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Lu Z et al, 2016: Low-intensity Extracorporeal Shock Wave Treatment Improves Erectile Function: A Systematic Review and Meta-analysis.

Lu Z, Lin G, Reed-Maldonado A, Wang C, Lee YC, Lue TF.
Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.
Department of Urology, The First Hospital of Jilin University, Changchun, People's Republic of China.
Department of Urology, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

Abstract

CONTEXT: As a novel therapeutic method for erectile dysfunction (ED), low-intensity extracorporeal shock wave treatment (LI-ESWT) has been applied recently in the clinical setting. We feel that a summary of the current literature and a systematic review to evaluate the therapeutic efficacy of LI-ESWT for ED would be helpful for physicians who are interested in using this modality to treat patients with ED.OBJECTIVE: A systematic review of the evidence regarding LI-ESWT for patients with ED was undertaken with a meta-analysis to identify the efficacy of the treatment modality.
EVIDENCE ACQUISITION: A comprehensive search of the PubMed and Embase databases to November 2015 was performed. Studies reporting on patients with ED treated with LI-ESWT were included. The International Index of Erectile Function (IIEF) and the Erection Hardness Score (EHS) were the most commonly used tools to evaluate the therapeutic efficacy of LI-ESWT.
EVIDENCE SYNTHESIS: There were 14 studies including 833 patients from 2005 to 2015. Seven studies were randomized controlled trials (RCTs); however, in these studies, the setup parameters of LI-ESWT and the protocols of treatment were variable. The meta-analysis revealed that LI-ESWT could significantly improve IIEF (mean difference: 2.00; 95% confidence interval [CI], 0.99-3.00; p<0.0001) and EHS (risk difference: 0.16; 95% CI, 0.04-0.29; p=0.01). Therapeutic efficacy could last at least 3 mo. The patients with mild-moderate ED had better therapeutic efficacy after treatment than patients with more severe ED or comorbidities. Energy flux density, number of shock waves per treatment, and duration of LI-ESWT treatment were closely related to clinical outcome, especially regarding IIEF improvement.
CONCLUSIONS: The number of studies of LI-ESWT for ED have increased dramatically in recent years. Most of these studies presented encouraging results, regardless of variation in LI-ESWT setup parameters or treatment protocols. These studies suggest that LI-ESWT could significantly improve the IIEF and EHS of ED patients. The publication of robust evidence from additional RCTs and longer-term follow-up would provide more confidence regarding use of LI-ESWT for ED patients.PATIENT SUMMARY: We reviewed 14 studies of men who received low-intensity extracorporeal shock wave treatment (LI-ESWT) for erectile dysfunction (ED). There was evidence that these men experienced improvements in their ED following LI-ESWT.

Eur Urol. 2016 Jun 16. pii: S0302-2838(16)30259-7. doi: 10.1016/j.eururo.2016.05.050. [Epub ahead of print] Review.

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Comments 1

Hans-Göran Tiselius on Tuesday, 28 February 2017 12:09

The authors correctly conclude that there has been a dramatic increase in low-intensive extracorporeal shockwave treatment (LI-ESWT) for patients with erectile dysfunction. This article is a meta-analysis of literature data. In different studies the effect has been evaluated in terms of IIEF (International Index of Erectile Dysfunction) and EH (Erectile Hardness Index).

The 14 studies that provided the basis for this report comprise experience in 833 patients.

Most articles showed significant improvements, but duration of follow-up was usually short.

Energy density, number of pulses applied, duration of treatment and number of treatments per week as well as number of sites exposed to shockwaves varied considerably. Seven RCTs were examined and in those studies significantly improved IIEF was recorded in only four!

The best results were recorded in patients with Peyronies disease whereas the effect in patients with co-morbidities was poor. One major concern is the heterogeneity of the patients. Although positive effects were obtained it seems necessary to define the optimal treatment.

The authors express doubts on the clinical relevance of IIEF and recommend future use of MCID (minimally clinically important difference).

In the Letter to the Editor regarding this review the heterogeneity of the patients groups was emphasized and it is strongly suggested that analysis should be carried out for groups with common pathology. This would avoid underestimation of the effect of LI-ESWT.

The authors correctly conclude that there has been a dramatic increase in low-intensive extracorporeal shockwave treatment (LI-ESWT) for patients with erectile dysfunction. This article is a meta-analysis of literature data. In different studies the effect has been evaluated in terms of IIEF (International Index of Erectile Dysfunction) and EH (Erectile Hardness Index). The 14 studies that provided the basis for this report comprise experience in 833 patients. Most articles showed significant improvements, but duration of follow-up was usually short. Energy density, number of pulses applied, duration of treatment and number of treatments per week as well as number of sites exposed to shockwaves varied considerably. Seven RCTs were examined and in those studies significantly improved IIEF was recorded in only four! The best results were recorded in patients with Peyronies disease whereas the effect in patients with co-morbidities was poor. One major concern is the heterogeneity of the patients. Although positive effects were obtained it seems necessary to define the optimal treatment. The authors express doubts on the clinical relevance of IIEF and recommend future use of MCID (minimally clinically important difference). In the Letter to the Editor regarding this review the heterogeneity of the patients groups was emphasized and it is strongly suggested that analysis should be carried out for groups with common pathology. This would avoid underestimation of the effect of LI-ESWT.
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