Potential applications of low-energy shock waves in functional urology

Radial Type Low-Intensity Extracorporeal Shockwave Therapy Enhances Penile Microvascular Perfusion in an Aging Rat Model: A Novel Interventional Strategy to Treat Erectile Dysfunction

PURPOSE

Physiological aging is associated with microvascular dysfunction, including in the penis, and this may contribute to age-related erectile dysfunction (ED). Low-intensity extracorporeal shockwave therapy (Li-ESWT) is a non-invasive intervention for ED, but its effect on penile microvascular function, remains unclear. Our objectives are to (i) evaluate the effect of Li-ESWT (specifically radial type ESWT [rESWT]) on penile microvascular perfusion (PMP) in aging rats, (ii) elucidate a possible mechanism, and (iii) evaluate its impact on angiogenic and smooth muscle biomarkers in cavernosal tissue.

MATERIALS AND METHODS

Male rats (n=9; 15-18 months) were anesthetized and subjected to rESWT while monitoring PMP. The nitric oxide (NO) pathway involvement was assessed by measuring the effect of rESWT on PMP following an intracavernosal injection of N(G)-nitroarginine methyl ester (L-NAME) (NO synthase inhibitor). To elucidate the cellular mechanism, another group of rats received repeated rESWT (n=4) or no treatment (n=4) three times/week for two weeks. Rats were euthanized at the end of the study and penile tissues were analyzed for angiogenic markers (vascular endothelial growth factor-A [VEGF-A], endothelial nitric oxide synthase [eNOS]) and smooth muscle content (α-actin) using immunostaining, Western blot, and quantitative polymerase chain reaction (qPCR).

RESULTS

rESWT resulted in more than a 2-fold increase in PMP (from 68.5 arbitrary units; 163.7 AU). L-NAME injection produced a <40%-50% decrease (185.3 to 101.0 AU) in rESWT-induced PMP response. Immunostaining revealed increased α-actin, eNOS, and VEGF-A in the cavernosum and these findings were confirmed by qPCR and Western blot results.

CONCLUSIONS

rESWT improved PMP, which may be mediated via increased VEGF expression, which stimulates the NO/cyclic guanosine monophosphate pathway, resulting in sustained PMP. rESWT devices could offer a safe, non-invasive treatment for age-related ED.

Long-term efficacy and safety of extracorporeal shock wave therapy (Li-ESWT) protocols in the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients

AIM

This study aims to evaluate the long-term effectiveness of Li-ESWT in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients and to compare the effect of treatment protocol differences on success.

METHOD

Between December 2019 and January 2021, the data of male patients over the age of 18 who applied to the urology outpatient clinic with CP/CPPS symptoms were retrospectively analyzed. International Prostate Symptom Index (IPSS) and International Index of Erectile Function-Erectile Function (IIEF-EF) questionnaires were filled in for the evaluation of erectile function. All patients received treatment with the Medispect Bold Li-ESWT. The treatment responses of the patients who received a total of 6 sessions from one session per week and 12 sessions from two sessions per week were compared.

RESULTS

A total of 129 patients were included in the study. Significant improvements were observed in the NIH-CPSI, IPSS, and IIEF-EF scores at the third month follow-ups of the patients after EWST (p < 0.001 for each). Improvements in scores were also found to be significant in NIH-CPSI, IPSS, and IIEF-EF at the 12th month evaluation. When the patients were evaluated according to the number of Li-ESWT sessions they received, the IPSS score average of the patient group who received 12 sessions of Li-ESWT was found to be lower than the patients who received 6 sessions of Li-ESWT (5.67 ± 2, 30 vs 4.51 ± 2.21; p = 0.005). There was no significant difference in the IIEF-EF and IPSS scores in the 12th month evaluations of the patients, but the mean NIH-CPSI score was found to be higher in the group that received 12 sessions of Li-ESWT (p = 0.003).

CONCLUSION

Li-ESWT in the treatment of CP/CPPS patients shows positive improvements in urinary symptoms, erectile function, and quality of life in patients unresponsive to other medical treatments. The increase in the number of sessions does not seem to influence the symptoms of the patients.

Electroacupuncture combined with extracorporeal shock wave therapy improves pain symptoms and inflammatory factor levels in knee osteoarthritis patients

Objective

To compare the clinical efficacy and safety of electroacupuncture combined with extracorporeal shock wave therapy (EESWT) and extracorporeal shock wave therapy (ESWT) in the treatment of knee osteoarthritis (KOA).

Methods

A total of 135 KOA patients who received EESWT treatment were selected as the EESWT group, and 135 KOA patients who received extracorporeal shock wave therapy (ESWT) were selected as the ESWT group. The clinical efficacy, inflammatory factors in joint synovial fluid and adverse events during treatment were compared before and after treatment.

Results

The clinical effective rate of patients in the EESWT group (89.63 %) after treatment was significantly higher than that of the ESWT group (74.81 %) (p < 0.01). The lysholm kness (LKSS) score and range of motion (ROM) of the patients in the EESWT group after treatment were higher than those of the ESWT group, while Lequesne index score, visual analogue scale (VAS) score and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were lower than those of the ESWT group (p < 0.01). Compared with ESWT group, the changes in the expression levels of nitric oxide (NO), superoxide dismutase (SOD), interleukin 1β (IL-1β), tumor necrosis factor-α (TNF-α), matrix metalloproteinase-3 (MMP-3), and transforming growth factor β1 (TGF-β1) in the synovial fluid of the EESWT group after treatment were significantly greater than those of the ESWT group (p < 0.01). No significant difference in the incidence of adverse events between the EESWT group and the ESWT group (p > 0.05).

Conclusion

EESWT significantly improves pain symptoms and inflammatory factor levels in KOA patients and is an optional KOA treatment option worthy of clinical attention.

Low-energy shock wave therapy ameliorates ischemic-induced overactive bladder in a rat model

This study was to evaluate whether Low-energy shock wave therapy (LESW) improves ischemic-induced overactive bladder in rats and investigate its therapeutic mechanisms. Sixteen-week-old male Sprague-Dawley rats were divided into three groups: arterial injury (AI), AI with LESW (AI-SW), and control groups. LESW was irradiated in AI-SW during 20-23 weeks of age. At 24 weeks of age, conscious cystometry was performed (each n = 8). The voiding interval was shortened in AI (mean ± SEM: 5.1 ± 0.8 min) than in control (17.3 ± 3.0 min), whereas significant improvements were observed in AI-SW (14.9 ± 3.3 min). The bladder blood flow was significantly increased in AI-SW than in AI. Microarray analysis revealed higher gene expression of soluble guanylate cyclase (sGC) α1 and β1 in the bladder of AI-SW compared to AI. Protein expression of sGCα1 and sGCβ1 was higher in AI-SW and control groups than in AI. Cyclic guanosine monophosphate (cGMP) was elevated in AI-SW. As an early genetic response, vascular endothelial growth factor and CD31 were highly expressed 24 h after the first LESW. Suburothelial thinning observed in AI was restored in AI-SW. Activation of sGC-cGMP may play a therapeutic role of LESW in the functional recovery of the bladder.

Effect of low energy shock wave on testicular microenvironment homeostasis in rats

OBJECTIVE

To further investigate whether two sets of low-energy extracorporeal shock waves (LESWs) impulse parameters, i.e., 0.02 mJ/mm² for 500 impulses and 0.04 mJ/mm² for 500 impulses, which have been shown to directly affect the testes, can promote testicular spermatogenesis or positively regulate homeostasis of the testicular microenvironment.

METHODS

(1) Twenty-four experimental rats were randomly divided into a 0.02 mJ/mm² 500 impulses group (L1 group), a 0.04 mJ/mm² 500 impulses group (M1 group), a sham intervention group (S group) and a blank control group (N group). The experiment period was 8 weeks. (2) Apoptosis of the spermatogenic cells in the left testicle was detected by the TUNEL method, VEGF and eNOs protein expression was detected by immunohistochemistry, and histomorphological changes were observed in PAS-stained sections. Moreover, the morphologies of the spermatogenic tubules and testicular stroma were quantitatively analyzed by stereological analysis. The right testicle was used for Western blot detection of the protein expression levels of Bax, Cytochrome C, Caspase-3, Bcl-2, VEGF and eNOs.

RESULTS

Compared with the other three groups, the rate of M1 testicular germ cell apoptosis induced by shock treatment was higher, the expression levels of proapoptotic proteins increased significantly while that of the antiapoptotic protein was lower, and the suppression of cell proliferation correlated with the protein expression levels. Additionally, with respect to the absolute volume of the seminiferous tubules, the absolute interstitial testicular volume notably increased, producing a series of biological effects working against testicular sperm production and function. However, there was no significant difference between the L1 group and the N and S groups.

CONCLUSIONS

LESWs treatment with impulse parameters of 0.02 mJ/mm² for 500 impulses showed a better protective effect on testicular spermatic function in rats and has a positive regulatory biological effect.

Metabolomics Analysis Reveals the Differential Metabolites and Establishes the Therapeutic Effect Prediction Nomogram Among CP/CPPS Patients Who Respond or Do Not Respond to LiST

Objective

Low-intensity shockwave therapy (LiST) has been applied in the clinical treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), but few studies have focused on the prediction of its therapeutic effect before treatment.

Methods

Seventy-five CP/CPPS patients from our institute between July 2020 and May 2021 were enrolled and received 3 Hz, 0.25 mJ/mm² LiST once a week over the course of four weeks. The scores of the NIH-CPSI, IPSS questionnaire and demographic features before treatment were recorded. The plasma before LiST treatment was also collected, while liquid chromatography-tandem mass spectrometry was used to detect the metabolites. Least absolute shrinkage and selection operator (LASSO) regression analysis was employed to identify the prediction metabolites and generate the metabolism score. Receiver operating characteristic curves and calibration curves were drawn to assess the prediction accuracy of the nomogram.

Results

Twelve metabolites were identified at incomparable levels before and after LiST treatment. The metabolism score generated by LASSO analysis presented a perfect prediction value (AUC: 0.848, 95% CI: 0.719-0.940) in the training cohort and further increased to 0.892 (95% CI: 0.802-0.983) on the nomogram, which accompanied with the NIH-CPSI scores and age. Similar results of the metabolism score (AUC: 0.732, 95% CI: 0.516-0.889) and total nomogram (AUC: 0.968, 95% CI: 0.909-1.000) were obtained in the testing cohort. Further enrichment of the 12 metabolites indicated that the glycine and serine metabolism pathway was involved in the LiST treatment.

Conclusion

We used our system to accurately and quantitatively measure plasma metabolites and establish a predictive model to identify suitable patients for LiST treatment.

New Frontiers of Extracorporeal Shock Wave Medicine in Urology from Bench to Clinical Studies

A shock wave (SW), which carries energy and propagates through a medium, is a type of continuous transmitted sonic wave that can achieve rapid energy transformations. SWs have been applied for many fields of medical science in various treatment settings. In urology, high-energy extracorporeal SWs have been used to disintegrate urolithiasis for 30 years. However, at lower energy levels, SWs enhance the expression of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), proliferating cell nuclear antigen (PCNA), chemoattractant factors, and the recruitment of progenitor cells, and inhibit inflammatory molecules. Low energy extracorporeal shock wave (LESW) therapy has been used in urology for treating chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), interstitial cystitis/bladder pain syndrome (IC/BPS), overactive bladder, stress urinary incontinence, and erectile dysfunction through the mechanisms of anti-inflammation, neovascularization, and tissue regeneration. Additionally, LESW have been proven to temporarily increase tissue permeability and facilitate intravesical botulinum toxin delivery for treating overactive bladders in animal studies and in a human clinical trial. LESW assisted drug delivery was also suggested to have a synergistic effect in combination with cisplatin to improve the anti-cancer effect for treating urothelial cancer in an in vitro and in vivo study. LESW assisted drug delivery in uro-oncology is an interesting suggestion, but no comprehensive clinical trials have been conducted as of yet. Taken together, LESW is a promising method for the treatment of various diseases in urology. However, further investigation with a large scale of clinical studies is necessary to confirm the real role of LESW in clinical use. This article provides information on the basics of SW physics, mechanisms of action on biological systems, and new frontiers of SW medicine in urology.

Use of the Shock Wave Therapy in Basic Research and Clinical Applications-From Bench to Bedsite

Shock Waves (SW) are acoustic disturbances that propagate through a medium carrying the energy. These specific sonic pulses are composed of two phases—high positive pressure, a rise time < 10 ns, and a tensile wave. Originally Shock Waves were introduced to clinical practice as a part of the lithotripsy therapy focused on disrupting calcific deposits in the body. Since that time, shock wave therapy (SWT) has gone far beyond the original application related to the destruction of kidney stones. In this narrative Review, we present basic clinical applications of the SWT along with the potential therapeutic application in clinical practice.

Comparison of Extracorporeal Shockwave Therapy with Non-Steroid Anti-Inflammatory Drugs and Intra-Articular Hyaluronic Acid Injection for Early Osteoarthritis of the Knees

Conservative treatments for early osteoarthritis (OA) of the knee included the use of non-steroid anti-inflammatory drugs (NSAIDs) and intra-articular hyaluronic acid (HA) injection. Recently, several animal studies reported that extracorporeal shockwave therapy (ESWT) demonstrated chondroprotective effects on knee OA. The present study compared the efficacy of oral NSAIDs, HA injection, and noninvasive ESWT for early OA of the knee. Forty-five patients with early knee OA were randomized into three groups. NSAIDs group received celecoxib 200 mg daily for 3 weeks. HA group received intra-articular injection of HA once a week for 3 weeks. ESWT group received ESWT for 3 sessions at bi-weekly interval. All patients were followed up for one year. Evaluations included the visual analogue scale (VAS) score, serum enzyme-linked immunosorbent assay (ELISA), plain radiography, dual-energy X-ray absorptiometry (DEXA), and magnetic resonance imaging (MRI). In addition, the functional scores were performed including, WOMAC (Western Ontario and McMaster Universities Arthritis Index) score, KOOS (knee injury and osteoarthritis outcome) score, and IKDC (International Knee Documentation Committee) score. All three groups showed significant improvement in VAS and functional scores as well as in the collected one-year follow-up data after treatments. ESWT group had better pain relief than NSAIDs and HA groups. ESWT group had better therapeutic effects in the functional scores than NSAIDs and HA groups. The bone mineral density (BMD) of proximal tibia is significantly increased after ESWT than others. In the serum ELISA, ESWT inhibited the expression of COMP in knee OA patients as compared with NSAIDs and HA groups. The parameters of MRI showed no significant differences between three groups after treatments. ESWT and intra-articular HA injection showed comparable results than NSAIDs. ESWT was superior in pain relief than HA and NSAIDs. The results demonstrated that ESWT was an effective and alternative therapy than HA and NSAIDs for early osteoarthritis of the knees.

Low intensity extracorporeal shockwave therapy for chronic pelvic pain syndrome patients with erectile dysfunction

INTRODUCTION

In this study, the efficacy of low intensity shock wave therapy (LSWT) in improving symptoms of chronic pelvic pain syndrome (CPPS) and erectile dysfunction (ED) was investigated.

METHODS

Men diagnosed with CPPS and ED (n = 50) were prescribed with LSWT. The LSWT was administered in 10 sessions over the course of 5 weeks at 3,000 pulses with .25 mJ/mm2 energy flow and 5 Hz frequency. Outcome parameters were measured before and after LSWT.

RESULTS

Clinical symptoms related to CPPS and ED were measured using four validated questionnaires namely National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Index of Erectile Function (IIEF), the International Prostate Symptom Score (IPSS), and Sexual Health Inventory for Men (SHIM). The effect of LSWT on each of the three domains of NIH-CPSI, namely Pain, Symptoms, and Quality of Life (QoL) were also analyzed. Uroflowmetry was measured to assess LSWT effect on urine voiding. The mean baseline CPPS symptoms on NIH-CPSI domains of pain, symptoms and QoL were 9.92 ± 5.72 (mean ± SD), 5.14 ± 14.5, and 8.02 ± 3.17, respectively. LSWT resulted in significant reduction of CPPS symptoms on all NIH-CPSI domains (Pain = .9 ± 1.37; Symptoms = .74 ± 1.03; QoL = 1.16 ± 1.78). The baseline means of CPPS symptoms on IIEF, IPSS, and SHIM were 45.42 ± 16.24, 24.68 ± 9.28, and 14.28 ± 6.02, respectively. LSWT significant improved CPPS symptoms on IIEF (49.48 ± 28.30) and IPSS (9.04 ± 7.01) but not on SHIM (16.02 ± 9.85). No statistically significant differences were observed with all uroflowmetry parameters.

CONCLUSION

The current study demonstrated for the first time the safety and efficacy of LSWT administered in 10 sessions over 5 weeks in improving symptoms of CPPS and ED without causing any significant adverse effect to the patient.

Cavernous Nerve Injury Resulted Erectile Dysfunction and Regeneration

Erectile dysfunction (ED) is an important cause of reduced quality of life for men and their partners. Recent studies have found that cavernous nerve injury (CNI) during prostate cancer surgery and other pelvic surgery results in medically induced CNIED in more than 80% of patients. The efficacy of first- and second-line treatment options for ED is poor. A great deal of research has been devoted to exploring new methods of neuroprotection and nerve regeneration to save erectile function in patients with CNIED, especially in patients with cavernous nerve injury after prostate cancer surgery. In addition, such as neuromodulatory proteins, proimmune ligands, gene therapy, stem cell therapy, and the current cutting-edge low-energy shock wave therapy have shown advantages in basic research and limited clinical studies. In the context of today's modern medicine, these new therapeutic techniques are expected to be new tools in the treatment of cavernous nerve injury erectile dysfunction. This article presents the main causes, mechanisms, and treatment of cavernous nerve injury erectile dysfunction and combines them with new treatment strategies.

Efficacy and safety evaluation of low-intensity extracorporeal shock wave therapy on prostatitis-like symptoms: An open-label, single-arm trial

The present work aims to evaluate the clinical efficacy and safety of low-intensity extracorporeal shock wave therapy (Li-ESWT) on patients with prostatitis-like symptoms (PLS). Patients with PLS were recruited and received four-week Li-ESWT (once per week), which was conducted at a frequency of 3 Hz with a preferred energy flow density of 0.25 mJ/mm² . The scores of the National Institute of Health Chronic Prostatitis Symptoms Index (NIH-CPSI), International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5), and Visual Analogue Scale (VAS) were recorded to assess the remission of disease in the 0, 1st, 2nd, 3rd, 4th, 5th, 8th and 16th weeks. A decrease of the NIH-CPSI score ≥6 was regarded as the effectiveness standard of Li-ESWT. Among 91 enrolled patients, the scores of all validated questionnaires presented significant improvements in the 4th week (p < .05) compared with that in baseline, except for IIEF-5. The treatment effective rates in the 1st, 2nd, 3rd, 4th, 5th, 8th and 16th weeks were 28.57%, 38.46%, 47.25%, 51.65%, 57.30%, 68.18% and 69.44%, respectively. No pronounced undesirable side effect has occurred. Li-ESWT is effective and safe in treating PLS. The efficacy can be maintained within three months.

Low-intensity extracorporeal shock wave therapy for midshaft clavicular delayed union: A case report and review of literature

BACKGROUND

One of the most common complications following surgery for midshaft clavicle fracture is nonunion/delayed union. Extracorporeal shock wave therapy (ESWT) is an alternative to promote new bone formation without surgical complications. To date, no literature has reported low-intensity ESWT (LI-ESWT) in delayed union of midshaft clavicle fracture.

CASE SUMMARY

We reported a 66-year-old Chinese amateur cyclist with clavicle delayed union treated with 10 sessions of LI-ESWT (radial, 0.057 mJ/mm², 3 Hz, 3000 shocks). No anesthetics were applied, and no side effects occurred. At the 4 mo and 7 mo follow-ups, the patient achieved clinical and radiographical recovery, respectively.

CONCLUSION

In conclusion, our findings indicated that LI-ESWT could be a good option for treating midshaft clavicular delayed union.

The Effect of Low-intensity Shockwave Therapy on Non-neurogenic Lower Urinary Tract Symptoms: A Systematic Review and Meta-analysis of Preclinical and Clinical Studies

CONTEXT

Low-intensity shockwave therapy (LiST) has emerged as an effective treatment for pain in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), and it has been postulated that LiST may also be effective in patients with lower urinary tract symptoms (LUTS).

OBJECTIVE

To perform a systematic review and meta-analysis of experimental and clinical studies exploring the effect of LiST on LUTS in an attempt to provide clinical implications for future research.

EVIDENCE ACQUISITION

We systematically searched PubMed, Cochrane Library, and Scopus databases from inception to March 2021 for relevant studies. We provided a qualitative synthesis regarding the role of LiST in LUTS and performed a single-arm, random-effect meta-analysis to assess the absolute effect of LiST on LUTS only in patients with CP/CPPS (PROSPERO: CRD42021238281).

EVIDENCE SYNTHESIS

We included 23 studies (11 experimental studies, seven nonrandomized controlled trials [non-RCTs], and five RCTs) in the systematic review and seven in the meta-analysis. All experimental studies were performed on rats with LUTS, and the clinical studies recruited a total of 539 participants. In patients with CP/CPPS, the absolute effect of LiST on maximum flow rate and postvoid residual was clinically insignificant. However, the available studies suggest that LiST is effective for the management of pain in patients with either CP/CPPS or interstitial cystitis/bladder pain syndrome. Additionally, LiST after intravesical instillation of botulinum neurotoxin type A may enhance its absorption and substitute botulinum neurotoxin type A injections in patients with overactive bladder. Furthermore, the available evidence is inconclusive about the role of LiST in patients with benign prostatic obstruction, stress urinary incontinence, or underactive bladder/detrusor hypoactivity.

CONCLUSIONS

LiST may be effective for some disorders causing LUTS. Still, further studies on the matter are necessary, since the available evidence is scarce.

PATIENT SUMMARY

Low-intensity shockwave therapy represents a safe, easily applied, indolent, and repeatable on an outpatient basis treatment modality that may improve lower urinary tract symptoms.

Therapeutic modality of induced uterine leiomyoma with shock waves in rats: The uterine blood flow, circulating ovarian hormones and histopathological findings

Uterine leiomyoma is the most common benign pelvic tumor and the primary indication for hysterectomy. We hypothesized tumor softening and shrinking through shock waves mechanobiological influence on fibroblasts of the induced leiomyoma in rats. Three rats served as control from thirty-three female Wistar rats subjected to leiomyoma induction using mono-sodium glutamate and estradiol benzoate. After assessing uterine leiomyoma development with Doppler ultrasonography, blood and tissue samples were collected for hormonal and histopathological analysis. Of the fifteen rats treated with shock waves, five rats were sacrificed after receiving two sessions (2S), another five rats were sacrificed after receiving four sessions (4S), and the last five rats were sacrificed after two weeks recovery period (recovered 4S). From the fifteen non-treated leiomyoma group, five rats were sacrificed after Doppler ultrasound assessment (Leiomyoma), another five rats were sacrificed with the 4S group (Leiomyoma 1Wk recovery), and the last five rats were sacrificed with the recovered 4S group (Recovered leiomyoma). The collected blood samples, estradiol (E2), Estrogen receptor, progesterone (P4), and progesterone receptor (PGR), were assayed. Total cholesterol, protein, albumin, and globulin were measured. Uterine arteries' blood flow velocities, indices, and volume were obtained. Tissue samples were stained with smooth muscle actin (SMA), trichrome-three, and (hematoxylin and eosin). Rats developed leiomyoma had the highest (P = 0.0001) gross and sonographic uterine horns diameters, uterine weight, uterine coefficient, E2, and ER. Both trichrome-three and SMA staining confirmed the leiomyoma development and the response to shock waves treatment. In conclusion, low-intensity shock waves proved curative to the induced leiomyoma.

Low-intensity extracorporeal shock wave therapy for male chronic pelvic pain syndrome: a systematic review and meta-analysis

Background

A systematic review of the evidence was conducted to evaluate the efficacy of low-intensity extracorporeal shock wave therapy (LI-ESWT) for patients with chronic pelvic pain syndrome (CPPS).

Methods

A comprehensive search was undertaken of the Cochrane Register, PubMed, and Embase databases for controlled trials that evaluated patients with CPPS who were treated with LI-ESWT and that were published before August 2019. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was the most frequently used tool to evaluate the treatment efficacy of LI-ESWT. The NIH-CPSI comprises subscales for pain [using a visual analog scale (VAS)], urinary function, and quality of life (QoL).

Results

Six studies analyzing 317 patients were published from 2009 to 2019. The overall meta-analysis of the data indicated that LI-ESWT demonstrated efficacy in the treatment of CPPS at 12 weeks [risk difference (RD): 0.46; 95% confidence interval (CI), 0.28–0.63; P<0.00001]. The studies were divided into 3 groups based on time after LI-ESWT (1, 12, and 24 weeks) and were compared in total NIH-CPSI scores, QoL, VAS scores, and urinary symptoms. The total NIH-CPSI scores, QoL, VAS scores, and urinary symptom scores improved significantly at 12 weeks after LI-ESWT (P<0.05), but not at 1 week or 24 weeks (P>0.05).

Conclusions

Based on these studies, LI-ESWT may transiently improve the total NIH-CPSI scores, QoL, pain scores, and urinary symptom scores of patients with CPPS. Future research may elucidate the mechanisms underlying the effects of LI-ESWT on CPPS. Well-designed and long-term multicenter randomized controlled trials are urgently needed to estimate the real potential and ultimate use of these devices in patients with CPPS.

EVALUATION OF EFFICACY OF EXTRACORPOREAL SHOCK WAVE THERAPY IN COMPLEX TREATMENT OF PATIENTS WITH CHRONIC NON-BACTERIAL PROSTATITIS / CHRONIC PELVIC PAIN SYNDROME

OBJECTIVE

The aim: Study of hemodynamics of the prostate and evaluation of the ef f ectiveness of extracorporeal shock wave therapy (ESWT) in the complex treatment of patients with chronic prostatitis with non-inf l ammatory chronic pelvic pain syndrome (NCPPS), (NIH III B).

PATIENTS AND METHODS

Materials and methods: There were 63 patients with NCPPS aged 29 to 45 years, with a disease duration of more than 3 years and low ef f i cacy of treatment against the background of standard therapy. All patients received standard therapy according to the clinical protocol. The main group (33 men - group II), against the background of standard therapy, received a course of ESWT, followed by a comparative assessment of clinical results regarding to the group of patients (30 men - group I) who received only standard therapy after the course, and after 3 and 6 months after treatment.

RESULTS

Results: According to the results of transrectal ultrasonography in Doppler mode, a marked decrease in volumetric blood fl ow in the prostate gland of patients was observed. The use of ESWT against the background of standard treatment contributed to a longer and more stable clinical ef f ect, with a signif i cant improvement in hemodynamic parameters in the prostate unlike the results in the group of patients receiving only standard therapy.

CONCLUSION

Conclusions: Signif i cant disorders of prostate hemodynamics were found in patients with NCPPS. Use on the background of standard treatment of ESWT in these patients is pathogenetically justif i ed with a lasting and stable clinical ef f ect.

Effect of low-energy shock wave therapy on intravesical epirubicin delivery in a rat model of bladder cancer

OBJECTIVES

To study the efficacy of low-energy shock wave therapy (LESW) on enhancing intravesical epirubicin (EPI) delivery in a rat model of bladder cancer (BCa).

MATERIALS AND METHODS

A total of 100 female Fischer rats were randomly allocated into five groups: control; BCa; LESW; EPI; and EPI plus LESW. After BCa induction by N-butyl-N-(4-hydroxybutyl)nitrosamine, EPI (0.6 mg/0.3 mL of EPI diluted in 0.3 mL saline) or saline (0.6 mL) was administered and retained in the bladders for 1 h with or without LESW treatment (300 pulses at 0.12 mJ/mm² ). This was repeated weekly for 6 weeks. Survival was then calculated, rats were weighed and their bladders were harvested for bladder/body ratio estimation, histopathological examination, p₅₃ immunostaining, miR-210, hypoxia-inducible factor (HIF)-1α, tumour necrosis factor (TNF)-α and interleukin (IL)-6 relative gene expression and fluorescence spectrophotometric drug quantification. Heart and blood samples were also collected for assessment of the safety profile and toxicity.

RESULTS

The EPI plus LESW group had significantly lower mortality rates, loss of body weight and bladder/body ratio. Histopathological results in terms of grossly visible bladder lesions, mucosal thickness, dysplasia formation and tumour invasion were significantly better in the combined treatment group. The EPI plus LESW group also had statistically significant lower expression levels of p₅₃ , miR-210, HIF-1α, TNF-α and IL-6. LESW increased urothelial concentration of EPI by 5.7-fold (P < 0.001). No laboratory variable exceeded the reference ranges in any of the groups. There was an improvement of the indicators of EPI-induced cardiomyopathy in terms of congestion, hyalinization and microvesicular steatosis of cardiomyocytes (P = 0.068, 0.003 and 0.046, respectively) in the EPI plus LESW group.

CONCLUSIONS

The combined use of intravesical EPI and LESW results in less BCa invasion and less dysplasia formation, as LESW increases urothelial permeability of EPI and enhances its delivery into tumour tissues, without subsequent toxicity.

Low-energy shock wave pretreatment recruit circulating endothelial progenitor cells to attenuate renal ischaemia reperfusion injury

Low‐energy shock wave (LESW) has been recognized as a promising non‐invasive intervention to prevent the organs or tissues against ischaemia reperfusion injury (IRI), whereas its effect on kidney injury is rarely explored. To investigate the protective role of pretreatment with LESW on renal IRI in rats, animals were randomly divided into Sham, LESW, IRI and LESW + IRI groups. At 4, 12, 24 hours and 3 and 7 days after reperfusion, serum samples and renal tissues were harvested for performing the analysis of renal function, histopathology, immunohistochemistry, flow cytometry and Western blot, as well as enzyme‐linked immunosorbent assay. Moreover, circulating endothelial progenitor cells (EPCs) were isolated, labelled with fluorescent dye and injected by tail vein. The fluorescent signals of EPCs were detected using fluorescence microscope and in vivo imaging system to track the distribution of injected circulating EPCs. Results showed that pretreatment with LESW could significantly reduce kidney injury biomarkers, tubular damage, and cell apoptosis, and promote cell proliferation and vascularization in IRI kidneys. The renoprotective role of LESW pretreatment would be attributed to the remarkably increased EPCs in the treated kidneys, part of which were recruited from circulation through SDF‐1/CXCR7 pathway. In conclusion, pretreatment with LESW could increase the recruitment of circulating EPCs to attenuate and repair renal IRI.

Low-intensity extracorporeal shock wave therapy for III B chronic pelvic pain syndrome

Background

To analyze the efficiency of low-intensity shock wave therapy (LI-ESWT) for patients with III B chronic pelvic pain syndrome (CPPS).

Methods

The study included an uncontrolled population of 32 patients who had suffered with CPPS for ≥3 months. LI-ESWT was performed without anesthesia via a perineal approach. The operation was carried out in four weeks by administering 12,000 shock waves. Using the Visual Analog Scale (VAS) and NIH-developed Chronic Prostatitis Symptom Index (NIH-CPSI), subsequent tests were performed at 1, 2, 4, and 12 weeks after the first LI-ESWT session.

Results

All patients who received the four week course as treatment responded actively on the pain VAS and the NIH-CPSI, and both were significantly improved (P<0.05). Compared with the baseline parameters, the NIH-CPSI total score and VAS exhibited substantial improvement at 4 and 12 weeks, where a total improvement at four weeks was reached. It is easy and safe to perform LI-ESWT without anesthesia on an outpatient basis.

Conclusions

LI-ESWT should be regarded as a promising new therapy for CPPS, as it is convenient to perform without any side-effects.

Radial Extracorporeal Shock Wave Therapy as a Novel Agent for Benign Prostatic Hyperplasia Refractory to Current Medical Therapy

This study aimed to assess efficacy and safety data from pilot trials of the radial extracorporeal shock wave therapy (rESWT) to treat benign prostatic hyperplasia (BPH) refractory to current medical therapy. A total of 29 men with lower urinary tract symptoms (LUTS) suggestive of BPH who had responded poorly to medical therapy for at least 6 months and were poor surgical candidates were enrolled. Each participant was treated with rESWT once a week for 8 weeks, each by 2000 impulses at 2.0 bar and 10 hertz of frequency. International Prostate Symptom Score (IPSS), quality of life (QoL), and International Index of Erectile Function-5 (IIEF-5) were evaluated before treatment, after the fourth and eighth rESWT, and 3 months after the end of treatment. Peak urinary flow ( Q_max) and postvoid residual (PVR) were assessed. Safety was also documented. Statistically significant clinical improvements were reported for IPSS, QoL, and IIEF-5 after treatment, and those were sustained until 3 months follow-up. Q_max and PVR improved evidently at 8 weeks with a 63% and 70% improvement, respectively. The only adverse event was the occasional perineum pain or discomfort, which usually disappeared within 3 days. The rESWT may be an effective, safe, and noninvasive treatment for symptomatic BPH in selected patients whose medical treatment has faced failure and are poor surgical candidates.

Role and mechanism of micro-energy treatment in regenerative medicine

With the continuous integration and intersection of life sciences, engineering and physics, the application for micro-energy in the basic and clinical research of regenerative medicine (RM) has made great progress. As a key target in the field of RM, stem cells have been widely used in the studies of regeneration. Recent studies have shown that micro-energy can regulate the biological behavior of stem cells to repair and regenerate injured organs and tissues by mechanical stimulation with appropriate intensity. Integrins-mediated related signaling pathways may play important roles in transducing mechanical force about micro-energy. However, the complete mechanism of mechanical force transduction needs further research. The purpose of this article is to review the biological effect and mechanism of micro-energy treatment on stem cells, to provide reference for further research.

Safety parameters of in vivo low-energy shock waves and their impact on adult rat testes

Low-energy shock waves (LESWs) have been widely used in the intervention of a subset of diseased tissues and organs with good results. However, it is unclear whether they can be used directly to intervene in the testes. Therefore, the aim of this study was to determine a relatively safe energy density and impulse number for rat testes. A total of 176 male rats were randomly and equally assigned to different intervention groups. Among them, 144 rats were assigned to 18 shock subgroups with different energy densities (0.02, 0.04 and 0.06 mJ/mm²), different impulse numbers (500, 1000 and 1500 impulses) and different shock periods (2 and 8 weeks). The remaining 32 rats were divided into the sham intervention (S) groups and the blank control (N) groups with observation periods of 2 weeks and 8 weeks. One day after the last LESWs intervention, all the rats were weighed, and the concentrations of reproductive endocrine hormones were measured, the semen quality and testicular tissue oxidative stress levels were analyzed, and histomorphology and ultrastructures were observed. We found that there were no significant differences in the whole-body physiological state, testicular tissue morphology, oxidative stress state and sperm quality between the L1 shock group and the corresponding S group and N group (all p˃0.05, respectively). However, the other parameters of the shock groups caused different degrees of damage to the structure and function of rat testes, and the whole-body physiological state was also adversely affected. This study demonstrated that LESWs with an energy density of 0.02 mJ/mm² and 500 impulses had no adverse effects on the rat testes.

Therapeutic Efficacy of onabotulinumtoxinA Delivered Using Various Approaches in Sensory Bladder Disorder

Cystoscopic onabotulinumtoxinA (onaBoNTA) intradetrusor injection is an efficient and durable modality for treating sensory bladder disorders. However, the inconvenience of using the cystoscopic technique and anesthesia, and the adverse effects of direct needle injection (e.g., haematuria, pain, and infections) have motivated researchers and clinicians to develop diverse injection-free procedures to improve accessibility and prevent adverse effects. However, determining suitable approaches to transfer onaBoNTA, a large molecular and hydrophilic protein, through the impermeable urothelium to reach therapeutic efficacy remains an unmet medical need. Researchers have provided potential solutions in three categories: To disrupt the barrier of the urothelium (e.g., protamine sulfate), to increase the permeability of the urothelium (e.g., electromotive drug delivery and low-energy shock wave), and to create a carrier for transportation (e.g., liposomes, thermosensitive hydrogel, and hyaluronan-phosphatidylethanolamine). Thus far, most of these novel administration techniques have not been well established in their long-term efficacy; therefore, additional clinical trials are warranted to validate the therapeutic efficacy and durability of these techniques. Finally, researchers may make progress with new combinations or biomaterials to change clinical practices in the future.

Low Energy Shock Wave Therapy Inhibits Inflammatory Molecules and Suppresses Prostatic Pain and Hypersensitivity in a Capsaicin Induced Prostatitis Model in Rats

The effect of low energy shock wave (LESW) therapy on the changes of inflammatory molecules and pain reaction was studied in a capsaicin (10 mM, 0.1 cc) induced prostatitis model in rats. Intraprostatic capsaicin injection induced a pain reaction, including closing of the eyes, hypolocomotion, and tactile allodynia, which effects were ameliorated by LESW treatment. LESW therapy (2Hz, energy flux density of 0.12 mJ/mm²) at 200 and 300 shocks significantly decreased capsaicin-induced inflammatory reactions, reflected by a reduction of tissue edema and inflammatory cells, COX-2 and TNF-α stained positive cells, however, the therapeutic effects were not observed at 100 shocks treated group. Capsaicin-induced IL-1β, COX-2, IL-6, caspase-1, and NGF upregulation on day 3 and 7, while NALP1 and TNF-α upregulation was observed on day 7. LESW significantly suppressed the expression of IL-1β, COX-2, caspase-1, NGF on day 3 and IL-1β, TNF-α, COX-2, NALP1, caspase-1, NGF expression on day 7 in a dose-dependent fashion. LESW has no significant effect on IL-6 expression. Intraprostatic capsaicin injection activates inflammatory molecules and induces prostatic pain and hypersensitivity, which effects were suppressed by LESW. These findings might be the potential mechanisms of LESW therapy for nonbacterial prostatitis in humans.

A systematic review of the long-term efficacy of low-intensity shockwave therapy for vasculogenic erectile dysfunction

PURPOSE

To look at the evidence base for LISWT as a treatment modality for vasculogenic erectile dysfunction, focusing on the long-term outcomes at over 6 months following treatment.

METHODS

A systematic literature search was conducted utilising MEDLINE and Scopus databases from 2010 to September 2018 by two independent reviewers. Outcome measures extracted for long-term efficacy included International Index of Erectile Function scores and Erection Hardness Scores. Subgroup analysis for LISWT effectiveness included age, PDE5i responsiveness, presence of vascular co-morbidities and smoking status.

RESULTS

The search identified eleven studies, representing a total of 799 patients. Nine studies found a significant improvement in erectile function after LISWT at 6-month follow-up (median IIEF-EF improvement in 5.3 at 6 months). However, of five studies assessing erectile function at 12 months; two identified a plateauing of results, with three a deterioration (IIEF-EF score changes of - 2 to 0.1 from 6 months). Erectile function did, however, remain above baseline results in all of these studies. Subgroup analysis revealed increasing age to reduce the response to LISWT treatment. Whilst ED severity, PDE5i responsiveness and co-morbidities potentially influence effectiveness, results are still inconsistent.

CONCLUSIONS

LISWT may be a safe and acceptable potential ED treatment with demonstrated benefits at 6 months. There is some question regarding efficacy deterioration beyond this, but there is still a demonstrated benefit seen even at 12 months post treatment. However, quality of evidence remains low with larger multiinstitutional studies required, standardising confounders such as shockwave administration and oral medication use.

Efficacy of Radial Extracorporeal Shock Wave Therapy for Chronic Pelvic Pain Syndrome: A Nonrandomized Controlled Trial

This study aims to determine the effect of radial extracorporeal shock wave therapy (rESWT) versus drug when treating chronic pelvic pain syndrome (CPPS; type III B chronic prostatitis). The study included 45 participants with CPPS, divided into two groups: Group I comprised 25 participants, who were treated with rESWT (3,000 pulses each; pressure: 1.8-2.0 bar; frequency: 10 Hz) once a week; Group II consisted of 20 participants who received a combination of an α-blocker and an anti-inflammatory agent. Participants were treated for 8 weeks. The assessments were done before treatment, after the fourth and eighth rESWT, and 3 months after the end of treatment by Visual Analogue Scale (VAS) for pain, National Institutes of Health-developed Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score (IPSS), quality of life (QoL), and International Index of Erectile Function-5 (IIEF-5). Both groups of participants showed statistically significant improvement in all the assessments ( p < .001) after the treatment, with significantly better results in Group I in NIH-CPSI ( p < .001). The recurrence rate of symptoms in Group I at 3 months after end of treatment was much lower than that in Group II (4% vs. 50%, p < .001). This prospectively nonrandomized, control study revealed perineal rESWT as a new therapy option for CPPS with statistically significant effects in comparison to drugs at least for 3 months after cessation of treatment.

The protective effect of low-energy shock wave on testicular ischemia-reperfusion injury is mediated by the PI3K/AKT/NRF2 pathway

AIMS

Testicular ischemia-reperfusion (IR) injury is the primary pathophysiological consequence of testicular torsion. Low-energy shock wave (LESW) is an effective treatment for certain diseases. The present study investigated whether LESW could improve on testicular IR injury in rats and examined the involved mechanism.

MAIN METHODS

Testicular reperfusion was induced in rats after 1-h ischemia. The first LESW treatment was performed 30 min prior to testicular reperfusion, and then every other day for another 3 applications. LY294002 was applied to investigate the involved mechanism. Testicular morphological changes and malonaldehyde (MDA) level were respectively assessed by hematoxylin-eosin staining. Western blot and thiobarbituric acid method. Western blot, real-time quantitative PCR and immunohistochemistry were performed to assess the apoptosis, the activation of phosphatidylinositol-4,5-bisphosphate 3-kinase/protein kinase B (PI3K/AKT) pathway the nuclear factor erythroid 2-related factor 2 (NRF2) and vascular endothelial growth factor A (VEGF-A) level in the testis of rats.

KEY FINDINGS

LESW improved testicular IR injury in rats. Moreover, LESW upregulated the phosphorylation levels of AKT and glycogen synthase kinase 3β (GSK-3β). Also, it upregulated the levels of nuclear NRF2, heme oxygenase 1 (HO-1) and NAD(P)H quinone dehydrogenase 1 (NQO-1) in these rats. Nevertheless, LY294002 blocked these protective effects. LESW also upregulated VEGF-A level in rats with testicular IR injury.

SIGNIFICANCE

This study demonstrated that LESW could ameliorate testicular IR injury in rats, which might be attributed to the activation of PI3K/AKT/NRF2 pathway. These findings suggested the potential of LESW in the treatment of testicular torsion.