Evaluation and Management of Testosterone Deficiency: AUA Guideline.

PURPOSE: There has been a marked increase in testosterone prescriptions in the past decade resulting in a growing need to give practicing clinicians proper guidance on the evaluation and management of the testosterone deficient patient. MATERIALS AND METHODS: A systematic review utilized research from the Mayo Clinic Evidence Based Practice Center and additional supplementation by the authors. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/). RESULTS: This guideline was developed by a multi-disciplinary panel to inform clinicians on the proper assessment of patients with testosterone deficiency and the safe and effective management of men on testosterone therapy. Additional statements were developed to guide the clinician on the appropriate care of patients who are at risk for or have cardiovascular disease or prostate cancer as well as patients who are interested in preserving fertility. CONCLUSIONS: The care of testosterone deficient patients should focus on accurate assessment of total testosterone levels, symptoms, and signs as well as proper on-treatment monitoring to ensure therapeutic testosterone levels are reached and symptoms are ameliorated. Future longitudinal observational studies and clinical trials of significant duration in this space will improve diagnostic techniques and treatment of men with testosterone deficiency as well as provide more data on the adverse events that may be associated with testosterone therapy.

Factors associated with suicide in patients with genitourinary malignancies.

BACKGROUND: Approximately 70% of all suicides in patients aged >60 years are attributed to physical illness, with higher rates noted in patients with cancer. The purpose of the current study was to characterize suicide rates among patients with genitourinary cancers and identify factors associated with suicide in this specific cohort. METHODS: Patients with prostate, bladder, kidney, testis, and penile cancer were identified in the Surveillance, Epidemiology, and End Results database (1988-2010). Standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs) were calculated for each anatomic site. Multivariable logistic regression models generated odds ratios (ORs) for the identification of factors associated with suicide for each malignancy. RESULTS: There were 2268 suicides identified among 1,239,522 individuals with genitourinary malignancies observed for 7,307,377 person-years. The SMRs for patients with cancer were 1.37 for prostate cancer (95% CI, 0.99-1.86), 2.71 for bladder cancer (95% CI, 2.02-3.62), 1.86 for kidney cancer (95% CI, 1.32-2.62), 1.23 for testis cancer (95% CI, 0.88-1.73), and 0.95 for penile cancer (95% CI, 0.65-1.35). On multivariable analysis, male sex was found to be associated with odds of suicide among patients with bladder cancer (OR, 6.63) and kidney cancer (OR, 4.98). Increasing age was associated with suicide for patients with prostate, bladder, and testis cancer (OR range, 1.03-1.06). Distant disease was associated with suicide in patients with prostate, bladder, and kidney cancer (OR range, 2.82-5.43). Among patients with prostate, bladder, and kidney cancer, African American patients were less likely to commit suicide compared with white individuals (OR range, 0.26-0.46). CONCLUSIONS: Suicide in patients with genitourinary malignancies poses a public health dilemma, especially among men, the elderly, and those with aggressive disease. Clinicians should be aware of risk factors for suicide in these patients.

A phase II, single-blind, randomized, crossover evaluation of the safety and efficacy of avanafil using visual sexual stimulation in patients with mild to moderate erectile dysfunction.

OBJECTIVE: To evaluate the safety, efficacy and time course of three doses of avanafil (50 mg, 100 mg and 200 mg) compared with sildenafil 50 mg or placebo, given in conjunction with visual sexual stimulation (VSS) videos in men with mild to moderate erectile dysfunction (ED). PATIENTS AND METHODS: Male patients, 35-70 years of age, with mild to moderate ED of ≥6 months duration, were included in the study. During the course of the study, each patient received placebo, active control (sildenafil 50 mg), and one dose of avanafil (50 mg, 100 mg or 200 mg), all administered in random order at least 72 h apart. RigiScan® (Dacomed Corp., Minneapolis, MN, USA) monitoring was used in conjunction with 20-min VSS videos (20, 60, and 100 min after dosing) to determine the duration of and time to ≥60% penile rigidity, maximum rigidity, tumescent activity units (TAUs), rigidity activity units (RAUs), and responses to the five-point Erection Assessment Scale. Safety assessments included adverse events (AEs), vital sign changes in response to dosing, laboratory results (complete blood counts, chemistry panel, prostate-specific antigen, serum testosterone, prothrombin time and urine analysis) and physical examination findings. RESULTS: Eighty-three patients were randomized and received at least one dose of study medication; 82 patients completed the study. Peak response to avanafil occurred in the early interval (20-40 min after dosing), while peak response to sildenafil occurred either in the middle (60-80 min) or late (100-120 min) intervals after dosing. Results were qualitatively similar for all other efficacy endpoints. During the 20-40-min interval, the majority of values for TAUs and RAUs with the avanafil 50-mg, 100-mg and 200-mg treatments were significantly superior to placebo (P < 0.05). Avanafil treatment was generally well tolerated; facial flushing (7-15%) was the most commonly observed AE, and no visual disturbances were reported. CONCLUSION: A favourable safety profile and improvement in sexual function, coupled with rapid onset of action and durability of effect, make avanafil an attractive option for males with ED, especially in the setting of on-demand treatment.

Comprehensive History of the International Society for Sexual Medicine-Journals and Communication.

INTRODUCTION: This is a comprehensive history of the International Society for Sexual Medicine (ISSM) and its founding organizations regarding the publications, including the journals and the publication committee, and the communication tools of the organization since its inception. OBJECTIVES: The object of this review is to provide a detailed and comprehensive history of the publication and communication tools of the ISSM and the people who have participated in production of these efforts. METHODS: Recorded Publication Committee minutes, filed letters, the various journals themselves, printed News bulletins, and Publishers reports to the society served as source documents to produce this history. The author has participated in many of the journal establishments and has kept an extensive personnel file of the events related in this history. All written history has not only relied on personal memories of these events but have been verified from the stored personal files. Printed and website stored journal and News bulletin have served as source material for this history. Also, Power Point presentations by the editors of the journals at the Publication Committee meetings have served as source material. Finally, annual, and semi-annual reports of the Publishers presented at Publication Committee meetings of the ISSM are source material. RESULTS: After extensive review of the historical material listed in the Methods section of this abstract, this comprehensive history of the communication efforts of this society has provided a rich and dynamic historical document for this society. CONCLUSION: This extensive, detailed, and comprehensive history of the communication tools of this society help us to record and remember the events and the people involved in this process. Sharing scientific information and information regarding the life of the International Society for Sexual Medicine have been an important function of this society from early. Lewis RW. Comprehensive History of the International Society for Sexual Medicine-Journals and Communication. Sex Med Rev 2021;9:542-567.

Comprehensive History of the International Society for Sexual Medicine.

INTRODUCTION: This is a detailed comprehensive history of the International Society for Sexual Medicine (ISSM) since its beginning in 1978. This was constructed after interest was shown following an oral presentation to the Executive Committee of this organization during their 2020 virtual (Zoom) business meeting. OBJECTIVES: To provide for the membership of ISSM a detailed history of their society since its inception until 2020 and have this serve as a repository document for review of the long history as needed by the society. METHODS: Written documents were used as source material for this history. Some documents from my personal files included letters, minutes of meetings, program booklets. Other data published in our ISSM printed and online website served as sources. Finally, documents supplied to me by our business office regarding written files were used to provide valid documentation for the construction of this history. There were very few anecdotes from my memory that were included. RESULTS: The comprehensive nature of this history provides a repository of our rich history of events and people involved in the ISSM. CONCLUSION: This is the first comprehensive history of the ISSM that is collected from actual historical documents. Lewis RW. Comprehensive History of the International Society for Sexual Medicine. Sex Med Rev 2021;9:517-541.

Definitions/epidemiology/risk factors for sexual dysfunction.

INTRODUCTION: Accurate estimates of prevalence/incidence are important in understanding the true burden of male and female sexual dysfunction and in identifying risk factors for prevention efforts. This is the summary of the report by the International Consultation Committee for Sexual Medicine on Definitions/Epidemiology/Risk Factors for Sexual Dysfunction. AIM: The main aim of this article is to provide a general overview of the definitions of sexual dysfunction for men and women, the incidence and prevalence rates, and a description of the risk factors identified in large population-based studies. METHODS: Literature regarding definitions, descriptive and analytical epidemiology of sexual dysfunction in men and women were selected using evidence-based criteria. For descriptive epidemiological studies, a Prins score of 10 or higher was utilized to identify population-based studies with adequately stringent criteria. This report represents the opinions of eight experts from five countries developed in a consensus process and encompassing a detailed literature review over a 2-year period. MAIN OUTCOME MEASURES: The study aims to provide state-of-the-art prevalence and incidence rates reported for each dysfunction and stratified by age and gender. Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS: A wealth of information is presented on erectile dysfunction, its development through time, and its correlates. The field is still in need of more epidemiological studies on the other men's sexual dysfunction and on all women's sexual dysfunctions. CONCLUSIONS: A review of the currently available evidence from epidemiological studies is provided.

Summary of the recommendations on sexual dysfunctions in men.

INTRODUCTION: Sexual health is an integral part of overall health. Sexual dysfunction can have a major impact on quality of life and psychosocial and emotional well-being. AIM: To provide evidence-based, expert-opinion consensus guidelines for clinical management of sexual dysfunction in men. METHODS: An international consultation collaborating with major urologic and sexual medicine societies convened in Paris, July 2009. More than 190 multidisciplinary experts from 33 countries were assembled into 25 consultation committees. Committee members established scope and objectives for each chapter. Following an exhaustive review of available data and publications, committees developed evidence-based guidelines in each area. Main Outcome Measures. New algorithms and guidelines for assessment and treatment of sexual dysfunctions were developed based on work of previous consultations and evidence from scientific literature published from 2003 to 2009. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of medical literature, and cultural and ethical considerations. RESULTS: Algorithms, recommendations, and guidelines for sexual dysfunction in men are presented. These guidelines were developed in an evidence-based, patient-centered, multidisciplinary manner. It was felt that all sexual dysfunctions should be evaluated and managed following a uniform strategy, thus the International Consultation of Sexual Medicine (ICSM-5) developed a stepwise diagnostic and treatment algorithm for sexual dysfunction. The main goal of ICSM-5 is to unmask the underlying etiology and/or indicate appropriate treatment options according to men's and women's individual needs (patient-centered medicine) using the best available data from population-based research (evidence-based medicine). Specific evaluation, treatment guidelines, and algorithms were developed for every sexual dysfunction in men, including erectile dysfunction; disorders of libido, orgasm, and ejaculation; Peyronie's disease; and priapism. CONCLUSIONS: Sexual dysfunction in men represents a group of common medical conditions that need to be managed from a multidisciplinary perspective.

Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening.

OBJECTIVE: Prostate cancer is the most common malignancy among males, accounting for 19% of cancers, and the third most common cancer-related cause of death. Suicide rates in the United States have increased among males over the last decade. Further, suicide rates are higher in oncology patients, including patients with prostate cancer, compared to the general population. The objective of this article is to review the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation. MATERIALS AND METHODS: We reviewed the current literature pertaining to prostate cancer and depression, and prostate cancer and suicide. Furthermore, associations were made between erectile dysfunction and depression. RESULTS: Men with prostate cancer at increased risk for suicidal death are White, unmarried, elderly, and men with distant disease. Time since diagnosis is also an important factor, since men are at risk of suicide>15 years after diagnosis. Approximately 60% of men with prostate cancer experience mental health distress, with 10%-40% having clinically significant depression. Additionally, patients that received androgen deprivation therapy (ADT) are 23% more likely to develop depression compared to those without ADT. Longitudinal studies of prostate cancer patients suggest that erectile dysfunction after curative treatment may have a significant psychological effect leading to depression. Herein, a newly proposed screening algorithm suggests for an evaluation with the expanded prostate cancer index composite-clinical practice, patient health questionnaire-9, and an 8-question suicidal ideation questionnaire to assess for health-related quality of life, depression, and suicidal ideation. CONCLUSION: The burden of screening for erectile dysfunction, depression and suicidal ideation lies with the entire health care team, as there appears to be an association between these diagnoses, that is, compounded in patients with prostate cancer. The screening algorithm should assist with guiding timely and appropriate psychiatric referral to optimize outcomes in these high-risk patients.

Sensitization of TRAIL-resistant cells by inhibition of heat shock protein 90 with low-dose geldanamycin.

Due to its specificity and effectiveness, tumor necrosis factor-alpha-related apoptosis-inducing ligand (TRAIL) is being tested for cancer therapy. Inhibition of the function of heat shock protein 90 (HSP90) is under clinical trials for cancer therapy. However, some cancer cells are resistant to TRAIL, and at the dose required for inducing apoptosis, geldanamycin, a drug that inhibits HSP90 function, has shown adverse effects. Therefore, our working plan was to identify a sublethal dose of geldanamycin and combine it with TRAIL to induce apoptosis in TRAIL-resistant prostate cancer cells. Treatment of LNCaP with 250 nmol/L geldanamycin inhibited HSP90 function but did not induce significant apoptosis. However, combination of geldanamycin and TRAIL induced highly significant apoptosis in TRAIL-resistant LNCaP cells. In addition to inducing caspase activity and apoptosis, treatment with geldanamycin and TRAIL decreased inhibitor of kappaB (IkappaB) kinase (IKK) complex proteins, IKKalpha, IKKbeta, and IKKgamma. The loss of IKK affected IkappaBalpha/nuclear factor-kappaB (NF-kappaB) interaction and reduced nuclear transport of NF-kappaB, resulting in reduced NF-kappaB activity. Our data show increase in apoptosis using low, suboptimal dose of geldanamycin when used with TRAIL. These results provide a means to alleviate two problems: resistance to TRAIL and adverse effects of high-dose geldanamycin.

Therapeutic advantage of combining calcium channel blockers and TRAIL in prostate cancer.

Disruption of intracellular calcium initiates multiple cell-damaging processes, such as apoptosis. In normal cells, the levels of Ca(2+) are low in the mitochondria, whereas in apoptotic cells, Ca(2+) increases. Mitochondria uptake Ca(2+) via an inner membrane channel called the uniporter and extrude it into the cytoplasm through a Na(+)/Ca(2+) exchanger. Overload of Ca(2+) in the mitochondria in CGP-treated cells leads to its damage, thus affecting cellular function and survival. The goal of these experiments was to determine the importance of mitochondrial calcium ([Ca(2+)](m)) in apoptosis of prostate cancer cells. Furthermore, we have examined the advantages of increasing the [Ca(2+)](m) and treating the cells with tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), a potent apoptotic agent. Our results show that, under these treatment conditions, inhibiting the Na(+)/Ca(2+) exchanger using benzothiazepin CGP-37157 (CGP) did not induce apoptosis. However, combination of CGP and TRAIL increased the apoptotic response approximately 25-fold compared with control. Increase in apoptosis followed enhanced levels of [Ca(2+)](m) and was accompanied by pronounced mitochondrial changes characteristic of mitochondria-mediated apoptosis. Experiments with calcium ionophores showed that mere increase in cytosolic and/or mitochondrial Ca(2+) was not sufficient to induce apoptosis. These results have therapeutic implications as inhibitors of Na(+)/Ca(2+) exchanger are being used for treating some neurologic and cardiologic ailments, and TRAIL induces apoptosis preferentially in cancer cells. Furthermore, this system provides an excellent model to investigate the role of [Ca(2+)](m) in apoptosis.

Mitochondria from TRAIL-resistant prostate cancer cells are capable of responding to apoptotic stimuli.

TNFalpha-related apoptosis inducing ligand (TRAIL) has been shown to induce apoptosis in prostate cancer cells. However, some prostate cancer cells, such as LNCaP are resistant to TRAIL. In addition to the involvement of several pathways in the TRAIL-resistance of LNCaP, it has been shown that mitochondrial response to TRIAL is low in these cells. Therefore, in this study, using in vitro cell free and reconstitution models, we have demonstrated that mitochondria from these cells are capable of responding to apoptotic stimuli. Furthermore, experiments to determine the influence of cytochrome c on apoptotic response noted that incubation of cytosol with exogenous cytochrome c induced truncation of Bid. We have demonstrated that truncation of Bid by exogenous cytochrome c is mediated through the activation of caspases-9 and -3. Incubation of cytosol with recombinant caspases-9 and -3 in the absence or presence of inhibitors showed that activation of caspase-9, leading to the activation of caspase-3 was necessary for the truncation of Bid. Published results indicate that in apoptotic cells cytochrome c is released from the mitochondria in two installments, an early small amount and a late larger amount. Our results suggest that the initial release of cytochrome generates tBid that is capable of translocation into the mitochondria causing further release of cytochrome c. Thus, in addition to providing functional explanation for the biphasic release of cytochrome c from mitochondria, we demonstrate the presence of a feedback amplification of mitochondrial apoptotic signal.

Combination of proteasomal inhibitors lactacystin and MG132 induced synergistic apoptosis in prostate cancer cells.

The proteasome inhibitor Velcade (bortezomib/PS-341) has been shown to block the targeted proteolytic degradation of short-lived proteins that are involved in cell maintenance, growth, division, and death, advocating the use of proteasomal inhibitors as therapeutic agents. Although many studies focused on the use of one proteasomal inhibitor for therapy, we hypothesized that the combination of proteasome inhibitors Lactacystin (AG Scientific, Inc., San Diego CA) and MG132 (Biomol International, Plymouth Meeting, PA) may be more effective in inducing apoptosis. Additionally, this regimen would enable the use of sublethal doses of individual drugs, thus reducing adverse effects. Results indicate a significant increase in apoptosis when LNCaP prostate cancer cells were treated with increasing levels of Lactacystin, MG132, or a combination of sublethal doses of these two inhibitors. Furthermore, induction in apoptosis coincided with a significant loss of IKKalpha, IKKbeta, and IKKgamma proteins and NFkappaB activity. In addition to describing effective therapeutic agents, we provide a model system to facilitate the investigation of the mechanism of action of these drugs and their effects on the IKK-NFkappaB axis.

Mifepristone pretreatment overcomes resistance of prostate cancer cells to tumor necrosis factor alpha-related apoptosis-inducing ligand (TRAIL).

Examination of the effects of TRAIL (tumor necrosis factor alpha-related apoptosis-inducing ligand) showed higher apoptotic response in LNCaP C4-2, whereas LNCaP were resistant. However, treatment of LNCaP with Mifepristone, an antiprogestin, before TRAIL induced significant apoptosis, similar to the levels observed in LNCaP C4-2. Experiments to determine the reasons for altered response of the cell lines showed no significant differences in death/decoy receptors and caspase-8 activity. However, treatment induced increased truncation of Bid and activation of caspases -9, -7, and -3 in LNCaP C4-2. Time course experiments showed that caspase-8 was activated before the involvement of mitochondrial pathway, and caspase-9 was responsible for activation of caspases -7 and -3. Use of specific caspase inhibitors demonstrated the presence of a short-loop feedback activation of Bid. Published reports suggested that increased phosphorylation of Akt was responsible for resistance of LNCaP to TRAIL. However, no significant differences were noticed in the levels of phosphorylated Akt in TRAIL-resistant LNCaP and TRAIL-sensitive LNCaP C4-2. On the basis of our results, it is suggested that the differences in response of the two cell lines to TRAIL is at the mitochondrial level.

Intracavernosal Injection for the Diagnosis, Evaluation, and Treatment of Erectile Dysfunction: A Review.

INTRODUCTION: Intracavernosal injection (ICI) of a vasoactive agent has been an important part of the diagnosis, evaluation, and treatment of erectile dysfunction (ED) since its initial description by Virag in 1982. AIM: To review the literature and summarize the use of ICI and its role in the diagnosis, evaluation, and treatment of ED. METHODS: Literature review. MAIN OUTCOME MEASURE: To define the role of ICI's utility in the diagnosis, evaluation, and treatment of ED. RESULTS: When used in conjunction with color penile Doppler ultrasound for ED evaluation and diagnosis, ICI helps to detect penile vascular abnormalities and allows for differentiation between the multiple vasculogenic causes of impotence, thus helping clinicians to select the optimal treatment modality for each patient. Patients utilizing ICI continue to report high efficacy and satisfaction rates relative to other treatment options despite ICI's designation as a second-line therapy since the introduction of oral phosphodiesterase type 5 inhibitors in 1998. In recent years, ICI has also become an important part of penile rehabilitation programs following radical prostatectomy, as regular use of ICI is thought to increase the rate at which patients experience return of spontaneous erection through preservation of penile tissue integrity and prevention of corporeal smooth muscle atrophy. CONCLUSIONS: ICI of vasoactive agents remains an important tool in treating and diagnosing ED, with high patient satisfaction and efficacy rates. However, the dropout rate for ICI therapy remains relatively high, and it may be associated with priapism, ecchymoses, hematoma formation, and penile fibrosis. Patients should be educated on the benefits and limitations of ICI therapy prior to beginning treatment in order to minimize dropout rates. Additional studies are necessary to better understand the possible long-term benefits of ICI therapy and how to most effectively structure the penile rehabilitation program after radical prostatectomy. Belew D, Klaassen Z, and Lewis RW. Intracavernosal injection for the diagnosis, evaluation, and treatment of erectile dysfunction: A review. Sex Med Rev 2015;3:11-23.

Role of genomics-based strategies in overcoming chemotherapeutic resistance.

As cancer is being recognized as a failure of apoptosis, apoptosis-based strategies are being designed. Caspases are critical for the induction of apoptosis and their decreased expression is correlated with increased grade of cancer, while increased expression of caspases rendered the cancer cells susceptible to chemotherapy. However, the endogenous functions of caspases are inhibited by inhibitors of apoptosis (IAPs) that bind activated caspases. Methods to suppress the function of IAP induced apoptosis in chemo-resistant cancer cells. The function of IAPs is inhibited by Second Mitochondria-Derived Activator Of Caspase (Smac) or Direct IAP Binding Protein With Low Pi (DIABLO). Upon apoptotic stimulus Smac/DIABLO is released from the mitochondria, which binds to IAPs and inhibits their caspase-binding activity. Overexpression of Smac/DIABLO sensitized neuroblastoma to TRAIL (TNFalpha-Related Apoptosis-Inducing Ligand). Activation of TRAIL pathway has become an important method of inducing apoptosis except in TRAIL-resistant cells. However, treatment of these cells with other cytotoxic drugs sensitizes them to TRAIL, providing effective therapeutic advantages. In addition to activating apoptotic pathways, inhibiting or suppression of cell proliferation is necessary to sensitize cancer cells to apoptosis. Critical among these proteins are NFkappaB and Akt. NFkappaB blocked apoptosis by interfering with the function of TNFalpha/TRAIL and/or through the activation of antiapoptotic proteins of the Bcl2 family. Similarly, Akt mediate cell survival via the regulation of cell survival proteins and by blocking the function of proapoptotic Bad by phosphorylation. Altering the expression of Akt by dominant negative constructs or by expression of PTEN interferes with Akt function. In summary, this review points out the complexity of interactions of the cell survival and death pathways and highlights some methods to manipulate them to achieve therapeutic advantage.

Reduced response of prostate cancer cells to TRAIL is modulated by NFkappaB-mediated inhibition of caspases and Bid activation.

We describe the effects of tumor necrosis factor alpha-related apoptosis inducing ligand (TRAIL) on the induction of apoptosis in two related prostate cancer cell lines, PC3AR and PC3Neo. TRAIL is a potent drug, which induces apoptosis preferentially in cancer cells. Treatment of prostate cancer cells, reduced survival by approximately 41% in PC3AR, but only approximately 18% PC3Neo were killed. Western analysis demonstrated that increased apoptotic response of PC3AR cells may be due to differential response of death receptors DR4, DR5 and decoy receptors DcR1 and DcR2. Caspases-8, -9, -3 and Bid were highly activated in PC3AR cells compared to PC3Neo. Furthermore, lower apoptotic response of PC3Neo was probably due to higher expression of NFkappaB. Blocking the function of NFkappaB by adenoviral infection of mutated IkappaB, increased apoptotic response confirming the influence of NFkappaB. Thus, we have demonstrated the role of NFkappaB in the differential response of prostate cancer cells to TRAIL.

Mifepristone-induced secretion of transforming growth factor beta1-induced apoptosis in prostate cancer cells.

Successful therapy should induce apoptosis in prostate cancer cells irrespective of their androgen response. We have investigated the possibility of utilizing Mifepristone and Tamoxifen as treatment options for prostate cancer cells. Because preliminary results demonstrated induction of apoptosis by these drugs, the mechanism of induction of apoptosis was investigated. LNCaP-C4 prostate cancer cells were treated with Mifepristone and/or Tamoxifen. To confirm cytotoxic effects, nude mice with LNCaP-C4 xenografts were treated with Mifepristone and Tamoxifen. Cell viability was assayed using Sulforhodamine B (SRB) assay and DNA fragmentation was measured by ELISA. Culture media from vehicle- and drug-treated cells were collected and secretion of transforming growth factor beta1 (TGFbeta1) was estimated by ELISA. Role of TGFbeta1 was confirmed by inhibiting its function using TGFbeta1 antibody or M6P, which blocked activation of TGFbeta1. Apoptotic effects were determined by immunoblots of cytochrome c levels in cytosol and by in vitro colorimetric assay of caspase-3 activity. Results showed that although both drugs induced apoptosis in LNCaP-C4 cells, Mifepristone was more effective. The effects of these drugs on xenografts confirmed in vitro results. It was hypothesized that drug-induced secretion of TGFbeta1 may be responsible for induction of apoptosis. Neutralization of TGFbeta1 with an antibody or blocking the activation of TGFbeta1 by M6P abrogated the effects of Mifepristone and Tamoxifen confirming our hypothesis. Furthermore, treatment with Mifepristone and/or Tamoxifen released cytochrome c into the cytoplasm and induced activity of caspase-3, providing evidence that the drug-stimulated secretion of TGFbeta1 was responsible for induction of apoptosis in these cells. In conclusion, both Mifepristone and Tamoxifen induced apoptosis mediated through TGFbeta1. However, no critical advantage was noted by the addition of Tamoxifen to Mifepristone treatment.

Nitric oxide inhibits RhoA/Rho-kinase signaling to cause penile erection.

The RhoA/Rho-kinase pathway mediates vasoconstriction in the cavernosal circulation. Inhibition of this pathway leads to penile erection in the in vivo rat model. These studies examined the hypothesis that nitric oxide (NO) inhibits RhoA/Rho-kinase signaling as part of normal erection. The results show that NO causes increased intracavernosal pressure and that this response is potentiated by prior treatment with a threshold dose of the Rho-kinase inhibitor, (+)-(R)-trans-4-(1-Aminoethyl)-N-(4-pyridyl) cyclohexanecarboxamide dihydrochloride, monohydrate (Y-27632). These results support the hypothesis that NO inhibits Rho-kinase-induced cavernosal vasoconstriction during erection.

[Inhibition of tonic contraction of smooth muscle: a new approach to achieve erection dysfunction].

It has shown that vasoconstriction in the cavernosal circulation is mediated by the RhoA/Rho-kinase calcium sensitization pathway. Inhibition of Rho-kinase activity in cavernosal smooth muscle with Y-27632 resulted in an erectile response marked by elevated intracavernosal pressure (ICP) without a significant change in men arterial pressure (MAP). To explain how erection can occurred in the presence of this strong vasoconstrictive signal, we have hypothesized that nitric oxide (NO) induces vasodilation leading to erection by directly inhibiting activity of the RhoA/Rho-kinase pathway, thereby reducing vasoconstriction. Administration of Y-27632 restored erectile function in rat models of hypogonadism and hypertension, suggesting that Rho-kinase inhibition may have potential clinical value. In addition, our results show that topical application of Y-27632 may be an effective mode of treatment for erectile dysfunction.