International Journal of Radiation Oncology*Biology*Physics
Clinical investigation: prostateMeta-analysis of rates of erectile function after treatment of localized prostate carcinoma☆
Introduction
In 1997, a meta-analysis was published of the rates of erectile dysfunction after radical prostatectomy and external beam radiotherapy (EBRT) (1). The results of this study have been used in patient 2, 3, 4 and professional 5, 6, 7, 8 educational materials and have provided a standard against which new treatments and findings are compared 9, 10, 11.
The reasons to update this meta-analysis are several. First, brachytherapy and cryotherapy could not be included in the 1997 meta-analysis because the number of published articles on these treatments was insufficient. With more published studies available, it is now possible to include brachytherapy and cryotherapy. Second, the 1997 study included articles in which the treating physician conducted the assessment of erectile function. The treating physician assessment of treatment complications has been shown to be biased 12, 13. With this finding, it is important to update the meta-analyses and exclude articles that may be biased in this way. Third, quality-of-life issues and, particularly, erectile function remain an important consideration for patients who have to choose between several possible prostate cancer treatments (14). The two traditional treatments, EBRT and radical prostatectomy, are considered to be equivalent in terms of survival benefits (15). The two newer treatments of brachytherapy and cryotherapy are also thought to offer survival benefits comparable to the traditional treatments 16, 17, 18, 19, 20, 21. In addition, watchful waiting still presents a reasonable choice for some patients (22). Given that none of these options are considered medically superior, healthcare professionals and patients often turn to the published data of the complication rates for each treatment to guide their decision. Hence, accurate estimates of the complication rates are needed. Finally, there are still no published randomized clinical trials comparing the available prostate cancer treatments with regard to their complication rates. Current knowledge is largely based on case series from single institutions reporting on single treatment methods. Consequently, a meta-analysis that combines the available case series continues to be the best method for obtaining estimates of the complication rates for each treatment. The results from meta-analyses are more robust than those obtained by referring to a single study or the box scores of significant results and avoid the subjectivity of a narrative review (23).
Section snippets
Data sources and study selection
A comprehensive literature search was conducted in December 2001 using the databases Medline and Cancerlit. Articles published in English, French, Dutch, or German were reviewed. The studies were selected using the following inclusion criteria: (1) articles published from 1970 onward; (2) studies reporting results of EBRT, radical prostatectomy, brachytherapy, and cryotherapy (combined use with neoadjuvant hormonal therapy was permitted); (3) studies reporting data on primary, discrete data
Description of studies
In total, 1475 articles were reviewed. Of these, 44 were excluded because they relied exclusively on the treating physician’s assessment of erectile function. Only 54 study reports met all the inclusion criteria and were selected for this meta-analysis (references for the articles are available from the corresponding author). A breakdown of the number of studies for each treatment method is given in Table 1. Among the studies reporting on radical prostatectomy, we distinguished between studies
Discussion
The potential loss of erectile function is a major consideration for prostate cancer patients when assessing their treatment options. For some men, it may influence whether to undergo treatment at all 30, 31, 32. This meta-analysis provides estimates on the relative probability of maintaining erectile function after EBRT, brachytherapy plus EBRT, brachytherapy, standard radical prostatectomy, nerve-sparing radical prostatectomy, and cryotherapy. The findings showed statistically significant
Conclusion
The findings indicate that men who are concerned about retaining their erectile function have reason to choose one treatment over another. Brachytherapy had the highest probability approximately 1 year after treatment and thus appears to offer the best chance of retaining erectile function after treatment for localized prostate cancer, at least in the short term. Patients need to be cautioned that further declines may occur with time. It should be noted that any advantage of brachytherapy over
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The Natural History of Erectile Dysfunction After Prostatic Radiotherapy: A Systematic Review and Meta-Analysis
2017, Journal of Sexual MedicineCitation Excerpt :We excluded studies of surgery, cryotherapy, and high-intensity focused ultrasound therapy. Studies without baseline measurements of ED or studies that asked patients to self-recall erectile function before RT were excluded to avoid recall bias.9 Figure 1 presents the flow of evidence acquisition and the application of our inclusion and exclusion criteria.
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Supported by a grant from Indigo Medical, Johnson and Johnson.