Prediction of erectile function following treatment for prostate cancer

Erectile function preservation after salvage radiation therapy for biochemically recurrent prostate cancer after prostatectomy: Five-year results of the SAKK 09/10 randomized phase 3 trial

Objectives

To evaluate effects of dose intensified salvage radiotherapy (sRT) on erectile function in biochemically recurrent prostate cancer (PC) after radical prostatectomy (RP).

Materials and methods

Eligible patients had evidence of biochemical failure after RP and a PSA at randomization of ≤ 2 ng/ml. Erectile dysfunction (ED) was investigated as secondary endpoint within the multicentre randomized trial (February 2011 to April 2014) in patients receiving either 64 Gy or 70 Gy sRT. ED and quality of life (QoL) were assessed using CTCAE v4.0 and the EORTC QoL questionnaires C30 and PR25 at baseline and up to 5 years after sRT.

Results

344 patients were evaluable. After RP 197 (57.3 %) patients had G0-2 ED while G3 ED was recorded in 147 (42.7 %) patients. Subsequently, sexual activity and functioning was impaired. 5 years after sRT, 101 (29.4 %) patients noted G0-2 ED. During follow-up, 44.2 % of patients with baseline G3 ED showed any improvement and 61.4 % of patients with baseline G0-2 ED showed worsening. Shorter time interval between RP and start of sRT (p = 0.007) and older age at randomization (p = 0.005) were significant predictors to more baseline ED and low sexual activity in the long-term. Age (p = 0.010) and RT technique (p = 0.031) had a significant impact on occurrence of long-term ED grade 3 and worse sexual functioning. During follow-up, no differences were found in erectile function, sexual activity, and sexual functioning between the 64 Gy and 70 Gy arm.

Conclusion

ED after RP is a known long-term side effect with significant impact on patients' QoL. ED was further affected by sRT, but dose intensification of sRT showed no significant impact on erectile function recovery or prevalence of de novo ED after sRT. Age, tumor stage, prostatectomy and RT-techniques, nerve-sparing and observation time were associated with long-term erectile function outcome.ClinicalTrials.gov. Identifier: NCT01272050.

Overview of Radiation Therapy in the Management of Localized and Metastatic Prostate Cancer

PURPOSE OF REVIEW

The goal is to describe the evolution of radiation therapy (RT) utilization in the management of localized and metastatic prostate cancer.

RECENT FINDINGS

Long term data for a variety of hypofractionated definitive RT dose-fractionation schemes has matured, allowing patients and providers many standard-of-care options to choose from. Post-prostatectomy, adjuvant RT has largely been replaced by an early salvage approach. Multiparametric MRI and PSMA PET have enabled increasingly targeted RT delivery to the prostate and oligometastatic tumors. Areas of active investigation include determining the value of proton beam therapy and perirectal spacers, and optimally incorporate genomic tumor profiling and next generation hormonal therapies with RT in the curative setting. The use of radiation therapy to treat prostate cancer is rapidly evolving. In the coming years, there will be continued improvements in a variety of areas to enhance the value of RT in multidisciplinary prostate cancer management.

Urinary and Sexual Impact of Robotic Radical Prostatectomy: Reporting of Patient-reported Outcome Measures in the First Year after Radical Prostatectomy in a Contemporary Multicentre Cohort in the United Kingdom

Background and objective

Radical prostatectomy (RP) is an established treatment for localised prostate cancer that can have a significant impact on urinary and sexual function, with recovery over time. Our aim was to describe functional recovery in the first year after RP, reporting descriptive outcomes alongside validated patient-reported outcome measure scores (Expanded Prostate Cancer Index Composite, EPIC-26).

Methods

Men undergoing RP between September 2015 and November 2019 completed EPIC-26 at baseline and 1, 3, 6, and 12 mo.

Key findings and limitations

Overall, 2030 men consented to participation, underwent RP, and completed EPIC-26. At baseline, 97% were pad-free (1928/1996; 95% confidence interval [CI] 96-97%) and 77% were leak-free and pad-free (1529/1996; 95% CI 75-78), with a median EPIC-26 incontinence domain score of 100 (interquartile range [IQR] 86-100). At 12 mo, 65% were pad-free (904/1388; 95% CI 63-68%) and 42% were leak-free and pad-free (583/1388; 95% CI 39-45%), with a median EPIC-26 score of 76 (IQR 61-100). While one in three men reported wearing a pad at 12 mo, fewer than one in ten men needed more than 1 pad/d. At baseline, 1.9% reported a "moderate or big problem" with urine leakage, which increased to 9.7% at 12 mo. At baseline, the median sexual domain score among 1880 men was 74 (IQR 43-92) and 52% had erections sufficient for intercourse without medication (975/1880; 95% CI 50-54%). Among these 975 men, 630 responded at 12 mo, of whom 17% reported sufficient erections for intercourse (105/630; 95% CI 14-20%), without medication in 6% (37/630; 95% CI 4-8%) and needing medication in 11% (68/630; 95% CI 9-13%); the median EPIC-26 domain score was 26 (IQR 13-57).

Conclusions and clinical implications

Reporting of functional outcomes after RP in terms of easily understood concepts such as pad-free and leak-free status, and erections with and with medication, alongside the classical report using EPIC-26 domain scores, increases the understanding of RP recovery patterns over the first year.

Patient summary

At 12 months after surgery for prostate cancer, one in ten men reported a moderate or big problem with urine leakage and one in five men reported sufficient erections.

Epigenetics as a Key Factor in Prostate Cancer

Nowadays, prostate cancer is one of the most common forms of malignant neoplasms in men all over the world. Against the background of increasing incidence, there is a high mortality rate from prostate cancer, which is associated with an inadequate treatment strategy. Such a high prevalence of prostate cancer requires the development of methods that can ensure early detection of the disease, improve the effectiveness of treatment, and predict the therapeutic effect. Under these circumstances, it becomes crucial to focus on the development of effective diagnostic and therapeutic approaches. Due to the development of molecular genetic methods, a large number of studies have been accumulated on the role of epigenetic regulation of gene activity in cancer development, since it is epigenetic changes that can be detected at the earliest stages of cancer development. The presence of epigenetic aberrations in tumor tissue and correlations with drug resistance suggest new therapeutic approaches. Detection of epigenetic alterations such as CpG island methylation, histone modification, and microRNAs as biomarkers will improve the diagnosis of the disease, and the use of these strategies as targets for therapy will allow for greater personalization of prostate cancer treatment.

Impact of neoadjuvant relugolix on patient-reported sexual function and bother

Introduction

Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT).

Methods

Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage.

Results

The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother.

Discussion

In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.

Quality of Life Longitudinal Evaluation in Prostate Cancer Patients from Radiotherapy Start to 5 Years after IMRT-IGRT

PURPOSE

The purpose of this study is to study the evolution of quality of life (QoL) in the first 5 years following Intensity-modulated radiation therapy (IMRT) for prostate cancer (PCa) and to determine possible associations with clinical/treatment data.

MATERIAL AND METHODS

Patients were enrolled in a prospective multicentre observational trial in 2010-2014 and treated with conventional (74-80 Gy, 1.8-2 Gy/fr) or moderately hypofractionated IMRT (65-75.2 Gy, 2.2-2.7 Gy/fr). QoL was evaluated by means of EORTC QLQ-C30 at baseline, at radiation therapy (RT) end, and every 6 months up to 5 years after IMRT end. Fourteen QoL dimensions were investigated separately. The longitudinal evaluation of QoL was analysed by means of Analysis of variances (ANOVA) for multiple measures.

RESULTS

A total of 391 patients with complete sets of questionnaires across 5 years were available. The longitudinal analysis showed a trend toward the significant worsening of QoL at RT end for global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. QoL worsening was recovered within 6 months from RT end, with the only exception being physical functioning. Based on ANOVA, the most impaired time point was RT end. QoL dimension analysis at this time indicated that acute Grade ≥ 2 gastrointestinal (GI) toxicity significantly impacted global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. Acute Grade ≥ 2 genitourinary (GU) toxicity resulted in lower role functioning and higher pain. Prophylactic lymph-nodal irradiation (WPRT) resulted in significantly lower QoL for global health, fatigue, appetite loss, and diarrhoea; lower pain with the use of neoadjuvant/concomitant hormonal therapy; and lower fatigue with the use of an anti-androgen.

CONCLUSIONS

In this prospective, longitudinal, observational study, high radiation IMRT doses delivered for PCa led to a temporary worsening of QoL, which tended to be completely resolved at six months. Such transient worsening was mostly associated with acute GI/GU toxicity, WPRT, and higher prescription doses.

A pooled long-term follow-up after radiotherapy for prostate cancer with and without a rectal hydrogel spacer: impact of hydrogel on decline in sexual quality of life

Purpose

The purpose of this study was to analyze the impact of prostate rectal spacers on sexual quality of life (QOL) following external beam radiation therapy (RT).

Methods and materials

Patient- reported QOL was evaluated using the Expanded Prostate Cancer Index Composite (EPIC). Patients were pooled from two sources: a randomized controlled trial and a non-randomized cohort of patients from a single institution. Both cohorts used the same spacing product and QOL instrument. Analysis was limited to those with good baseline pre-treatment sexual QOL (EPIC >/= 60). Differences in QOL summary score and individual items were assessed compared with baseline and between treatment arms.

Results

A total of 128 men had good baseline sexual function and were evaluated (64% with spacer and 36% without) with QOL data available for median 33 months (range: 2.5-69.4 months). Men without spacer were more likely to have declines in sexual function (p < 0.0001), bother (p = 0.0002), and sexual summary score (p < 0.0001). A minimally important difference of 10 points (1xMID) and 20 point (2xMID) was more likely without rectal spacer [10 points: odds ratio 3.53, (95% confidence interval 1.11-11.2), p = 0.032; 20 points: odds ratio 3.29, (95% confidence interval 1.16-9.33), p = 0.025]. Seven of 13 QOL items were statistically superior with hydrogel (six of nine functional and one of four bother), while no items were statistically superior for control. At baseline, more men treated with hydrogel had erections sufficient for intercourse; however, when analyzed only by the men with best baseline erectile potential and excluding those with worse function, the benefit of rectal spacing was maintained with a higher likelihood of preservation of erections sufficient for intercourse in those treated with hydrogel.

Conclusion

In this pooled analysis of QOL after prostate RT, the utilization of a hydrogel spacer was associated with better sexual QOL, less men with measurable declines in sexual QOL, and higher rates of adequate erectile function.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Low-intensity extracorporeal shockwave therapy in the treatment of erectile dysfunction - a narrative review

OBJECTIVES

To provide an overview of low-intensity extracorporeal shockwave therapy (LIEST) for erectile dysfunction (ED), pointing out which concepts are already consolidated and which paths we still need to advance.

MATERIALS AND METHODS

We performed a narrative review of the literature on the role of shockwave therapies in erectile dysfunction, selecting publications in PUBMED, including only relevant clinical trials, systematic reviews and meta-analyses.

RESULTS

We found 11 studies (7 clinical trials, 3 systematic review and 1 meta-analysis) that evaluated the use of LIEST for the treatment of erectile dysfunction. One clinical trial evaluated the applicability in Peyronie's Disease and one other clinical trial evaluated the applicability after radical prostatectomy.

CONCLUSIONS

The literature presents little scientific evidence but suggests good results with the use of LIEST for ED. Despite a real optimism since it is a treatment modality capable of acting on the pathophysiology of ED, we must remain cautious, until a larger volume of higher quality studies allows us to establish which patient profile, type of energy and application protocol will achieve clinically satisfactory results.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

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

Association between overweight, obesity, and quality of life of patients receiving an anticancer treatment for prostate cancer: a systematic literature review

BACKGROUND

Prostate cancer (PCa) and obesity are two ever-increasing public health issues that can independently impair the quality of life (QOL) of affected patients. Our objective was to evaluate the impact of overweight and obesity on the QOL of patients with PCa receiving an anticancer treatment.

METHODS

We performed a systematic review of the literature using PubMed, Embase, Cochrane Library and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The search equation targeted studies that included PCa patients who had a body mass index (BMI) greater than 25 kg/m², who were receiving anticancer therapy, and whose QOL was analyzed according to validated or non-validated scores.

RESULTS

Of 759 identified articles, we selected 20 studies published between 2000 and 2019 of 12,529 patients treated for PCa, including 5549 overweight or obese patients. QOL assessment was performed using nine validated scales and two non-validated questionnaires. Of seven studies on radiotherapy, six found obesity to have a negative impact on patients' QOL (especially urinary, sexual, and bowel-related QOL). Thirteen studies assessed the QOL of patients who underwent radical prostatectomy, with a BMI > 25 kg/m² having no observed impact. In obese patients under 65 years of age and without comorbidities, nerve-sparing surgery appeared to limit the deterioration of QOL. Four studies on brachytherapy found discordant results. One study showed greater QOL impairment in obese patients receiving first-generation hormone therapy than in those with normal or decreased BMI. No study evaluated the QOL of overweight or obese patients receiving other types of systemic treatment.

CONCLUSION

Based on the published data, the level of evidence for an association between QOL and overweight or obesity in patients treated for PCa is not high. Prospective cohort studies including this type of patient population are warranted to answer this topical public health issue.

Combining prostate health index and multiparametric magnetic resonance imaging may better predict extraprostatic extension after radical prostatectomy

BACKGROUND

In patients undergoing radical prostatectomy (RP) for prostate cancer (PCa), preoperative prediction of extraprostatic extension (EPE) can facilitate patient selection for nerve-sparing procedures. Since both multiparametric magnetic resonance imaging (mpMRI) and prostate health index (PHI) have shown promise for the diagnosis and prognostication of PCa, we investigated whether a combination of mpMRI and PHI evaluations can improve the prediction of EPE after RP.

METHODS

Patients diagnosed with PCa and treated with RP were prospectively enrolled between February 2017 and July 2019. Preoperative blood samples were analyzed for PHI (defined as [p2PSA/fPSA] × √tPSA), and mpMRI examinations were performed and interpreted by a single experienced uroradiologist retrospectively. The area under the receiver operating characteristic curve (ROC) was used to determine the performance of mpMRI, PHI, and their combination in predicting EPE after RP.

RESULTS

A total of 163 patients were included for analysis. The pathological T stage was T3a or more in 59.5%. Overall staging accuracy of mpMRI for EPE was 72.4% (sensitivity and specificity: 73.2% and 71.2%, respectively). The area under the ROC of the combination of mpMRI and PHI in predicting EPE (0.785) was higher than those of mpMRI alone (0.717; p = 0.0007) and PHI alone (0.722; p = 0.0236). mpMRI showed false-negative non-EPE results in 26 patients (16%), and a PHI threshold of >40 could avoid undiagnosed EPE before RP in 21 of these 26 patients.

CONCLUSION

The combination of PHI and mpMRI may better predict the EPE preoperatively, facilitating preoperative counseling and tailoring the need for nerve-sparing RP.

Focal Therapy for Prostate Cancer: The Impact on Sexual Function

Focal therapy (FT) has emerged as a potential treatment for localized prostate cancer (PCa) with encouraging functional outcomes. According to the compelling evidence based on meta-analyses and recent trials, erectile function (EF) is mostly retained at 6 and 12 months after FT when compared to baseline. These findings are consistent across different energy sources reported to date. However, overall, quality of life, including impotence, was not the endpoint for most studies. Additionally, impotency has not been consistently reported in most of the recent literature. Furthermore, confounding factors such as baseline potency and usage of phosphodiesterase 5 inhibitors (PDE5-I) were also frequently undisclosed. Long-term functional outcomes are awaited. To fully comprehend how FT affects EF, more extensive long-term randomized clinical trials using EF as a primary outcome are needed.

Effect of Race and Ethnicity on Risk of Radiotherapy Toxicity and Implications for Radiogenomics

AIMS

Patient factors affect the risk of radiotherapy toxicity, but many are poorly defined. Studies have shown that race affects cancer incidence, survival, drug response, molecular pathways and epigenetics. Effects on radiosensitivity and radiotherapy toxicity are not well studied. The aim of the present study was to identify the effects of race and ethnicity on the risk of radiotherapy toxicity.

MATERIALS AND METHODS

A systematic review was carried out of PubMed, Ovid Medline and Ovid Embase with no year limit. PRISMA 2020 guidelines were followed. Two independent assessors reviewed papers.

RESULTS

Of 607 papers screened, 46 fulfilled the inclusion criteria. Papers were published between 1996 and 2021 and involved 30-28,354 individuals (median 433). Most involved patients with prostate (33%), breast (26%) and lung (9%) cancer. Both early and late toxicities were studied. Some studies reported a higher risk of toxicity in White men with prostate cancer compared with other races and ethnicities. For breast cancer patients, some reported an increased risk of toxicity in White women compared with other race and ethnic groups. In general, it was difficult to draw conclusions due to insufficient reporting and analysis of race and ethnicity in published literature.

CONCLUSIONS

Reporting of race and ethnicity in radiotherapy studies must be harmonised and improved and frameworks are needed to improve the quality of reporting. Further research is needed to understand how ancestral heritage might affect radiosensitivity and risk of radiotherapy toxicity.

High levels of health-related quality of life five years after curative treatment of prostate cancer with HDR-brachytherapy and external beam radiation

BACKGROUND AND PURPOSE

The aim of this cross-sectional study was to investigate long-term health-related quality of life (HRQoL) in men with prostate cancer treated 2002-2008 with external beam radiotherapy (EBRT) combined with high dose-rate brachytherapy (HDRBT), Cohort A, and to compare these data with age-adjusted normative data. In addition, differences in HRQoL following adjustments of the brachytherapy technique in 2001 were investigated by comparing Cohort A with men treated at the same clinic from 1998-2000, Cohort B.

METHODS AND MATERIAL

Cohort A: 1495 men treated with EBRT 2 Gy to 50 Gy and 2 fractions of 10 Gy HDRBT at a single centre, 2002-2008, still alive at five years. As part of routine follow-up, the patients responded to the EORTC QLQ-C30 and PR-25 questionnaires. Cohort B: HRQoL data was retrieved from an earlier study from the original article.

RESULTS

In Cohort A, 1046 (70%) men completed the questionnaires at five years, median age 66 years. In general, HRQoL mean scores were high and similar to Swedish age-matched normative data. Concerning disease-specific HRQoL, low levels of bowel and urinary problems were reported, in contrast to a substantial effect on sexual functioning. 'No' or 'A little' problems with faecal incontinence and urinary incontinence were reported by 98% and 93% of patients, respectively. The corresponding figure for sexual functioning was 39%. A difference in the frequency of nocturia in favour of Cohort A was the only statistically significant difference between Cohort A and B found in general and disease-specific HRQOL (p = 0.03), despite modifications in the brachytherapy procedure introduced in 2001.

CONCLUSION

Long-term general HRQoL was rated high and comparable to an aged-matched reference population five years after treatment with combined radiotherapy. Disease-specific HRQoL was still affected, foremost in the sexual domain.

High Neuroticism Is Related to More Overall Functional Problems and Lower Function Scores in Men Who Had Surgery for Non-Relapsing Prostate Cancer

The personality trait of neuroticism is associated with adverse health outcomes after cancer treatment, but few studies concern men treated for prostate cancer. We examined men with high and low neuroticism treated with radical prostatectomy for curable prostate cancer without relapse. We compared overall problems and domain summary scores (DSSs) between these groups, and if high neuroticism at pre-treatment was a significant predictor of overall problems and DSSs at follow-up. A sample of 462 relapse-free Norwegian men self-rated neuroticism, overall problems, and DSSs by the EPIC-26 before surgery and at three years’ follow-up. Twenty-one percent of the sample had high neuroticism. Patients with high neuroticism reported significantly more overall problems and DSSs at pre-treatment. At follow-up, only overall bowel problems and urinary irritation/obstruction and bowel DSSs were different. High neuroticism was a significant predictor of overall bowel problems and bowel and irritation/obstruction DSSs at follow-up. High neuroticism at pre-treatment was significantly associated with a higher rate of overall problems both at pre-treatment and follow-up and had some significant predictions concerning bowel problems and urinary obstruction at follow-up. Screening for neuroticism at pre-treatment could identify patients in need of more counseling concerning later adverse health outcomes.

Development and Validation of Dynamic Multivariate Prediction Models of Sexual Function Recovery in Patients with Prostate Cancer Undergoing Radical Prostatectomy: Results from the MUSIC Statewide Collaborative

Background

Radical prostatectomy (RP) is the most common definitive treatment for men with intermediate-risk prostate cancer and is frequently complicated by erectile dysfunction.

Objective

To develop and validate models to predict 12- and 24-month post-RP sexual function.

Design, setting, and participants

Using Michigan Urological Surgery Improvement Collaborative (MUSIC) registry data from 2016 to 2021, we developed dynamic, multivariate, random-forest models to predict sexual function recovery following RP. Model factors (established a priori) included baseline patient characteristics and repeated assessments of sexual satisfaction, and Expanded Prostate Cancer Index Composite 26 (EPIC-26) overall scores and sexual domain questions.

Outcome measurements and statistical analysis

We evaluated three outcomes related to sexual function: (1) the EPIC-26 sexual domain score (range 0–100); (2) the EPIC-26 sexual domain score dichotomized at ≥73 for “good” function; and (3) a dichotomized variable for erection quality at 12 and 24 months after RP. A gradient-boosting decision tree was used for the prediction models, which combines many decision trees into a single model. We evaluated the performance of our model using the root mean squared error (RMSE) and mean absolute error (MAE) for the EPIC-26 score as a continuous variable, and the area under the receiver operating characteristic curve (AUC) for the dichotomized EPIC-26 sexual domain score (SDS) and erection quality. All analyses were conducted using R v3.6.3.

Results and limitations

We identified 3983 patients at 12 months and 2494 patients at 24 months who were randomized to the derivation cohort at 12 and 24 months, respectively. Using baseline information only, our model predicted the 12-month EPIC-26 SDS with RMSE of 24 and MAE of 20. The AUC for predicting EPIC-26 SDS ≥73 (a previously published threshold) was 0.82. Our model predicted 24-month EPIC-26 SDS with RMSE of 26 and MAE of 21, and AUC for SDS ≥73 of 0.81. Inclusion of post-RP data improved the AUC to 0.91 and 0.94 at 12 and 24 months, respectively. A web tool has also been developed and is available at https://ml4lhs.shinyapps.io/askmusic_prostate_pro/.

Conclusions

Our model provides a valid way to predict sexual function recovery at 12 and 24 months after RP. With this dynamic, multivariate (multiple outcomes) model, accurate predictions can be made for decision-making and during survivorship, which may reduce decision regret.

Patient summary

Our prediction model allows patients considering prostate cancer surgery to understand their probability before and after surgery of recovering their erectile function and may reduce decision regret.

Symptom burden profiles in men with advanced prostate cancer undergoing androgen deprivation therapy

To identify symptom burden profiles among men with advanced prostate cancer undergoing androgen-deprivation therapy and examine their association with baseline sociodemographic and medical characteristics and psychosocial outcomes over time. Latent profile analysis was employed to identify distinct groups based on the Expanded Prostate Index Composite and the McGill Pain Questionnaire at baseline. Psychosocial outcomes were assessed at baseline, 6- and 12-month follow-ups. Three profiles emerged: "high symptom burden," "high sexual bother," and "low symptom burden." Men with "high symptom burden" were younger and exhibited higher baseline levels of depression, stress, cancer-specific distress, and anxiety than men in the other two groups. However, men with "high symptom burden" also demonstrated improvement in these psychosocial outcomes over time. Men with advanced prostate cancer who experience multiple co-occurring symptoms demonstrate worse psychosocial adjustment. Patients with substantial symptom burden, and specifically young men, may benefit from prompt referral to supportive care services.

Applications of artificial intelligence in the diagnosis and prediction of erectile dysfunction: a narrative review

Despite the high prevalence of erectile dysfunction, patients are reluctant to seek medical advice, which leads to low diagnostic rates in clinical practice. Artificial intelligence has been widely applied in the diagnosis of many diseases and may alleviate the situation. However, the applications of artificial intelligence in erectile dysfunction have not been reviewed to date. Therefore, the assistance from artificial intelligence needs to be summarized. In this review, 418 publications before January 10, 2021, regarding artificial intelligence applications in diagnosing and predicting erectile dysfunction, were retrieved from five databases, including PubMed, EMBASE, the Cochrane Library, and two Chinese databases (WANFANG and CNKI). In addition, the reference lists of the included studies or relevant reviews were checked to avoid bias. Finally, 30 articles were reviewed to summarize the current status, merits, and limitations of applying artificial intelligence in diagnosing and predicting erectile dysfunction. The results showed that artificial intelligence contributed to developing novel diagnostic questionnaires, equipment, expert systems, classifiers by images and predictive models. However, most of the included studies were not subjected to external validations, resulting in doubt on the generalizability. In the future, more rigorously designed studies with high-quality datasets for erectile dysfunction are required.

Predicting post-radiation genitourinary hospital admissions in patients with localised prostate cancer

PURPOSE

The risk of treatment-related toxicity is important for patients with localised prostate cancer to consider when deciding between treatment options. We developed a model to predict hospitalisation for radiation-induced genitourinary toxicity based on patient characteristics.

METHODS

The prospective South Australian Prostate Cancer Clinical Outcomes registry was used to identify men with localised prostate cancer who underwent curative intent external beam radiotherapy (EBRT) between 1998 and 2019. Multivariable Cox proportional regression was performed. Model discrimination, calibration, internal validation and utility were assessed using C-statistics and area under ROC, calibration plots, bootstrapping, and decision curve analysis, respectively.

RESULTS

There were 3,243 patients treated with EBRT included, of which 644 (20%) patients had a treated-related admission. In multivariable analysis, diabetes (HR 1.35, 95% CI 1.13-1.60, p < 0.001), smoking (HR 1.78, 95% CI 1.40-2.12, p < 0.001), and bladder outlet obstruction (BOO) without transurethral resection of prostate (TURP) (HR 7.49, 95% CI 6.18-9.08 p < 0.001) followed by BOO with TURP (HR 4.96, 95% CI 4.10-5.99 p < 0.001) were strong independent predictors of hospitalisation (censor-adjusted c-statistic = 0.80). The model was well-calibrated (AUC = 0.76). The global proportional hazards were met. In internal validation through bootstrapping, the model was reasonably discriminate at five (AUC 0.75) years after radiotherapy.

CONCLUSIONS

This is the first study to develop a predictive model for genitourinary toxicity requiring hospitalisation amongst men with prostate cancer treated with EBRT. Patients with localised prostate cancer and concurrent BOO may benefit from TURP before EBRT.

Robot-Assisted Radical Prostatectomy Maneuvers to Attenuate Erectile Dysfunction: Technical Description and Video Compilation

Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.

Patient Education for Radical Prostatectomy: Development of a Program Tailored to the Needs of Prostate Cancer Patients

In all, 30% to 90% of prostate cancer patients undergoing radical prostatectomy (RP) recover their erectile capacity. No effective post RP erectile rehabilitation program exists to date. The aim of this exploratory qualitative study is to explore the needs of these patients and to develop a patient education program (PEP) which meets these needs. Interviews were carried out by a socio-anthropologist with prostate cancer patients treated by RP within the 6 previous months. The needs and expectations identified led to the choice of a logical model of change for the construction of the PEP. Nineteen patients were included in the study; 17 of them were living with a partner. Two categories of patients appeared during the interviews: informed patients resigned to lose their sexuality and patients misinformed about the consequences of the surgery. The tailored program was built on the Health Belief Model and provides six individual sessions, including one with the partner, to meet the needs identified. This study designed the first program to target comprehensively the overall sexuality of the patient and his partner, and not only erection issues. To demonstrate the effectiveness of this program, a controlled, multicentric clinical trial is currently ongoing.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

Oncological and Functional Outcomes of Patients Undergoing Individualized Partial Gland Cryoablation of the Prostate: A Single-Institution Experience

Objectives: We aim at reporting the functional and oncological outcomes in men with localized prostate cancer who underwent individualized partial gland cryoablation of the prostate by using validated quality-of-life instruments. Methods: We retrospectively reviewed our cryosurgery database between July 2003 and September 2019 for men who were treated with individualized partial gland cryoablation of the prostate at our tertiary care center. Baseline and periodic urinary and sexual function surveys were administered throughout the post-treatment period. Results: A total of 82 men were included in the study. Median follow-up was 28 months (interquartile range: 10.5-59.3 months). A total of 71 men underwent primary individualized partial gland cryoablation, whereas 11 men underwent salvage partial gland ablation. Failure-free survival at 1 to 5 years was 98%, 89%, 84%, 75%, and 75% in the primary therapy group, and 100%, 80%, and 40% in the salvage group at 1 to 3 years, respectively. In the primary therapy group, all 71 patients remained free of pads at 3 months and throughout the follow-up period. Men who had undergone primary focal cryoablation had a higher post-treatment International Index of Erectile Function (IIEF) score, followed by men treated with primary hemi-cryoablation and primary subtotal cryoablation. The American Urological Association (AUA) symptom scores decreased regardless of the type of partial gland ablation performed, with subtotal ablation having the lowest score compared with hemiablation and focal cryoablation. No patient developed a fistula in the primary group, and 1 (9%) patient developed a fistula in the salvage group. Conclusion: Individualized partial gland cryoablation of the prostate is able to achieve excellent oncological and functional outcomes in select men with localized prostate cancer.

Comorbidity, lifestyle factors, and sexual satisfaction among Chinese cancer survivors

Objectives

This study aims to explore the prevalence of sexual satisfaction among Chinese cancer survivors, and explore the association of sexual satisfaction with comorbidity and lifestyle factors.

Methods

A cross‐sectional study was performed among 3996 Chinese cancer survivors recruited at Shanghai Cancer Rehabilitation Club from March to April 2017. Data were collected through self‐reported questionnaires. The questionnaire includes information about demographic, cancer characteristics, comorbidities, lifestyle factors, and sexual satisfaction. Sexual satisfaction was measured by a single‐item scale. The distribution of sexual satisfaction among different demographic and cancer characteristics was compared using the chi‐squared test. Logistic regression models were conducted to assess the effects of lifestyle factors, comorbidities on sexual satisfaction after adjustment for demographic and cancer characteristics.

Results

More than 40% of male and female cancer survivors reported no sexual satisfaction. Sexual satisfaction of cancer survivors is significantly associated with both the number and the type of comorbidities. Heart disease, musculoskeletal system disease, diabetes, and hyperlipidemia are the comorbidities significantly associated with sexual satisfaction of cancer survivors. Lifestyle factors other than smoking, including exercise or fitness, drinking alcohol, and eating fruits and vegetables are significantly correlated with sexual satisfaction. Besides, all of the above associations show gender differences. In addition, demographic characteristics include sex, age, marital status, living status, and average monthly income are also significantly associated with sexual satisfaction of cancer survivors.

Conclusion

Comorbidity and lifestyle factors are associated with sexual satisfaction of cancer survivors, and the associations show gender differences. Improving the lifestyles of cancer survivors, and controlling and reducing their comorbidities are important for improving their sexual satisfaction.

This study aims to investigate the prevalence of sexual satisfaction among Chinese cancer survivors, and explore the association of sexual satisfaction with comorbidity and lifestyle factors. Comorbidity and lifestyle factors are associated with sexual satisfaction of cancer survivors, and the associations show gender differences. Improving the lifestyles of cancer survivors, and controlling and reducing their comorbidities are important for improving their sexual satisfaction.

Sexual function outcomes of radiation and androgen deprivation therapy for localized prostate cancer in men with good baseline function

BACKGROUND

Sexual dysfunction, including erectile dysfunction and loss of libido, are common among men undergoing treatment for localized prostate cancer. Both local treatments and systemic androgen deprivation therapy may contribute to these outcomes and are differentially indicated based on disease characteristics. We sought to compare sexual function through 5 years after radiation treatment with and without androgen deprivation therapy in men with good baseline sexual function to better understand long-term effects in this understudied subset of patients.

METHODS

We retrospectively reviewed a prospectively assembled population-based cohort of men who underwent radiation with and without androgen deprivation therapy for intermediate or high-risk localized prostate cancer. Sexual function was assessed longitudinally over 5 years. Men with erections sufficient for intercourse at baseline were selected for inclusion.

RESULTS

Out of 167 patients included, 73 underwent radiation alone and 94 received androgen deprivation therapy plus radiation (51 with intermediate and 43 with high-risk disease). Androgen deprivation therapy use was associated with worse sexual function through 1 year regardless of disease risk. This difference was no longer statistically significant at 3 years in the intermediate-risk group. Compared to radiation alone, androgen deprivation therapy in high-risk disease was associated with worse sexual function at 3 years (effect: -20.3 points, CI [-31.8, -8.8], p < 0.001) but not at 5 years (effect: -3.4, CI [-17.2, 10.5], p = 0.63).

CONCLUSIONS

Androgen deprivation therapy plus radiation is associated with worse sexual function through 3-years follow-up in men with high-risk prostate cancer compared to radiation alone. The addition of androgen deprivation therapy in the treatment of intermediate-risk disease does not appear to result in worse sexual function at 3 or 5-year follow-up compared to radiation alone.

Modeling-Based Decision Support System for Radical Prostatectomy Versus External Beam Radiotherapy for Prostate Cancer Incorporating an In Silico Clinical Trial and a Cost-Utility Study

Simple Summary

Low–intermediate prostate cancer has a number of viable treatment options, such as radical prostatectomy and radiotherapy, with similar survival outcomes but different treatment-related side effects. The aim of this study is to facilitate patient-specific treatment selection by developing a decision support system (DSS) that incorporates predictive models for cancer-free survival and treatment-related side effects. We challenged this DSS by validating it against randomized clinical trials and assessing the benefit through a cost–utility analysis. We aim to expand upon the applications of this DSS by using it as the basis for an in silico clinical trial for an underrepresented patient group. This modeling study shows that DSS-based treatment decisions will result in a clinically relevant increase in the patients’ quality of life and can be used for in silico trials.

Abstract

The aim of this study is to build a decision support system (DSS) to select radical prostatectomy (RP) or external beam radiotherapy (EBRT) for low- to intermediate-risk prostate cancer patients. We used an individual state-transition model based on predictive models for estimating tumor control and toxicity probabilities. We performed analyses on a synthetically generated dataset of 1000 patients with realistic clinical parameters, externally validated by comparison to randomized clinical trials, and set up an in silico clinical trial for elderly patients. We assessed the cost-effectiveness (CE) of the DSS for treatment selection by comparing it to randomized treatment allotment. Using the DSS, 47.8% of synthetic patients were selected for RP and 52.2% for EBRT. During validation, differences with the simulations of late toxicity and biochemical failure never exceeded 2%. The in silico trial showed that for elderly patients, toxicity has more influence on the decision than TCP, and the predicted QoL depends on the initial erectile function. The DSS is estimated to result in cost savings (EUR 323 (95% CI: EUR 213–433)) and more quality-adjusted life years (QALYs; 0.11 years, 95% CI: 0.00–0.22) than randomized treatment selection.

Impact of Age on Patient-Reported Outcomes Following Stereotactic Body Radiation Therapy for Prostate Cancer

Purpose

Stereotactic body radiation therapy (SBRT) delivers large radiation doses to the prostate while minimizing exposure to adjacent normal tissues. Large fraction sizes may increase the risks of functional decrements. Elderly men may be at an increased risk of these toxicities due to poor baseline function and hence limited reserve. This study describes patient-reported outcomes following SBRT for clinically localized prostate cancer in the elderly.

Methods

Between 2007 and 2017, 179 hormone-naive elderly patients (≥ 70 years old) and 210 patients under 70 years old with clinically localized prostate cancer were treated with 35-36.25 Gy SBRT in five fractions utilizing the CyberKnife Radiosurgical System (Accuray Inc.). Quality of life (QOL) was assessed using the Expanded Prostate Index Composite-Short Form (EPIC-26) questionnaire at baseline and at 1, 3, 6, 12, 18, 24, 30, and 36 months following the completion of treatment. EPIC scores range from 0 to 100, with lower values representing worsening symptoms.

Results

EPIC scores in the elderly cohort mirrored those in the younger cohort. EPIC urinary obstructive/irritative scores declined at one month post-SBRT (mean change from baseline ≥70: -7.9; <70: -11.1) before returning to baseline at three months post-SBRT (mean change from baseline ≥70: -0.4; <70: -1.4). The EPIC urinary incontinence scores declined slowly over the three years following treatment without recovery (mean change from baseline ≥70: -6.6; <70: -4.8). EPIC Bowel scores transiently declined at one month post-SBRT (mean change from baseline ≥70: -8.5; <70: -9.1) and then experienced a second more protracted decline over the next three years without recovery (mean change from baseline ≥70: -4.5; <70: -1.8). Hormonal EPIC scores were not impacted by radiation treatment or age. Older men had lower baseline and post-treatment EPIC sexual summary scores at all time points. However, there was no clinically significant difference in the EPIC sexual bother score between younger and older men at baseline and following treatment.

Conclusions

In the first three years following treatment, the impact of SBRT treatment on patient-reported outcomes was minimal. Our findings suggest that SBRT for clinically localized prostate cancer should not be deferred in older men solely due to concerns of increased morbidity. Further studies should be conducted to evaluate the impact of age on outcomes or morbidity following SBRT.

The one hundred most cited publications in prostate brachytherapy

PURPOSE

The aim of this study is to identify the leaders in research on prostate brachytherapy through a bibliometric analysis of the top 100 most cited publications in the field.

METHODS AND MATERIALS

A broad search was performed with the term "prostate brachytherapy" using the Web of Science database to generate wide-ranging results that were reviewed by reading the abstracts and, if necessary, the articles to select the top 100 most cited publications.

RESULTS

The median of the total citation count was 187 (range 132-1464). The median citation per year index (citations/year since publication) was 13.5 (range 6.3-379.0). In all publications, the first author was also the corresponding author. The top publishing countries of the first author included the United States (n = 78), Canada (n = 6), the UK (n = 5), and Germany (n = 4). The journal with the most publications was the International Journal of Radiation Oncology Biology Physics (n = 38). There were 27 more publications on low-dose-rate (LDR) than on high-dose-rate (HDR) (43 vs 16) among the top 100. HDR publications had only one first author that had three articles in comparison to LDR publications, which had four first authors, each with three articles on LDR. The United States was the leading country in 43.8% of HDR publications (n = 7) and 88.4% of LDR publications (n = 38).

CONCLUSIONS

Our bibliometric analysis of the top 100 most cited publications clearly demonstrates the North American dominance in the publications of prostate brachytherapy, especially in LDR. However, European first authors were more frequent in HDR publications.

Complications and side effects of high-dose-rate prostate brachytherapy

PURPOSE

To describe technical challenges and complications encountered during and after high-dose-rate prostate brachytherapy (HDR-BT) and review management of these complications.

METHODS AND MATERIALS

The authors performed a systematic review of the literature on toxicities encountered after prostate HDR-BT +/- external beam radiotherapy. A total of 397 studies were identified, of which 64 were included. A focused review of literature regarding the management of acute and late toxicities also performed.

RESULTS

Most acute toxicities include grade 0-2 genitourinary and gastrointestinal toxicity. Overall, Grade 3+ Common Terminology Criteria for Adverse Events toxicity after HDR-BT was low [genitourinary: 0-1%; gastrointestinal 0-3%]. Rates of fistula formation were <1%, and radiation cystitis/proctitis were <14% and more commonly reported in cohorts treated with HDR-BT boost and external beam radiotherapy.

CONCLUSIONS

HDR-BT both as monotherapy or combined with external beam radiotherapy for prostate cancer is well tolerated. Serious complications are rare.

Sexual aspects of shared decision making and prehabilitation in men diagnosed with prostate cancer

This article addresses sexual aspects of two related HCP-roles in the period between a diagnosis of prostate cancer (PC) and the start of treatment. First, the 'lovemap-perspective' is used to fine-tune the process of shared decision making. Then sexual prehabilitation is explored in detail, in the belief that better sexual function before starting treatment is more likely to lead to better post-treatment outcomes. Recommendations will be shared on further development of sexual prehabilitation approaches.

Predictors of erectile dysfunction after transperineal template prostate biopsy

Purpose

To investigate the incidence and possible contributing factors of erectile dysfunction (ED) after transperineal template prostate biopsy (TTPB).

Materials and Methods

Males undergoing TTPB were prospectively administered a Sexual Health Inventory for Men (SHIM) questionnaire before biopsy and one month after. SHIM questionnaires were repeated at 3- and 9-months for males not receiving interventional treatment. Sexually inactive males were excluded. Interval change in SHIM categories based upon baseline characteristics were evaluated. Multivariable logistic regression models were used to evaluate predictors of change in SHIM score category.

Results

A total of 576 males were included in our sample. Of these, 450 (78%) males underwent their first biopsy. A decline in SHIM category within the immediate 4-weeks post-biopsy was reported by 167 males (31% of total eligible sample). Age was the strongest predictor of decline in SHIM category, the predicted probability of a decline in SHIM at age 50 was 10% (95% confidence interval [CI], 1%–19%), 32% at age 60 (95% CI, 25%–40%) and 36% at age 70 (95% CI, 29%–44%). For new onset ED, the predicted probability of ED within 4-weeks post-TTPB were 6.7% at age 50 (95% CI, 0%–15%), 26% at age 60 (95% CI, 17%–34%) and 31% at age 70 (95% CI, 21%–40%).

Conclusions

Older age at biopsy is an independent predictor of immediate ED after TTPB in sexually active males. This association was observed in the subgroup with no pre-existing ED. These findings provide useful information when counselling males undergoing TTPB.

Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study

BACKGROUND

Preservation of erectile function is an important postoperative quality of life concern for patients after robot-assisted radical prostatectomy (RARP) for prostate cancer. Although erectile function may recover, many men continue to suffer from erectile dysfunction (ED).

AIM

This study aims to determine whether satisfaction with sexual life improves in patients with ED after RARP and which factors are associated with satisfaction during follow-up.

METHODS

A review was carried out of a prospectively maintained database of patients with prostate cancer who underwent a RARP between 2006 and 2019. The "International Index of Erectile Function" questionnaire was used to describe ED (range 5-25), overall satisfaction with sexual life and sexual desire (range for both: 2-10). Patients with ED due to RARP were compared with those without ED after RARP. Mixed effect model was used to test differences in satisfaction over time. Mann-Whitney U tests and multiple logistic regression were used to assess factors associated with being satisfied at 24 and 36 months.

OUTCOMES

The main outcomes of this study are the overall satisfaction with sexual life score over time and factors which influence sexual satisfaction.

RESULTS

Data of 2808 patients were reviewed. Patients whose erectile function was not known (n = 643) or who had ED at the baseline (n = 1281) were excluded. About 884 patients were included for analysis. They had an overall satisfaction score of 8.4. Patients with ED due to RARP had mean overall satisfaction scores of 4.8, 4.8, 4.9, and 4.6 at 6 mo, 12 mo, 24 mo, and 36 mo. These scores were significantly lower than those of patients without ED at every time point. In multiple regression analysis, higher overall satisfaction score at the baseline and higher sexual desire at 24 and 36 months' follow-up were associated with satisfaction with sexual life at 24 and 36 months' follow-up. No association was found for erectile function.

CLINICAL IMPLICATIONS

Interventions focusing on adjustment to the changes in sexual functioning might improve sexual satisfaction; especially for those men who continue to suffer from ED.

STRENGTHS & LIMITATIONS

Strengths of this study are the large number of patients, time of follow-up, and use of multiple validated questionnaires. Our results must be interpreted within the limits of retrospectively collected, observational data.

CONCLUSION

Satisfaction with sexual life in men with ED due to RARP may take a long time to improve. One could counsel patients that sexual satisfaction is based on individual baseline sexual satisfaction and the return of sexual desire after RARP. Albers LF, Tillier CN, van Muilekom HAM, et al. Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study. J Sex Med 2021;18:339-346.

Outcomes of Minimally Invasive Radical Prostatectomy-a Contemporary Review

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.

Optimizing Surgical Techniques in Robot-Assisted Radical Prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most common surgical treatment of localized prostate cancer. The ideal procedure would achieve maximum oncological efficacy while minimizing associated side effects, such as erectile dysfunction and urinary incontinence. Surgeon experience and surgical technique affect RARP outcomes. Here, the authors review RARP technical modifications aimed at optimizing cancer control and postoperative urinary and sexual function.

Impact of Sarcopenia on Erectile Function after Nerve-Sparing Robot-Assisted Radical Prostatectomy

PURPOSE

To determine the impact of sarcopenia on erectile functional outcomes after a nerve-sparing (NS) robot-assisted radical prostatectomy (RARP) using patient-reported validated questionnaires.

MATERIALS AND METHODS

In this retrospective study, RARP was performed on 841 patients at Okayama University Hospital, of which 132 underwent NS RARP. Erectile functional outcomes were assessed using the 5-item version of the International Index of Erectile Function (IIEF-5) and the Expanded Prostate Cancer Index Composite before and 1, 3, 6, and 12 months after surgery. Automated measurement of skeletal muscle at L3 was achieved using volume analyzer software and normalizing for height (cm²/m²) to calculate skeletal muscle index (SMI). Patients who had an IIEF-5≤4 comprised the group with erectile dysfunction (ED), and those with an IIEF-5≤5 made up the non-ED group.

RESULTS

This study enrolled 95 patients of median age 65 years with a preoperative IIEF-5 of 16. There were no significant differences between patients with and without sarcopenia among those with preoperative IIEF-5. Postoperatively, in the ED group, SMI and preoperative IIEF-5 were significantly lower than in the non-ED group. Multiple linear regression analysis revealed that (1) both SMI and preoperative IIEF-5 were independent predictors of ED, and (2) sarcopenia and preoperative IIEF-5 were predictors of ED at 12 months after NS RARP.

CONCLUSIONS

Patients with sarcopenia can have worse erectile functional outcomes after NS RARP. Sarcopenia and a lower preoperative IIEF-5 score may be predictive of postoperative ED.

Risk of erectile dysfunction after modern radiotherapy for intact prostate cancer

BACKGROUND

Erectile dysfunction (ED) is a prevalent side effect of prostate cancer treatment. We hypothesized that the previously reported rates of ED may have improved with the advent of modern technology. The purpose of this project was to evaluate modern external beam radiotherapy and brachytherapy techniques to determine the incidence of radiotherapy (RT) induced ED.

METHODS

A systematic review of the literature published between January 2002 and December 2018 was performed to obtain patient reported rates of ED after definitive external beam radiotherapy, ultrafractionated stereotactic radiotherapy, and brachytherapy (BT) to the prostate in men who were potent prior to RT. Univariate and multivariate analyses of radiation dose, treatment strategy, and length of follow-up were analyzed to ascertain their relationship with RT-induced ED.

RESULTS

Of 890 articles reviewed, 24 met inclusion criteria, providing data from 2714 patients. Diminished erectile function status post RT was common and similar across all studies. The median increase in men reporting ED was 17%, 26%, 23%, and 23%, 3DCRT, IMRT, low dose rate BT, and SBRT, respectively, at 2-year median follow-up.

CONCLUSION

ED is a common side effect of RT. Risk of post-RT ED is similar for both LDR brachytherapy and external beam RT with advanced prostate targeting and penile-bulb sparing techniques utilized in modern RT techniques.

Challenges in Reporting the Effect of Radiotherapy on Erectile Function

BACKGROUND

Erectile dysfunction (ED) is the most common side effect of prostate radiotherapy (RT), but reported rates over time and across modalities have varied widely.

AIM

To evaluate the published literature between 2002 and 2018 for high quality data utilizing prospectively gathered patient-reported ED, and to summarize the challenges in reporting of RT-induced ED (RIED).

METHODS

A PubMed search and literature review was performed to identify articles describing rates of ED before and after definitive external beam RT or brachytherapy without androgen deprivation.

OUTCOMES

Patient-reported ED, patient and treatment variables, and study follow-up constituted the main outcomes of this study.

RESULTS

24 articles were identified, reporting RIED rates between 17% and 90%. Variables contributing to this range included patient, treatment, and study characteristics known to impact ED reporting.

CLINICAL IMPLICATIONS

For future studies, we recommend the use of validated patient-reported questionnaires and reporting of baseline function and comorbidities, RT type and dose, and use of androgen deprivation therapy and erectile aids at the time of ED measurement. With sufficient follow-up to understand the late nature of RIED, these recommendations will improve comparison of results between studies and the applicability of results to patients undergoing pretreatment counseling regarding the risks of RIED.

STRENGTHS & LIMITATIONS

The literature search and formulation of results were based on a broad understanding of the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the literature, but because of the focus on data reporting, a comprehensive systematic review of all RIED literature was not performed.

CONCLUSION

Reported rates of ED after RT vary widely due to differences in patients' baseline reported erectile function, age, comorbidities, and characteristics of the treatment delivered. The methodology of ED measurement has significant impact on the applicability and comparability of results to other studies and clinical practice. Nukala V, Incrocci L, Hunt AA, et al. Challenges in Reporting the Effect of Radiotherapy on Erectile Function. J Sex Med 2020;17:1053-1059.

Development of Prostate Cancer Organoid Culture Models in Basic Medicine and Translational Research

Prostate cancer (PC) is the most prevalent cancer in men and the second main cause of cancer-related death in Western society. The lack of proper PC models that recapitulate the molecular and genomic landscape of clinical disease has hampered progress toward translational research to understand the disease initiation, progression, and therapeutic responses in each patient. Although several models have been developed, they hardly emulated the complicated PC microenvironment. Precision medicine is an emerging approach predicting appropriate therapies for individual cancer patients by means of various analyses of individual genomic profiling and targeting specific cancer pathways. In PC, precision medicine also has the potential to impose changes in clinical practices. Here, we describe the various PC models with special focus on PC organoids and their values in basic medicine, personalized therapy, and translational researches in vitro and in vivo, which could help to achieve the full transformative power of cancer precision medicine.

Development and Internal Validation of a Web-based Tool to Predict Sexual, Urinary, and Bowel Function Longitudinally After Radiation Therapy, Surgery, or Observation

BACKGROUND

Shared decision making to guide treatment of localized prostate cancer requires delivery of the anticipated quality of life (QOL) outcomes of contemporary treatment options (including radical prostatectomy [RP], intensity-modulated radiation therapy [RT], and active surveillance [AS]). Predicting these QOL outcomes based on personalized features is necessary.

OBJECTIVE

To create an easy-to-use tool to predict personalized sexual, urinary, bowel, and hormonal function outcomes after RP, RT, and AS.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, population-based cohort study was conducted utilizing US cancer registries of 2563 men diagnosed with localized prostate cancer in 2011-2012.

INTERVENTION

Patient-reported urinary, sexual, and bowel function up to 5 yr after treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patient-reported urinary, sexual, bowel, and hormonal function through 5 yr after treatment were collected using the 26-item Expanded Prostate Index Composite (EPIC-26) questionnaire. Comprehensive models to predict domain scores were fit, which included age, race, D'Amico classification, body mass index, EPIC-26 baseline function, treatment, and standardized scores measuring comorbidity, general QOL, and psychosocial health. We reduced these models by removing the instrument scores and replacing D'Amico classification with prostate-specific antigen (PSA) and Gleason score. For the final model, we performed bootstrap internal validation to assess model calibration from which an easy-to-use web-based tool was developed.

RESULTS AND LIMITATIONS

The prediction models achieved bias-corrected R-squared values of 0.386, 0.232, 0.183, 0.214, and 0.309 for sexual function, urinary incontinence, urinary irritative, bowel, and hormonal domains, respectively. Differences in R-squared values between the comprehensive and parsimonious models were small in magnitude. Calibration was excellent. The web-based tool is available at https://statez.shinyapps.io/PCDSPred/.

CONCLUSIONS

Functional outcomes after treatment for localized prostate cancer can be predicted at the time of diagnosis based on age, race, PSA, biopsy grade, baseline function, and a general question regarding overall health. Providers and patients can use this prediction tool to inform shared decision making.

PATIENT SUMMARY

In this report, we studied patient-reported sexual, urinary, hormonal, and bowel function through 5 yr after treatment with radical prostatectomy, radiation therapy, or active surveillance for localized prostate cancer. We developed a web-based predictive tool that can be used to predict one's outcomes after treatment based on age, race, prostate-specific antigen, biopsy grade, pretreatment baseline function, and a general question regarding overall health. We hope both patients and providers can use this tool to better understand expected outcomes after treatment, further enhancing shared decision making between providers and patients.

Impact of Pelvic Radiation Therapy on Inflatable Penile Prosthesis Reoperation Rates

INTRODUCTION

Considering that radiation therapy (RT) compromises soft tissue microvasculature, impairs wound healing, and causes cavernosal fibrosis, inflatable penile prosthesis (IPP) outcomes may be adversely affected in men treated with RT.

AIM

To compare IPP outcomes among those who had undergone prior RT vs a cohort who underwent radical prostatectomy (RP) before insertion of IPP.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare Database was queried for men with prostate cancer (PCa) who underwent RT (n = 83,277) or RP (n = 32,608) with subsequent IPP insertion between 2002 and 2013. Men who had undergone both RT and RP were excluded from the analysis.

MAIN OUTCOME MEASURE

The primary outcome was reoperation, defined by removal, revision, or replacement of the IPP.

RESULTS

We identified 350 men who received an IPP following RT and 653 who received an IPP following RP. Men who underwent RT were older (P < .01) and had more comorbidities (P < .01). There were no significant differences in overall reoperation rates at 90 days (P = .78), 1 year (P = .52), or 3 years (P = .48). Time-to-event analysis demonstrated that RT was not associated with an increased likelihood of overall reoperation (hazard ratio [HR] 1.46, 95% confidence interval [CI] 0.94-2.29, P = .09). There was no association between time from RT to IPP and overall reoperation rates.

CLINICAL IMPLICATIONS

Prior RT for the treatment of PCa does not impact the revision or removal rates of IPPs as compared with a cohort of non-radiated patients who underwent RP.

STRENGTH & LIMITATIONS

The strength includes the analysis of outcomes among a contemporary, nationwide cohort with robust follow-up. Using diagnosis and procedure codes, we were thoroughly able to capture reoperations. Limitations include the lack of specific indications for reoperation and inability to control for surgeon experience or technique.

CONCLUSION

IPP is a safe and effective treatment of erectile dysfunction that should be offered to men with a history of pelvic radiation who have failed medical therapy. Golan R, Patel NA, Sun T, et al. Impact of pelvic radiation therapy on inflatable penile prosthesis reoperation rates. J Sex Med 2018;15:1653-1658.

Sexual function recovery after robot-assisted radical prostatectomy: Outcomes from an Italian referral centre and predicting nomogram

Aims of this study were to assess sexual recovery after robotic-assisted radical prostatectomy (RARP) and to build a nomogram predicting 1-year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre-operatively, then at 45 days, and at 3, 6, 9, and 12 months post-operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient- and disease-related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1-year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate-specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre-operative counselling.