THE EXPERIENCE OF COMBINED APPLICATION OF PLATELETRICH PLASMA THERAPY AND SHOCKWAVE THERAPY IN TREATMENT OF ERECTILE DYSFUNCTION OF VASCULAR ORIGIN

Annotation In order to compare the clinical eff ect of platelet rich plasma-therapy and local negative pressure-therapy on the background of pharmacotherapy with Icariin and combined platelet rich plasma-therapy in combination with shock-wave therapy and vacuum device therapy on the background of pharmacotherapy with Icariin in the treatment of erectile dysfunction of arterial and arterial-venous origin, 50 patients of the «Men’s Health» Clinic (Kiev) were examined with using clinical, laboratory and sonographic methods. Based on the results of the study, the high eff ectiveness of platelet rich plasma-therapy, shock-wave therapy and vacuum device -therapy and Icariin combinations use in the arterial and arterial-venous erectile dysfunction therapy in comparison with platelet rich plasma-therapy and vacuum device therapy and Icariin. According to our data intracavernosus activation of plate-cells was conducted by shock-wave method in a fi rst time ever.

Since the last decades of 20th century, phosphodiesterase fi fth type inhibitors (PDE-5), as an erectogenic agent, have become the most prescribed group of drugs with EDVO. In spite of the unambiguous symptomatic orientation of the action mechanism of PDE-5 not only doesn't demonstrate absolute eff ectiveness, but also, due to the marketing image of the "universal remedy", reduce patient's interest in pathogenetic and etiotropic therapy. This leads to the acute demand to consider new, primarily bio-and physiotherapeutic options for the treatment of EDVO [2,[4][5][6].
In the fi rst two decades of the twenty-fi rst century, cellular and modern physiotherapeutic technologies should be distinguished, by not only its fundamental progress and evolution, but also by overcoming the mistrust of clinicians and entering in to clinical practice as routine therapeutic procedures. With regard to the problem of EDVO, the proven pathogenetic eff ect has been shown by methods of vector (gene) therapy, stem cells and local platelet-rich plasma therapy (PRP-therapy), modern physiotherapeutic techniques such as low-intensity pulsed ultrasound and low-intensity extracorporeal shock-wave therapy (LESWT) [1, [4][5][6].
The analysis of the Ukrainian androurological clinic on the background of law and economic conjuncture -economic and technological (according to vector therapy demands) and legal and ethical (according to embryonic stem cell therapy demands), shows the priority of PRP-therapy and modern physiotherapeutic techniques [2].
At present, there are original clinical studies dedicated to EDVO treatment with PRP-therapy, which results are about to confi rm the pathogenetic eff ect as an intensifi cation of blood circulation in vessels of cavernous bodies by double mechanism: stimulation of neovascularization processes (morphological eff ect) and correction of endothelial dysfunction (functional eff ect), as a results of platelet growth factors biological activity. In fact, signal-based native biomarkers, stimulating the restructuring of the tissues of the penis, are meant. This mechanism can be considered as a basic one in the combination of PRP-therapy and LESWT, which mechanism is based on the mechano-biological eff ects on local tissues [6].
Interdisciplinary researches dedicated to the study of the mechanisms and clinical eff ects of LESWT on hemodynamics in atherosclerotic vessels indicates an increase of the vascular endothelial growth factor (VEGF) and its Flt-1 receptors expression, that leads to neovascularization and an increase in the effi ciency of local hemodynamics [6][7][8].
Other mechanisms underlie in the eff ect of PRP-therapy, where the main point is the repair of the vascular wall endothelial membrane, by stimulation of the endothelial progenitor cells induced by platelet growth factors, as well as the synergistic optimization of the endothelial and neuronal NO synthases production and the improvement of the vascular walls smooth muscle cell functions. In addition to the direct eff ect of proliferation, the phenomenon of recruiting and homing of mesenchymal stem cells is present providing the multimodality of neoangiogenesis [1, 7,12].
The methodology of PRP-therapy indicates the release of growth factors from platelets, which is realized due to its biochemical activation by thrombin and calcium chloride, as well as recently described techniques -activation by ultrasound or shock-wave impact [9][10][11]. An important aspect of the combined use of PRP-therapy and LESWT is the phenomenon of local platelets activation inside the cavernous bodies of penis. It is greatly increases the local concentration of growth factors. Another promising addition to a set of therapeutic procedures may be the local negative pressure therapy (LNP-therapy), which, besides the direct eff ect, contributes the delay in the leak of PRP from the primal site, minimizing the non-target eff ects of PRP-therapy.
Among the pharmacotherapeutic agents that promising to be complement to mentioned above mechanisms, we should highlight Ikariin (ICA), the fl avonoid of Epimedium brevicornum Maxim, with a spectrum of eff ects: biological activity similar to PDE-5, stimulation of production of nitric oxide (NO), affi nity to androgen receptors, as well as antioxidant activity. All that makes ICA the perspective addition to the PRP-therapy, LESWT and LNP-therapy of EDVO, especially taking into account the patients preferences for natural origin substances [8].
Nevertheless, the relative novelty of the PRP-therapy in EDVO treatment, accompanied by lack of patients demands (primarily due to effective marketing of pharmacotherapy), requires a search for ways to improve the eff ectiveness of PRP-therapy. A promising area is the analysis of the eff ectiveness of the combined usage of PRP, LESWT and LNP in a single therapeutic model for EDVO treatment [2,6].
The aim of the study was to compare the clinical eff ect of combination of PRP-therapy and LNP-therapy and combination of PRP-therapy, LESWT and LNP-therapy, both on the background of pharmacotherapy with ICA in treatment of ED of arterial and arterial-venous origin.
Design. The study was conducted in a prospective design in parallel groups, as part of an open clinical study.
The study was conducted in 3 stages: 1) preliminary: development of research methodology, examination of patients to determine their compliance with the criteria for participation in the study, structuring the contingent, the formation of study groups; 2) therapeutic: treatment according to the proposed therapeutic models in parallel groups; 3) follow-up: monitoring and comparing the clinical eff ect of the proposed therapeutic models in parallel groups in 3 time-points.
Materials. The contingent of the study comprised 50 patients with EDVO (arterial and combined forms). Homogenization of the study population was carried out according to the age criterion (from 40 to 65 years), the duration of the ED (from 6 months to 5 years), ethnicity (Caucasoid race), and sexual preferences (heterosexual).
The following exclusion criteria were used: -Isolated-neurogenic ED (priority of etiological therapy before the methods studied); -Isolated-psychogenic ED (false positive and false-negative results); -Signifi cant pathology of the prostate gland, infl ammatory diseases exacerbations (priority of etiological therapy before the methods studied); -Signifi cant disorders in the sex-hormones metabolism, that can aff ect the erectile function (priority of etiological therapy before the methods studied); -Pathology of sexual preferences with a signifi cant change in the stereotype of sexual intercourse (the impossibility of a correct interpretation of the clinical eff ect). -Pronounced somatic pathology requiring priority treatment or induction of remission: cardiovascular pathology that disrupts functioning, oncological pathology, systemic connective tissue diseases, acute infectious diseases.
In the population of the study, comorbid pathology was presented, later it has been symmetrically distributed among the study groups (Table 1). The division of population into groups had been done by the symmetry of the patients' age and the duration of ED manifestations with the informed consent to participate in a particular study group. The following research groups were formed: -the main group (MG): 25 patients undergoing a course of therapy with concurrent use of a combination of PRP-therapy, LESWT and LNP-therapy and pharmacotherapy with ICA; -control group (CG): 25 patients undergoing the course of therapy by the concurrent use of a combination of PRP-therapy and LNPtherapy and ICA;

Methods:
1) clinical examination and observation + clinical questionnaire "International Index of Erectile Function (IIEF), in order to establish the extent of erectile dysfunction; 2) a standard set of laboratory and instrumental studies -to exclude counter indications for treatment. Also, all patients passed expanded immunogram, the study of IgG, IgM and PCR in saliva and blood to HCV 1,2; HCV 6, HCV 7, Varicella zoster, EBV, CMV, followed by consultation of a clinical immunologist and infectious disease specialist (to exclude causes of pathological immune status to avoid biological therapy eff ect distortion). Prior to the main treatment, antiviral, immunomodulating and hepatotropic drugs has been prescribed.
3) sonographic: -trans-rectal sonographic examination of the prostate to determine the presence of pathology; -pharmacodopplerography of penis with video-erotic stimulation (pharmacological stimulation -a standard dose of sildenafi l 1 hour before the beginning of session, conducted on the background of video-erotic stimulation of erection) in order to establish the actual violations of erectile hemodynamics and further monitoring of clinical eff ects of treatment. -ultrasound scanning of cavernous bodies: to control the injections of PRP (imaging echographic phenomena occurring after injection of PRP and its time recording) in setting the procedure of PRP-therapy (for indicating a delay in PRP leak from cavernous tissue).
Results. According to the research tasks, the following therapeutic models were used in parallel groups: -MG (25 patients): parallel application of combination PRP-therapy (1 complex of injections per week for 6 weeks), LESWT (2 times a week 3000 strikes in 7 standard areas of the penis, frequency 10 Hz, total power up to 1 mJ/mm2) for 6 weeks (each fi rst weekly procedure was carried out in combination with PRP and LNP procedures (for intracavernous platelet activation), the second procedure without PRP), ICA pharmacotherapy, orally, 50 mg/day in 1 reception (evening), during all course of therapy + 6 weeks (total 12 weeks). -CG (25 patients): PRP-therapy (1 complex of injections per week for 6 and weeks) combined with LNP and ICA pharmacotherapy, orally, 50 mg / day in one session (evening), during all course of therapy + 6 weeks (total 12 weeks).
Within the framework of the development of the research methodology, a standardized technique for obtaining PRP was chosen. It consist of taking 72 ml of blood from the patient's ulnar vein (followed by placement in 9-ml vacuum tubes with 3,8% sodium citrate solution), centrifuging at 500g for 5 min, subsequent collection of plasma and repeated centrifugation at 1538g for 3 min, release of the lower plasma layer in a volume of 1 ml, activation of platelet growth factors with 0,1 ml of 10% calcium chloride solution [4].
The treatment procedure using PRP consists of a complex of injections performed using a syringe (1,0 ml capacity) along the lateral surface of the penis: proximally, distally 1,0 ml per each locus; further 1,0 ml approaching albuginea (multifocal); further on 0,5 ml of PRP in both ischia-cavernous muscles; and 1,0 ml per each peduncle of the penis.
In the MG, after this (in a period of 5-10 minutes, that corresponds to ultrasonographic data of PRP presence in cavernous tissue), LESWT and LNP procedures are performed to reach the condition of intracavernous platelet activation.
Eff ectiveness control and comparison was performed using dopplerography of the penis, control by: peak systolic velocity (PSV), end-diastolic velocity (EDV) and the clinical questionnaire of IIEF in three time-points: 6th week of treatment (the end of PRP-therapy course), 12th week (the end of ICA course) and 24th week. The results of the follow-up phase of the study are presented in Table. 2. Based on the results of the pharmacodopplerographic study, signifi cant diff erences in the parameters of erectile hemodynamics were revealed at diff erent stages of the study. Thus, by the 12th week, the mean PSV index in the state of stimulation in MG signifi cantly exceeded the same indicator in CG -25,7 ± 0,15 cm/s and 24,2 ± 0,17 cm/s, respectively. A similar trend persisted in the 24th week: the value of PSV in stimulation in MG (32,6 ± 0,17 cm/s) is signifi cantly greater than in CG (30,7 ± 0,15 cm/s).
The presence of an earlier eff ect on the PSV in stimulation indicates the therapeutic effi cacy of PRP+LESWT+LNP+ICA model according to the functional condition of cavernous tissues upon activation of erectile hemodynamics, demonstrating a greater activation of PRP in MG that is confi rmed by a lesser eff ect in CG.
Signifi cant diff erences in the PSV in stimulation among the groups of study are observed only by the 24th week: at this time-point the mean group value among CG patients was 4,3 ± 0,17 cm/s, while for MG it was 3,9 ± 0,2 cm/s.
Basing on the results of the IIEF evaluation, significant differences in the rates of erectile dysfunction were revealed at different timepoints. Thus, by the 24th week, the mean group value of erectile function in MG significantly exceeded the same indicator in CG -22,8 ± 0,19 and 20,7 ± 0,24, respectively. In addition, significant differences in sexual intercourse satisfaction in groups of study were found in different time-points: by the 12th week, MG patients had demonstrated greater sexual intercourse satisfaction than patients of CG, 9,4 ± 0,19 versus 8,8 ± 0,18, respectively; by the 24th week the average value for this domain for MG was 10,9 ± 0,22, versus 9,8 ± 0,26 for CG.
Signifi cant diff erences between the groups were also detected by the index of the orgasmic function: by the 12th week MG had their orgasmic function index higher than CG patients -6,9 ± 0,17 and 6,2 ± 0,22, respectively. A similar tendency persisted by the 24th week in MG (7.8 ± 0.19) and CG (7.0 ± 0.21).
By the libido parameter, signifi cant diff erences in comparison groups were found only in the last two time-points: by the 12th week, MG patients have shown a signifi cantly higher level of sexual desire compared to CG -8,6 ± 0,28 versus 7,1 ± 0,22 points, respectively; by the 24th week the mean value for this domain for MG was 8,8 ± 0,19 points, versus 7.9 ± 0.24 points in CG.
Reliable diff erence between the comparison groups for the indicator of general satisfaction were detected already at the early post-therapeutic stage and persisted for the whole period of follow-up observation. By the 6th week MG and CG patients showed values of general satisfaction at the levels of 5,2 ± 0,21 and 4,5 ± 0,23, respectively, by the 12th week -6,0 ± 0,18 and 5,1 ± 0,16; by the 24th week -6,2 ± 0,26 and 5,4 ± 0,3.
It was revealed that the improvement in hemodynamic parameters in MG occurred at earlier stages and was followed by more pronounced clinical eff ect. It was also found that the severity of clinical markers of erectile dysfunction correlates with the degree of compensation of cavernous hemodynamics.
Among the additional eff ects of therapy, it noteworthy that 16 MG patients and 14 CG patients after the course of treatment completely abandoned pharmacological support, with argumentation of erectile function restoration. 3 more MG patients left from the group of PDE-5non-responders.
Basing on the research materials, an application for the grant of a patent for invention No. a2018 04939 dated 05/05/2018 "A method of treatment of erectile dysfunction of vascular origins", has been registered.

Conclusions.
1. By the results of the study, the effi cacy of PRP-therapy of arterial and combined forms EDVO in combination with LESWT, LNP-therapy and ICA was higher in comparison to a similar therapeutic model, but with no LESWT component. This effi cacy impact appears to be associated with intracavernous activation of PRP (and a corresponding increase of growth factors levels), what requires further confi rmation in more detailed clinical studies.
2. It was revealed that improvement of hemodynamic parameters in MG occurred at earlier stages and was followed by more pronounced clinical eff ect. It was also found that the severity of the clinical markers of erectile dysfunction correlates with the degree of cavernous hemodynamics compensation that indicates the compliance of the clinical eff ect with the functional condition of cavernous hemodynamics.