, Universitätsklinikum Essen (AöR), Hufelandstraße 55, 45147, Essen, Deutschland.
| |
Collapse
|
10
|
Ye M, Zhao F, Ma K, Zhou K, Ma J, Fu H, Xu Z, Huang W, Wang W, Zhao J, Lv B. Enhanced effects of salidroside on erectile function and corpora cavernosa autophagy in a cavernous nerve injury rat model. Andrologia 2021; 53:e14044. [PMID: 33709426 DOI: 10.1111/and.14044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/10/2021] [Accepted: 02/21/2021] [Indexed: 12/31/2022] Open
Abstract
We explored the efficacy and mechanisms of salidroside treatment for erectile dysfunction induced by bilateral cavernous nerve injury (BCNI). Forty male rats were divided into four groups as follows: sham (cavernous nerves exposed only) (S); BCNI (M); BCNI + rapamycin (M + rapamycin); and BCNI + salidroside (M + salidroside). Erectile function in the rats was measured by intracavernosal pressure. Penile tissue was harvested for transmission electron microscopy, immunohistochemistry, immunofluorescence, Masson's trichrome staining, haematoxylin-eosin staining, TdT-mediated dUTP Nick End Labeling and western blotting. The M group exhibited a decrease in erectile responses and increased apoptosis and fibrosis compared to these in the S group. Meanwhile, nerve content and the penile atrophy index were also decreased in the M group. Treatment with salidroside and rapamycin for 3 weeks partially restored erectile function and significantly attenuated corporal apoptosis, fibrosis, nerve content and penile atrophy in the M group. Moreover, the autophagy level was further enhanced in the M + salidroside group, which was the same as that in the positive observation group (M + rapamycin). Salidroside treatment not only improved erectile function in rats with BCNI, but also inhibited apoptosis and fibrosis and ameliorated the loss of nerve content and endothelial and corpus cavernosum smooth muscle cells by promoting protective autophagy.
Collapse
Affiliation(s)
- Miaoyong Ye
- Department of Urology, The First People's Hospital of Wenling, The Affiliated Wenling Hospital of Wenzhou Medical University, Wenling, China.,The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Fan Zhao
- Department of Urology and Andrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Ke Ma
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Kang Zhou
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jianxiong Ma
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huiying Fu
- Research Institute of Urology and Andrology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zengbao Xu
- Department of Urology, Huzhou Hospital of Traditional Chinese Medicine, Huzhou, China
| | - Wenjie Huang
- Department of Urology and Andrology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Wenzhi Wang
- Department of Urology and Andrology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jianfeng Zhao
- Department of Urology and Andrology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Bodong Lv
- Research Institute of Urology and Andrology, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Urology and Andrology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.,Key Laboratory of Integrative Chinese and Western Medicine for Prevention and Treatment of Sexual Dysfunction of Zhejiang Province, Hangzhou, China
| |
Collapse
|
11
|
Yang J, Jian ZY, Wang J. Phosphodiesterase type-5 inhibitors for erectile dysfunction following nerve-sparing radical prostatectomy: A network meta-analysis. Medicine (Baltimore) 2021; 100:e23778. [PMID: 33663041 PMCID: PMC7909136 DOI: 10.1097/md.0000000000023778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 11/16/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To verify which phosphodiesterase type 5 inhibitors (PDE5is) strategy is better for erectile dysfunction (ED) following nerve-sparing radical prostatectomy (NSRP). METHODS This systematic literature search was conducted in MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials database to identify eligible studies from the startup of these databases to 1 November, 2019. The ED recovery rate was the main outcome. Traditional pair-wise meta-analysis and multivariate random-effects network meta-analysis (NMA) were performed to explore direct and indirect comparisons, respectively. The surface under the cumulative ranking (SUCRA) probabilities was used to evaluate the efficacy of treatments. RESULTS A total of 14 randomized controlled trials with four kinds of PDE5is were included. Further pooled evidence suggested that PDE5is followed by NSRP had a benefit for penile rehabilitation compared to placebo using traditional pair-wise meta-analyses. Our NMA showed that Avanafil 200 mg on demand might be most likely to be the best treatment option according to the first rank of SUCRA both in NMA (SUCRA 83.5) and sensitivity analysis (SUCRA 90.2). CONCLUSION Avanafil 200 mg on demand has the highest probability of being the best intervention among PDE5is in treating ED following NSRP. However, more randomized controlled trials are needed to validate this in consideration of the published data regarding Avanafil is relatively small scale.
Collapse
Affiliation(s)
- Jie Yang
- Department of Urology, Chengdu First People's Hospital
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guoxue Xiang, Chengdu, Sichuan, P.R.C
| | - Zhong-Yu Jian
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guoxue Xiang, Chengdu, Sichuan, P.R.C
- West China Biomedical Big Data Center, Sichuan University, Chengdu, China
| | - Jia Wang
- Department of Urology, Institute of Urology (Laboratory of Reconstructive Urology), West China Hospital, Sichuan University, Guoxue Xiang, Chengdu, Sichuan, P.R.C
| |
Collapse
|
12
|
Bhat KRS, Raghunath SK, Srivatsa N, Tejus C, Vishruth K, Kumar RA. Outcomes of Minimally Invasive Radical Prostatectomy-a Contemporary Review. Indian J Surg Oncol 2020; 11:580-588. [PMID: 33299276 PMCID: PMC7714884 DOI: 10.1007/s13193-020-01125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022] Open
Abstract
Prostatectomy has been widely accepted as a treatment option for prostate cancer and can be performed via an open, laparoscopic, and robotic approach. The outcomes following prostatectomy are primarily sub-grouped into oncological and functional outcomes. Oncological outcomes have been comparable in the above three surgical modalities. However, the robotic platform seems to have a better functional outcome compared to open prostatectomy. The data on the outcome of the laparoscopic approach is scarce and is not widely performed due to technical difficulty. With experience continence outcomes have reached a plateau in many robotic series, however, the potency outcome is the real Achilles tendon of this procedure. Many factors influence potency outcomes but the amount and quality of nerve-sparing is one factor that is under a surgeon's control and it improves with experience.
Collapse
Affiliation(s)
| | - S. K. Raghunath
- Trustwell Hospital, No 5, J C Road, Bangalore, 560002 India
- HCG Hospital, Bengaluru, Karnataka India
| | | | - C. Tejus
- HCG Hospital, Bengaluru, Karnataka India
| | | | | |
Collapse
|
13
|
Standardized reporting for sexual function following prostate cancer treatment. Int J Impot Res 2020; 32:549-550. [DOI: 10.1038/s41443-020-0251-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 12/25/2022]
|
14
|
Walker LM, Santos-Iglesias P. On the Relationship Between Erectile Function and Sexual Distress in Men with Prostate Cancer. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:1575-1588. [PMID: 32072396 DOI: 10.1007/s10508-019-01603-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 06/10/2023]
Abstract
Erectile difficulties are common after prostate cancer (PCa) treatment and are associated with sexual distress. However, the relationship between erectile function and sexual distress has yet to be carefully examined. This study had three goals: (1) examine the relationship between erectile function and sexual distress; (2) determine groups of men based on erectile function and sexual distress; and (3) examine the psychosexual characteristics of these groups. A cross section of 233 sexually active men after PCa treatment (age M = 64.90 years, SD = 7.50) completed an online survey containing demographic, health, and sexuality and relationship questionnaires. The relationship between erectile function and sexual distress was curvilinear. Four groups of men were found: good erectile function and low sexual distress, poor erectile function and high sexual distress, but also good erectile function yet high sexual distress, and poor erectile function and low sexual distress. Regardless of erectile function, men with greater sexual distress were more depressed, reported additional sexual concerns, placed less value on sex, were less sexually satisfied, and used protective buffering communication more frequently. They were also less likely to be satisfied with their adaptation to sexual changes and less likely to have found a solution to those changes. The relationship between erectile function and sexual distress is complex, characterized by a wide array of responses to erectile function (high and low distress) and multiple correlates of sexual distress. These results broaden the concept of sexual recovery after PCa treatment, which may assist clinicians and researchers to better address sexual problems after PCa treatment.
Collapse
Affiliation(s)
- Lauren M Walker
- Tom Baker Cancer Centre-Holy Cross Site, Division of Psychosocial Oncology, Department of Oncology, University of Calgary, 2202 2nd Street SW, Calgary, AB, T2S 3C1, Canada.
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada.
| | | |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Radical treatments for prostate cancer are associated with significant morbidity, including incontinence and erectile dysfunction. Advances in the field of prostate MRI and desire to reduce treatment morbidities have led to a rapid growth in focal treatments for prostate cancer. Here, we review novel focal prostate cancer treatments and their associated recent clinical data, with a particular focus on data reported within the last 24 months. RECENT FINDINGS High-intensity focal ultrasound, focal laser ablation, irreversible electroporation, focal cryotherapy, and photodynamic therapy have been used as treatment modalities for localized prostate cancer treatment. Despite the great variety of treatment techniques, each of these modalities is characterized by a significant rate of prostate cancer persistence within treatment zones (6-50%) and the presence of residual cancer within the prostate on rebiopsy (24-49%). These treatments, however, are associated with very low rates of high-grade complications, rare incontinence, and only mild or transient reductions in erectile function. The most common adverse events are urinary tract infections, hematuria, and urinary retention. SUMMARY Prostate cancer focal therapy is an attractive option for well-selected patients because of its low complication profile; however, long-term oncologic outcome is still lacking and early recurrence rates are high, limiting the ability of most urologic associations from endorsing its routine use.
Collapse
|
16
|
The association between gut microbiome and erectile dysfunction: a community-based cross-sectional study in Japan. Int Urol Nephrol 2020; 52:1421-1428. [PMID: 32193686 DOI: 10.1007/s11255-020-02443-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/10/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE We investigated the gut microbiome in subjects with erectile dysfunction (ED) in a community-based population. METHODS This cross-sectional study surveyed comprehensive health status in 408 men who participated in the Iwaki Health Promotion Project in 2015 in Hirosaki, Japan. The gut microbiome was assessed by tag sequencing of the 16S rRNA gene, which we extracted from fecal samples. Erectile function was evaluated with the five-item International Index of Erectile Function (IIEF-5), and the men were divided into two groups: low-IIEF-5 (≤ 16) and high-IIEF-5 (> 16). Of those, we selected age-adjusted 192 men (96 each) for analysis. We investigated the association of gut microbiome with IIEF-5 between the two groups. RESULTS Median age was 50 years. No significant difference was seen in the history of hypertension, DM, CKD, and CVD between the low-IIEF-5 and high-IIEF-5 groups. However, the relative abundance of Alistipes (related with anti-inflammation) and Clostoridium XVIII (related with bowel movement) was significantly different between the two groups. Multivariate logistic analysis demonstrated that the relative abundance of Clostridium XVIII (OR, 2.06; 95% CI, 1.20-3.55, P = 0.009) and Alistipes (OR, 0.81; 95% CI, 0.66-0.99, P = 0.040) and, with an IPSS ≥ 8, were independent factors for low IIEF-5. CONCLUSION We observed significant association between the low-IIEF-5 and high-IIEF-5 groups in Alistipes and Clostoridium XVIII. Further study is necessary to access the causal relationship between the gut microbiome and ED.
Collapse
|
17
|
Haney NM, Talwar S, Akula PK, Reddy AG, Pema GS, Ninh TV, Rezk BM, Heidari Z, Bouljihad MT, Sikka SC, John V, Abdel-Mageed AB, Hellstrom WJG. Insulin-Like Growth Factor-1-Loaded Polymeric Poly(Lactic-Co-Glycolic) Acid Microspheres Improved Erectile Function in a Rat Model of Bilateral Cavernous Nerve Injury. J Sex Med 2020; 16:383-393. [PMID: 30846112 DOI: 10.1016/j.jsxm.2018.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/20/2018] [Accepted: 12/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have documented improvement in erectile function after bilateral cavernous nerve injury (BCNI) in rats with the use of pioglitazone. Our group determined this improvement to be mediated by the insulin-like growth factor-1 (IGF-1) pathway. AIM To eliminate the systemic effects of pioglitazone and evaluate the local delivery of IGF-1 by polymeric microspheres after BCNI in the rat. METHODS Male Sprague-Dawley rats aged 10-12 weeks were assigned at random to 3 groups: sham operation with phosphate buffered saline (PBS)-loaded microspheres (sham group), crush injury with PBS-loaded microspheres (crush group), and crush injury with IGF-1-loaded microspheres (IGF-1 group). Poly(lactic-co-glycolic) acid microspheres were injected underneath the major pelvic ganglion (MPG). IGF-1 was released at approximately 30 ng/mL/day per MPG per rat. OUTCOMES Functional results were demonstrated by maximal intracavernosal pressure (ICP) normalized to mean arterial pressure (MAP). Protein-level analysis data of IGF-1 receptor (IGF-1R), extracellular signal-regulated kinase (ERK)-1/2, and neuronal nitric oxide synthase (nNOS) were obtained using Western blot analysis and immunohistochemistry for both the cavernosal tissue and the MPG and cavernous nerve (CN). RESULTS At 2 weeks after nerve injury, animals treated with IGF-1 demonstrated improved erectile functional recovery (ICP/MAP) at all voltages compared with BCNI (2.5V, P = .001; 5V, P < .001; 7.5V, P < .001). Western blot results revealed that up-regulation of the IGF-1R and ERK-1/2 in both the nervous and erectile tissue was associated with improved erectile function recovery. There were no significant between-group differences in nNOS protein levels in cavernosal tissue, but there was an up-regulation of nNOS in the MPG and CN. Immunohistochemistry confirmed these trends. CLINICAL TRANSLATION Local up-regulation of the IGF-1R in the neurovascular bed at the time of nerve injury may help men preserve erectile function after pelvic surgery, such as radical prostatectomy, eliminating the need for systemic therapy. STRENGTHS & LIMITATIONS This study demonstrates that local drug delivery to the MPG and CN can affect the CN tissue downstream, but did not investigate the potential effects of up-regulation of the growth factor receptors on prostate cancer tissue. CONCLUSION Stimulating the IGF-1R at the level of the CN has the potential to mitigate erectile dysfunction in men after radical prostatectomy, but further research is needed to evaluate the safety of this growth factor in the setting of prostate cancer. Haney NM, Talwar S, Akula PK, et al. Insulin-Like Growth Factor-1-Loaded Polymeric Poly(Lactic-Co-Glycolic) Acid Microspheres Improved Erectile Function in a Rat Model of Bilateral Cavernous Nerve Injury. J Sex Med 2019;16:383-393.
Collapse
Affiliation(s)
- Nora M Haney
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sudha Talwar
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Prasad K Akula
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Amit G Reddy
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Geoffroy Sanga Pema
- Department of Natural Sciences, Southern University at New Orleans, New Orleans, LA, USA
| | - Thien V Ninh
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Bashir M Rezk
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA; Department of Natural Sciences, Southern University at New Orleans, New Orleans, LA, USA
| | - Zahra Heidari
- Department of Biochemical Engineering, Tulane University, New Orleans, LA, USA
| | - Mostafa T Bouljihad
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, LA, USA
| | - Suresh C Sikka
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Vijay John
- Department of Biochemical Engineering, Tulane University, New Orleans, LA, USA
| | - Asim B Abdel-Mageed
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA.
| |
Collapse
|
18
|
Okamoto T, Hatakeyama S, Imai A, Konishi S, Okita K, Yamamoto H, Tobisawa Y, Yoneyama T, Mori K, Yoneyama T, Hashimoto Y, Nakaji S, Ohyama C. The Relationship Between Gait Function and Erectile Dysfunction: Results from a Community-Based Cross-Sectional Study in Japan. J Sex Med 2019; 16:1922-1929. [DOI: 10.1016/j.jsxm.2019.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/14/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
|
19
|
Siltari A, Riikonen J, Fode M, Murtola TJ. Effects of Preoperative Atorvastatin Treatment On Erectile Function After Radical Prostatectomy: Results From a Subgroup of ESTO1, a Randomized, Double-Blind, Placebo-Controlled Study. J Sex Med 2019; 16:1597-1605. [PMID: 31405764 DOI: 10.1016/j.jsxm.2019.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Erectile dysfunction is common after radical prostatectomy because of damage to the cavernous nerves. Thus, it is important to identify new ways to avoid this problem. For example, statins have shown positive effects on erectile function and may have anti-inflammatory effects that improve recovery after surgery. AIM The aim of this exploratory analysis of a subgroup from ESTO1, a randomized, double-blind, placebo-controlled study, was to evaluate the preoperative use of atorvastatin on erectile function after radical prostatectomy. METHOD Patients were randomized to either 80 mg atorvastatin or placebo daily before undergoing radical prostatectomy from study inclusion to the day of surgery. Altogether 118 men with prostate cancer and scheduled for radical prostatectomy were asked to fill out the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire before surgery and at 3, 6, 9, and 12 months after surgery. MAIN OUTCOME MEASUREMENTS The study was exploratory, with the main outcome being the overall difference between IIEF-5 scores in the 2 groups at 12 months. Several hypotheses generating sub-analyses were conducted. RESULTS Overall, 85% filled out the IIEF-5 questionnaire before their operation and 85%, 81%, 78%, and 78% completed it at 3, 6, 9, and 12 months follow-up, respectively. 52% of men had information available at all time points. There were no statistically significant differences between the groups at baseline in either erectile function, comorbidities, or tumor characteristics. The median duration of use of atorvastatin and placebo before surgery was 27 and 25 days, respectively. Preoperative atorvastatin treatment had no statistically significant effect on erectile function after prostatectomy as compared with placebo, although IIEF-5 scores were higher at all time points in the statin arm. Furthermore, atorvastatin treatment compared with placebo improved IIEF-5 scores at 12 months after surgery when the cavernous nerves were at least partially intact bilaterally (P < .04, n = 65); however, after full bilateral or unilateral nerve-sparing, the difference was not statistically significant. CLINICAL IMPLICATION Short-term statin treatment did not improve recovery of erectile function after prostatectomy; however, further studies are needed before final conclusions. STRENGTHS & LIMITATIONS This was a randomized placebo-controlled study. Original ESTO1 study was designed to detect a difference in prostate cancer biomarkers. CONCLUSION Short-term atorvastatin treatment before radical prostatectomy had no statistically significant effect on the recovery of erectile functions in a non-selected cohort of patients undergoing radical prostatectomy. Further studies will be needed to clarify the role of long-term atorvastatin use before and after prostatectomy. Siltari A, Riikonen J, Fode M, et al. Effects of Preoperative Atorvastatin Treatment On Erectile Function After Radical Prostatectomy: Results From a Subgroup of ESTO1, a Randomized, Double-Blind, Placebo-Controlled Study. J Sex Med 2019;16:1597-1605.
Collapse
Affiliation(s)
- Aino Siltari
- Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Jarno Riikonen
- Tampere University Hospital, Department of Urology, Tampere, Finland
| | - Mikkel Fode
- Herlev and Gentofte Hospital, Department of Urology, Herlev, Denmark
| | - Teemu J Murtola
- Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland; Tampere University Hospital, Department of Urology, Tampere, Finland; Seinäjoki Central Hospital, Department of Surgery, Seinäjoki, Finland
| |
Collapse
|
20
|
Kim SW, Lee J, Park J, Chai JS, Oh S, Paick JS, Cho MC. Combination of LIM-kinase 2 and Jun Amino-terminal Kinase Inhibitors Improves Erectile Function in a Rat Model of Cavernous Nerve Injury. Urology 2019; 131:136-143. [PMID: 31202856 DOI: 10.1016/j.urology.2019.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/24/2019] [Accepted: 06/03/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine if combined administration of LIMK2 and JNK inhibitors in a rat model of erectile dysfunction induced by cavernosal nerve (CN) injury could restore erectile function by suppressing both cavernosal apoptosis and fibrosis via rectification of molecular pathways related to the structural alterations. METHODS Sixty 12-week-old male Sprague-Dawley rats were categorized into 4 groups: (1) Sham-surgery (Sham) group, (2) CN-crush-injury (CNCI), (3) CNCI group (CNCI+L+1.0J) treated with a combination of 10.0 mg/kg LIMK2-inhibitors and low-dose (1.0 mg/kg) JNK-inhibitors, and (4) CNCI group (CNCI+L+10.0J) treated with a combination of 10.0 mg/kg LIMK2-inhibitors and a high dose (10.0 mg/kg) of JNK-inhibitors. Ten days after surgery, erectile response, histological-studies, and Western-blot was investigated. RESULTS The CNCI group showed a reduced maximal ICP/MAP or AUC/MAP, decreased immunohistochemical-staining of α-SMA, decreased SM/collagen ratio, increased phospho-cJun-positive apoptotic cells, increased phospho-LIMK2-positive fibroblasts, increased cJun-phosphorylation, increased LIMK2/Cofilin-phosphorylation, decreased Bcl-2/Bax ratio, and increased protein-expression of fibronectin, compared to the Sham group. Both the CNCI+L+1.0J and CNCI+L+10.0J groups showed improvements in erectile-responses, content of cavernosal α-SMA, number of phospho-cJun-positive apoptotic cells, Bcl-2/Bax ratio and cJun phosphorylation. Their improvements in the CNCI+L+10.0J group showed a tendency to be greater than those in the CNCI+L+1.0J group. Also, in the 2 treatment groups, rectification of SM/collagen ratio, number of phospho-LIMK2-positive fibroblasts, LIMK2/Cofilin-phosphorylation, and protein-expression of fibronectin was observed. CONCLUSION This study suggests that combined inhibition of JNK and LIMK2 may improve erectile function by suppressing cavernosal apoptosis and fibrosis via restoration of cJun/Bcl-2/Bax and LIMK2/Cofilin pathways at 10 days after CN injury.
Collapse
Affiliation(s)
- Soo Woong Kim
- Department of Urology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Junghoon Lee
- Department of Urology, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Juhyun Park
- Department of Urology, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Ji Sun Chai
- Department of Urology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Jae-Seung Paick
- Department of Urology, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Min Chul Cho
- Department of Urology, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea.
| |
Collapse
|
21
|
Pioglitazone's beneficial effects on erectile function preservation after cavernosal nerve injury in the rat are negated by inhibition of the insulin-like growth factor-1 receptor: a preclinical study. Int J Impot Res 2018; 31:1-8. [PMID: 30072768 DOI: 10.1038/s41443-018-0054-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/12/2018] [Accepted: 06/16/2018] [Indexed: 11/08/2022]
Abstract
To determine if the insulin-like growth factor-1 (IGF-1) pathway is involved in the improvement in erectile function recovery in rats after nerve crush injury treated with pioglitazone (Pio). Sprague-Dawley rats were divided into four groups. The first group received sham operation (n = 5). The second group underwent bilateral cavernous nerve injury (BCNI, n = 7). The third group received BCNI and Pio treatment (BCNI + Pio, n = 7), whereas the fourth group underwent BCNI with Pio treatment and IGF-1 inhibition (BCNI + Pio + JB-1, n = 7). The IGF-1 receptor (IGF-1R) was inhibited by JB-1, a small molecular antagonist of the receptor. After 14 days of treatment, erectile function was measured via intracorporal pressure normalized to mean arterial pressure (ICP/MAP) and the major pelvic ganglion and cavernous nerve harvested for western blot and immunohistochemistry (IHC) of phosphorylated-IGF-1Rβ (p-IGF-1Rβ), phosphorylated-ERK1/2 (p-ERK1/2), and neuronal NOS (nNOS). BCNI + Pio animals exhibited improvements in ICP/MAP, similar to Sham animals, and BCNI + Pio + JB-1 rats demonstrated a reduced ICP/MAP similar to BCNI-only rats at all measured voltages. Western blot results showed upregulation of p-IGF-1Rβ was observed in the BCNI + Pio group. Low levels of p-ERK1/2 were seen in the JB-1-treated animals. The immunoblot results were supported by IHC findings. Intense IHC staining of nNOS was detected in the BCNI + Pio group. The group treated with JB-1 showed minimal protein expression of p-ERK1/2, nNOS, and p-IGF-1Rβ. Pio improves erectile function in rats undergoing BCNI via an IGF-1-mediated pathway.
Collapse
|
22
|
Spontaneous Regeneration of Nerve Fiber and Irreversibility of Corporal Smooth Muscle Fibrosis After Cavernous Nerve Crush Injury: Evidence From Serial Transmission Electron Microscopy and Intracavernous Pressure. Urology 2018; 118:98-106. [DOI: 10.1016/j.urology.2017.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/22/2017] [Accepted: 10/05/2017] [Indexed: 12/24/2022]
|
23
|
Abbou CC, Abdelbary A. Neuro-anatomic basis of potency recovery after radical prostatectomy: an expert's point of view. MINERVA CHIR 2018; 74:28-36. [PMID: 30037182 DOI: 10.23736/s0026-4733.18.07848-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION From 25% to 95% of those who have undergone radical prostatectomy (RP) report erectile dysfunction 12 months after surgery. We attempt a review of the available evidence regarding the anatomy of the cavernous nerves and the surgical refinements to enhance sexual function recovery after surgery. EVIDENCE ACQUISITION The PubMed/Medline database was searched. Duplicates were removed. Studies were selected by the authors according to the aim of the present review. EVIDENCE SYNTHESIS The cavernous nerves are deemed responsible for erections, but their exact function is still a matter of debate. They do not necessarily have the same distribution in all individuals: in most the cases, these nerves are located posterolaterally, however, it is not uncommon to find some fibers on the anterolateral aspects of the prostate, especially towards the apex. Several technical strategies were proposed in order to intraoperatively identify and spare the neurovascular bundles: despite all efforts, clinical results are still only partially satisfying. CONCLUSIONS The recovery of potency is one of the most unpredictable outcomes after RP. The advent of the robotic surgical system seems to have brought a trend towards a faster recovery of erectile function.
Collapse
Affiliation(s)
- Clément C Abbou
- Department of Urology, Henri Mondor Hospital, Créteil, France -
| | - Ahmed Abdelbary
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| |
Collapse
|
24
|
Fode M, Østergren PB, Jensen CFS, Jakobsen H, Sønksen J. Treatment effects of phosphodiesterase-5 inhibitors may improve with time following nerve-sparing radical prostatectomy. Scand J Urol 2017; 52:108-110. [DOI: 10.1080/21681805.2017.1387603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mikkel Fode
- Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark
| | | | | | - Henrik Jakobsen
- Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Jens Sønksen
- Department of Urology, Herlev and Gentofte Hospital, Herlev, Denmark
| |
Collapse
|
25
|
Alzweri LM, Burnett AL. PDE-5 inhibitors should be used post radical prostatectomy as erection function rehabilitation? | Opinion: Yes. Int Braz J Urol 2017; 43:385-389. [PMID: 28520336 PMCID: PMC5462127 DOI: 10.1590/s1677-5538.ibju.2017.03.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Laith M Alzweri
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute and Department of Urology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
26
|
Caillet K, Lipsker A, Alezra E, De Sousa P, Pignot G. [Surgical approach and sexual outcomes after radical prostatectomy]. Prog Urol 2017; 27:283-296. [PMID: 28392432 DOI: 10.1016/j.purol.2017.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 01/23/2017] [Accepted: 03/07/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Radical prostatectomy is curative surgical treatment of choice for localized prostate cancer. The objectives are cancer control, preservation of continence and preservation of sexuality, the combination of the three constituting the Trifecta. OBJECTIVE The objective of this study was to assess, through the analysis of the literature, the sexual outcomes according to surgical approach: radical prostatectomy by laparotomy (PRL), laparoscopic radical prostatectomy (PRLa) and laparoscopic robot-assisted radical prostatectomy (PRLaRA), when nerve sparing was practiced. METHODS An exhaustive and retrospective review of literature was conducted using the Pubmed search with the following keywords: "Prostatic Neoplasms" [Mesh], "Prostatectomy" [Mesh], "Erectile Dysfunction" [Mesh], "Robotics" [Mesh], "Laparoscopy" [Mesh], Nerve sparing. SELECTION CRITERIA The selected articles were prospective or retrospective series including more than 200 patients, randomized trials and meta-analyses published between 1990 and 2014. RESULTS A total of 21 prospective studies (6 on PRL, 4 on PRLa and 11 on PRLaRA), 12 retrospective studies (6 on PRL, 1 on PRLa and 5 on PRLaRA), 2 randomized controlled trial and 3 meta-analyses were selected from 1992 to 2013. There was no evidence of the superiority of one surgical approach compared to others in terms of sexuality. LIMITS Articles with level 1 of scientific evidence have discordant results, due to heterogeneity in the assessment criteria of postoperative sexual function. CONCLUSION According to our knowledge, there is currently no difference in terms of sexual outcomes between PRL, PRLA and PRLaRA approaches.
Collapse
Affiliation(s)
- K Caillet
- Service d'urologie-transplantation, université de Picardie-Jules-Verne, CHU Amiens-Picardie, avenue René-Laennec, 80054 Amiens cedex 1, France.
| | - A Lipsker
- Service d'urologie-transplantation, université de Picardie-Jules-Verne, CHU Amiens-Picardie, avenue René-Laennec, 80054 Amiens cedex 1, France
| | - E Alezra
- Service d'urologie-transplantation, université de Picardie-Jules-Verne, CHU Amiens-Picardie, avenue René-Laennec, 80054 Amiens cedex 1, France
| | - P De Sousa
- Service d'urologie-transplantation, université de Picardie-Jules-Verne, CHU Amiens-Picardie, avenue René-Laennec, 80054 Amiens cedex 1, France
| | - G Pignot
- Service d'urologie, chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte Marguerite, 13009 Marseille, France
| |
Collapse
|
27
|
Salonia A, Adaikan G, Buvat J, Carrier S, El-Meliegy A, Hatzimouratidis K, McCullough A, Morgentaler A, Torres LO, Khera M. Sexual Rehabilitation After Treatment For Prostate Cancer—Part 2: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017; 14:297-315. [DOI: 10.1016/j.jsxm.2016.11.324] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 11/15/2016] [Accepted: 11/19/2016] [Indexed: 01/06/2023]
|
28
|
The Long-Term Effect of Radical Prostatectomy on Erectile Function, Urinary Continence, and Lower Urinary Tract Symptoms: A Comparison to Age-Matched Healthy Controls. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9615080. [PMID: 28261619 PMCID: PMC5316428 DOI: 10.1155/2017/9615080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022]
Abstract
Introduction. To analyze the impact of radical prostatectomy (RPE) on erectile function and lower urinary tract function in comparison to age-matched healthy men. Materials and Methods. Patients who underwent radical retropubic prostatectomy completed questionnaires containing the IIEF-5, the Bristol female LUTS questionnaire, and the International Prostate Symptom Score (IPSS). Results. Patients after RPE were included (n = 363). Age-matched healthy men (n = 363) were included. The mean IIEF-5 of patients aged 61-70 yrs after RPE was 10.4 ± 6.6 versus 18.8 ± 5.3 in the control cohort; the respective values for men aged 71-80 yrs after RPE were 7.2 ± 6.5 versus 13.6 ± 7.7 in the control cohort. Urinary incontinence after RPE was reported in 41.9% (61-70 years) and 37.7% (71-80) versus 7.5% and 15.1% in the control cohort. The mean IPSS of patients after RPE aged 61-70 yrs was 5.0 ± 4.4 versus 5.5 ± 4.9 in the control cohort; the respective values for men aged 71-80 yrs were 6.0 ± 4.9 versus 7.5 ± 5.7 in the healthy cohort. Conclusions. The negative effect of radical prostatectomy on erectile and urinary incontinence remains substantial. The physiologically declining erectile and lower urinary tract function with ageing reduces the difference between healthy men and those after surgery. Healthy men have a higher IPSS presumably due to the presence of bladder outlet obstruction.
Collapse
|
29
|
Clavell-Hernández J, Wang R. The controversy surrounding penile rehabilitation after radical prostatectomy. Transl Androl Urol 2017; 6:2-11. [PMID: 28217445 PMCID: PMC5313301 DOI: 10.21037/tau.2016.08.14] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Radical prostatectomy (RP) techniques have been refined in the last few decades. Despite nerve-sparing surgery, erectile dysfunction (ED) still seems to be affecting more than half of patients undergoing RP. Penile rehabilitation consists of understanding the mechanisms that affect erectile function (EF) and utilizing pharmacologic agents, devices or interventions to promote male sexual function before and after any insult to the penile erectile physiologic axis. There currently is a limited amount of clinical trials that assess treatments with the goal of recovering post-prostatectomy EF. The goal of this article is to assess a contemporary series of trials that study penile rehabilitation. Although the current evidence lacks to prove its irrefutable effectiveness, advancements in research and technology forecast a promising future in penile rehabilitation management.
Collapse
Affiliation(s)
- Jonathan Clavell-Hernández
- Division of Urology, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Run Wang
- Division of Urology, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA;; University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
30
|
Fode M, Serefoglu EC, Albersen M, Sønksen J. Sexuality Following Radical Prostatectomy: Is Restoration of Erectile Function Enough? Sex Med Rev 2017; 5:110-119. [DOI: 10.1016/j.sxmr.2016.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/04/2016] [Accepted: 07/09/2016] [Indexed: 12/25/2022]
|
31
|
|
32
|
Impact of Tissue Sealing Sheet on Erectile Dysfunction in a Rat Model of Nerve-Sparing Radical Prostatectomy. J Sex Med 2016; 13:1448-54. [DOI: 10.1016/j.jsxm.2016.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/15/2022]
|
33
|
Liao CH, Wu YN, Chen BH, Lin YH, Ho HO, Chiang HS. Neuroprotective effect of docosahexaenoic acid nanoemulsion on erectile function in a rat model of bilateral cavernous nerve injury. Sci Rep 2016; 6:33040. [PMID: 27625175 PMCID: PMC5021993 DOI: 10.1038/srep33040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/18/2016] [Indexed: 12/27/2022] Open
Abstract
There is an unmet need for treatment of erectile dysfunction resulting from radical prostatectomy and cavernous nerve (CN) injury. Given the neuroprotective properties of docosahexaenoic acid (DHA), we investigated its effect on penile functional and structural recovery in a rat model of bilateral cavernous nerve injury. Rats were subject to CN injury and received intraperitoneal administration of either vehicle or a DHA nanoemulsion (nano-DHA) at 10, 50, or 250 μg/kg. Functional testing and histological analyses were performed at 28 days post-injury. The maximum intracavernosal pressure (ICP) and other measures of erectile function were significantly higher in the nano-DHA groups than in the vehicle group (p < 0.05). The ratio of area of expression of neuronal nitric oxide synthase (nNOS)/β-III tubulin, numbers of axon and smooth muscle cell content were significantly higher in the 50 μg/kg nano-DHA group than in the vehicle group (p < 0.05). A qualitative increase in the smooth muscle cells/collagen ratio and decrease in apoptosis was observed in the nano-DHA groups relative to the vehicle group: however, these differences were not statistically significant. Our data demonstrate that nano-DHA, particularly the 50 μg/kg regimen, improves erectile function after bilateral CN injury in rats by neuroprotection and other anti-fibrotic and anti-apoptotic mechanisms.
Collapse
Affiliation(s)
- Chun-Hou Liao
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,PhD Program in Nutrition &Food science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yi-No Wu
- PhD Program in Nutrition &Food science, Fu Jen Catholic University, New Taipei City, Taiwan.,Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Bin-Huei Chen
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan.,Department of Food Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ying-Hung Lin
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Hsiu-O Ho
- School of Pharmacy, Taipei Medical University, Taipei City, Taiwan
| | - Han-Sun Chiang
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.,PhD Program in Nutrition &Food science, Fu Jen Catholic University, New Taipei City, Taiwan.,Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City, Taiwan
| |
Collapse
|
34
|
Haahr MK, Jensen CH, Toyserkani NM, Andersen DC, Damkier P, Sørensen JA, Lund L, Sheikh SP. Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial. EBioMedicine 2016; 5:204-10. [PMID: 27077129 PMCID: PMC4816754 DOI: 10.1016/j.ebiom.2016.01.024] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 01/12/2016] [Accepted: 01/18/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer in men, and radical prostatectomy (RP) often results in erectile dysfunction (ED) and a substantially reduced quality of life. The efficacy of current interventions, principal treatment with PDE-5 inhibitors, is not satisfactory and this condition presents an unmet medical need. Preclinical studies using adipose-derived stem cells to treat ED have shown promising results. Herein, we report the results of a human phase 1 trial with autologous adipose-derived regenerative cells (ADRCs) freshly isolated after a liposuction. METHODS Seventeen men suffering from post RP ED, with no recovery using conventional therapy, were enrolled in a prospective phase 1 open-label and single-arm study. All subjects had RP performed 5-18 months before enrolment, and were followed for 6 months after intracavernosal transplantation. ADRCs were analyzed for the presence of stem cell surface markers, viability and ability to differentiate. Primary endpoint was the safety and tolerance of the cell therapy while the secondary outcome was improvement of erectile function. Any adverse events were reported and erectile function was assessed by IIEF-5 scores. The study is registered with ClinicalTrials.gov, NCT02240823. FINDINGS Intracavernous injection of ADRCs was well-tolerated and only minor events related to the liposuction and cell injections were reported at the one-month evaluation, but none at later time points. Overall during the study period, 8 of 17 men recovered their erectile function and were able to accomplish sexual intercourse. Post-hoc stratification according to urinary continence status was performed. Accordingly, for continent men (median IIEFinclusion = 7 (95% CI 5-12), 8 out of 11 men recovered erectile function (IIEF6months = 17 (6-23)), corresponding to a mean difference of 0.57 (0.38-0.85; p = 0.0069), versus inclusion. In contrast, incontinent men did not regain erectile function (median IIEF1/3/6 months = 5 (95% CI 5-6); mean difference 1 (95% CI 0.85-1.18), p > 0.9999). INTERPRETATION In this phase I trial a single intracavernosal injection of freshly isolated autologous ADRCs was a safe procedure. A potential efficacy is suggested by a significant improvement in IIEF-5 scores and erectile function. We suggest that ADRCs represent a promising interventional therapy of ED following prostatectomy. FUNDING Danish Medical Research Council, Odense University Hospital and the Danish Cancer Society.
Collapse
Key Words
- ADRC, adipose-derived regenerative cells
- Adipose-derived regenerative cells
- Adipose-derived stem cells
- Adipose-derived stromal vascular fraction
- BMI, body mass index
- CFU-F, fibroblastoid colony forming units
- Cell therapy
- Clinical trial
- ED, erectile dysfunction
- EHS, erection hardness score
- Erectile dysfunction
- ICIQ-UI SF, incontinence questionnaire – urinary incontinence – short form questionnaire
- IIEF-5, international index of erectile function-5
- LUTS, lower urinary tract symptoms
- NSAID, nonsteroidal antiinflammatory drug
- PDE-5, phosphodiesterase-5
- RP, radical prostatectomy
- SVF, stromal vascular fraction
Collapse
Affiliation(s)
- Martha Kirstine Haahr
- Department of Urology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Charlotte Harken Jensen
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark
| | - Navid Mohamadpour Toyserkani
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Ditte Caroline Andersen
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Per Damkier
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Jens Ahm Sørensen
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Lars Lund
- Department of Urology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, 5000 Odense C, Denmark
| | - Søren Paludan Sheikh
- Laboratory of Molecular and Cellular Cardiology, Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark; Institute of Molecular Medicine, University of Southern Denmark, Winsloewparken 21 3rd, 5000 Odense C, Denmark; The Danish Centre for Regenerative Medicine (www.danishcrm.com); Odense University Hospital, Denmark
| |
Collapse
|