title: Evaluating the relationship between erectile dysfunction and dose received by the penile bulb: using data from a randomised controlled trial of conformal radiotherapy in prostate cancer (MRC RT01, ISRCTN47772397).
abstract: OBJECTIVE
  To evaluate the relationship between erectile function and the radiation dose to the penile bulb and other proximal penile structures in men receiving conformal radiotherapy (CFRT) for prostate cancer (PCa).
  
  
  METHODS
  The Medical Research Council (MRC) RT01 trial randomised 843 men who had localised PCa to receive either 64 or 74 Gy after 3 - 6 months neoadjuvant hormonal treatment. Fifty-one men were selected who were potent prior to hormonal treatment, having completed both pre-hormone and 2-year post-CFRT Quality of Life assessments, and on whom dose volume data were available for analysis. The men were divided into three groups according to 2-year follow-up: potent, reduced potency, and impotent. The bulb of the penis together with the crura, were outlined on restored treatment plans. Dose - volume histograms were generated and compared between the three groups. An ordered logistic regression model was used to calculate the odds ratio of a range of dose - volume parameters to the penile bulb and effect on erectile dysfunction. The dose to the penile bulb was correlated to the dose received by the crura.
  
  
  RESULTS
  Of the 51 patients, 12 remained potent, 22 had reduced potency, and 17 were impotent at 2 years. No differences were seen in mean dose to the penile bulb by allocated treatment (t test = 1.61, p = 0.11). The mean doses to the penile bulb received by the potent, reduced potency, and impotent groups were 45.5 Gy (SD 17.1), 48 Gy (SD 16.1), and 59.2 Gy (SD 13.8), respectively. There was a strong correlation between the mean dose received by the penile bulb and dose to the crura (r = 0.82, p < 0.0001). 83.3% of impotent patients received a D90 > or = 50 Gy to the penile bulb compared with 29.4% of patients who maintained potency at 2 years (p = 0.006).
  
  
  CONCLUSIONS
  There is evidence from this study to suggest a dose volume effect on the penile bulb and erectile dysfunction. A D90 > or = 50 Gy is associated with a significant risk of erectile dysfunction and this should form a basis for selecting dose constraints in future dose escalation studies.
authors.affiliation: Academic Department of Radiotherapy and Oncology, The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, Surrey, UK.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Mangar
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Sydes
authors.forename: Helen L
authors.initials: HL
authors.lastname: Tucker
authors.forename: Jerome
authors.initials: J
authors.lastname: Coffey
authors.forename: Syed A
authors.initials: SA
authors.lastname: Sohaib
authors.forename: Stefano
authors.initials: S
authors.lastname: Gianolini
authors.forename: Steve
authors.initials: S
authors.lastname: Webb
authors.forename: Vincent S
authors.initials: VS
authors.lastname: Khoo
authors.forename: David P
authors.initials: DP
authors.lastname: Dearnaley
mesh_terms: D000230:Adenocarcinoma / Q000532:radiotherapy*; D000368:Aged; D015331:Cohort Studies; D004307:Dose-Response Relationship, Radiation; D007172:Erectile Dysfunction / Q000209:etiology*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010410:Penile Erection / Q000528:radiation effects*; D010413:Penis / Q000528:radiation effects*; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011788:Quality of Life; D011880:Radiotherapy Planning, Computer-Assisted; D020266:Radiotherapy, Conformal