Prostate mono brachytherapy (PMB) is an accepted treatment option for Gleason 6 prostate cancer. In individual cases, patients with Gleason 7 cancer with concerns of erectile dysfunction often elect to undergo PMB. Retrospectively, we analyzed our database with the hypothesis that PMB can be an accepted treatment option for Gleason 7 cancer. We identified 61 patients from the Cleveland Clinic database (1997-2003), that underwent PMB for a Gleason 7 cancer and had a minimum follow-up of 4 years. We compared it to 56 patients with Gleason 6 cancer from the author's personal series in the same time period. We subdivided the Gleason 7 cancers into Gleason 7 (3+4) and Gleason 7 (4+3). In our Gleason 7 group, we found 48 had Gleason 3+4 and 13 had Gleason 4+3 cancer. The mean age of the patients in Gleason 7 (3+4) group was 68.2 years; in Gleason 7 (4+3) – 71 years; in Gleason 6-65 years. The mean baseline PSA of both the groups were comparable; Gleason 6-6.67; overall Gleason 7-6.70. In Gleason 6 group, the mean PSA at 4 years was 0.18 ± 0.20 with a 3.5% biochemical failure rate (ASTRO). In Gleason 7 (3+4) group, the mean PSA at 4 years was 0.16 ± 0.17 with a 6.2% biochemical failure rate. In Gleason 7 (4+3) group, the mean PSA at 4 years was 0.70 ± 0.74 with a 23% biochemical failure rate. There were 3 failures in the Gleason 7 (3+4) group, 3 failures in Gleason 7 (4+3) group and 2 failures in Gleason 6 - all 8 failures occurring between 2 and 3 years. Our intermediate data indicates that prostate mono brachytherapy is an acceptable treatment option for low intermediate risk Gleason 7 cancers. At 4 years, our biochemical cure rate for Gleason 7 (3+4) cancer (94%) was comparable to Gleason 6 (97%). This data should impact positively on our selection criteria for prostate mono brachytherapy, such that low intermediate risk Gleason 7 cancers can be routinely recommended.

Prostate mono brachytherapy (PMB) is an accepted option for Gleason 6, low-volume Gleason 7 prostate cancers, and is being offered more frequently in younger patients. Unfortunately, erectile dysfunction can be a side effect from PMB, occurring frequently in the first 12 months following treatment. This study examines the use of early PDE-5 inhibitors (sildenafil citrate) in preventing subsequent erectile dysfunction following prostate brachytherapy. We examined a single surgeon series of 69 patients that had undergone prostate mono brachytherapy from 2002-2005. All patients had a minimum 1-year follow-up. Prospectively, patients had baseline, 6 and 12 month SHIM and IIEF-6 scores recorded. The 69 patients were divided into early sildenafil (31) and non sildenafil groups (38) and their SHIM and IIEF-6 scores were compared at 6 and 12 months. Daily sildenafil (25-50 mg) was given immediately in the perioperative period for a duration of 12 months. Overall, for the entire group, the mean PSA was 6.8; 78% had Gleason 6 cancer; 20% had Gleason 7 (3+4) cancer. The mean age in the early PDE-5 group was 62.8 years; in the non PDE-5 group, 66.0 years. The mean radiation units in the early PDE-5 group was 50.2; in the non PDE-5 group, 43.9U (p = 0.08). In the non PDE-5 group, the mean baseline SHIM score of 17.1 dropped quickly to 9.1 at 6 months and stayed at 9.3 at 12 months. In the early PDE-5 group, the mean baseline SHIM score of 21.8 decreased slightly to 17.6 at 6 months, and was maintained at 17.9 at 12 months (p > 0.01 vs. baseline). Using the Wilcoxon Rank Sum Test, the 6 and 12 month SHIM scores in the early PDE-5 group differed from the non PDE-5 group (p < 0.001). The IIEF-6 questionnaire confirmed the SHIM analysis. Following prostate mono brachytherapy, patients experience a significant decline in SHIM / IIEF-6 scores at 6 and 12 months. Our data indicates a 50% decrease in the quality of their erections. This gives us a window of opportunity to initiate an early intervention program with PDE-5 inhibitors, vacuum constriction devices or intraurethral alprostadil. In this study, the early use of sildenafil citrate following PMB maintained erectile function at both 6 and 12 months.