FOCAL THERAPY (WITH CRYOTHERAPY)

Cryotherapy (also called cryoablation) is the use of very cold temperatures to freeze and kill prostate cancer cells as well as most of the prostate.  During cryotherapy, thin metal probes are inserted through the skin and into the prostate. The probes are filled with a gas that causes the nearby prostate tissue to freze,  while sparing surrounding structures such as the bladder and urethra

Cryotherapy might be used to treat early-stage prostate cancer that’s confined to one part of the prostate if other treatments aren’t an option for you. Cryotherapy for prostate cancer can also be used when the cancer has returned after initial treatment.

In the past, cryotherapy for prostate cancer was associated with more long-term side effects than were other prostate cancer treatments. Advances in technology have reduced these side effects.

It is well known that when human tissue is exposed to temperatures below freezing that tissue damage occurs. With temperatures falling to -7° to -10° Celsius extra- cellular water (water in tissue but outside cells) begins to crystallize. This in turn increases the concentration of electrolytes in the extracellular fluid and begins to draw water from inside cells. As the temperature drops to °-15C ice crystals begin to form inside the cells. Cell membranes are damaged, and cells are destroyed. When tissue is cooled to -40°C, all metabolic processes stop.

Cryoablation in Clinical Practice

The original indication for cryoablation of the prostate was for salvage therapy in prostate cancer patients who had recurred after either external beam radiotherapy or brachytherapy. However, now prostate cryotherapy is also indicated for primary treatment of prostate cancer.

A typical patient is an older patient, particularly one with voiding symptoms that prohibit the safe application of radiation. Other indications would include lower risk cancers, and in patients with morbidities that would make surgery exceedingly risky.

Why it’s done

Your doctor may recommend cryotherapy for prostate cancer as an option at different times during your cancer treatment and for different reasons. Cryotherapy might be recommended:

• As the initial treatment for cancer if your cancer is confined to your prostate and other treatments aren’t an option for you
• As a treatment for prostate cancer that comes back after your initial treatment
  
  

Cryotherapy for prostate cancer generally isn’t recommended if you:

• Previously had surgery for rectal or anal cancer
• Have a condition that makes it difficult or impossible to monitor the prostate with an ultrasound probe during the procedure
• Have a large tumor that can’t be treated with cryotherapy without damaging surrounding tissue and organs, such as the rectum or bladder
  
  

Researchers are studying whether cryotherapy to treat one part of the prostate might be an option for cancer that’s confined to the prostate. Termed focal therapy, this strategy identifies the area of the prostate that contains the most aggressive cancer cells and treats that area only. Studies have found that focal therapy reduces the risk of side effects.

These needles are placed through the perineal skin between the scrotum and rectum under ultrasound guidance using a special template, much the way that seeds are placed for brachytherapy. Two freeze-thaw cycles are completed, after which time a catheter is placed in the bladder. Prostate cryotherapy takes around an hour to perform, and there is little pain afterward. For the first hour or two, a patient will commonly feel an urge to urinate which slowly dissipates. There can be blood in the urine of course, and as stated scrotal swelling is very common and should not concern the patient. The patient will be asked to remove his catheter six days later and see your doctor for a voiding trial the next day. Occasionally, especially in those with pre-existing urinary difficulties, the catheter must be replaced temporarily.

How you prepare

One day prior to the procedure, the patient is instructed to start taking a quinolone antibiotic (levaquin or cipro), undergo a bowel preparation, and assume a low fiber diet. On the day of the procedure, either general or spinal anesthesia is required.

What you can expect during cryotherapy for prostate cancer

Cryotherapy for prostate cancer is done in the hospital. You may be given a drug called a general anesthetic to put you in a sleep-like state. Sometimes a regional anesthetic is used so that you’ll remain aware of your surroundings but won’t feel anything in the treatment area.

Once the anesthetic takes effect, your doctor:

• Places an ultrasound probe in your rectum.
  
  
• Places a catheter inside the tube (urethra) that carries urine out of the body. The catheter is filled with a warming solution to keep the urethra from freezing during the procedure.
  
  
• Inserts several thin metal probes or needles through the area between the scrotum and the anus (perineum) into the prostate.
  
  
• Watches the images generated by the ultrasound probe to ensure correct placement of the needles.
  
  

• Releases a gas to circulate through the probes or needles that causes freezing in the prostate tissue.
  
  
• Monitors and controls the temperature of the needles and the amount of freezing within the prostate gland.
  
  
• May place a catheter into your bladder through your lower abdomen to assist in draining urine after cryotherapy.
  
  

Side Effects of Cryotherapy Treatment for Prostate Cancer

“COMPLICATION RATES STRONGLY DEPEND ON THE LOCATION AND SIZE OF THE PATIENT’S LESION, AS WELL AS THE OPERATOR’S EXPERIENCE.”

Early Side Effects (Immediately After Treatment and First Weeks):

• Tiredness and Lethargy: Patients may feel tired from the anesthesia right after treatment and may continue feeling fatigued for 1-2 weeks as the body heals. This is normal.
  
  

• Urinary Symptoms:
  • Urgency, frequency, getting up at night to urinate
  • Discomfort or burning when passing urine
  • Slower urine flow due to prostate swelling and inflammation
    
    
• These urinary symptoms typically improve over 6 to 8 weeks but can take up to 3 months in some patients.
  
  
• Most patients can return to desk-based work after 2-3 weeks and should avoid strenuous activities or abdominal pressure for the first 4 weeks, gradually resuming over the next 2-3 weeks.
  
  
• Blood in Urine: Occasional blood, blood clots, or tissue debris in urine is common as the body expels dead prostate tissue, similar to how a scab forms on a skin wound.
  
  
• Infections:
  • Urinary tract infections requiring antibiotics can occur.
  • Rarely, infections in the testicle (epididymo-orchitis) may develop.
  • Very rarely, infections may require hospital admission for intravenous antibiotics.
    
    

Rare Complications Related to Surgery or Anesthesia:

• Chest infections
• Blood clots in legs (deep vein thrombosis) or lungs (pulmonary embolism)
• Preventive measures such as compression stockings and blood-thinning injections during surgery are standard.
  
  

Long-Term Side Effects:

• Urinary Incontinence:
  • Risk of needing to wear at least one pad daily is very rare (about 0,2-0,5 %).
  • Risk may be higher if the tumor is near the urinary sphincter muscle; your doctor will advise if this applies.
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• Erectile Dysfunction (ED):
  • Risk varies from 5% to 15% depending on how much prostate tissue is treated and baseline erectile function.
  • Patients with good baseline function have a 5-10 % risk; those with poorer function have a 10-15 % risk.
  • Treating both sides of the prostate roughly doubles the risk.
    
    
• Dry Orgasm (No Seminal Fluid):
  • Average risk is about 15-20 %.
  • High risk if both sides are treated or the treatment is close to the middle prostate where seminal fluid tubes join.
  • Even when fluid is present, volume is usually reduced.
  • If fluid is present, it may contain viable sperm—contraception should be used if pregnancy is not desired.
  • No current effective treatment for dry orgasm.
    
    
• Bowel or Rectal Problems:
  • Long-term bowel problems are very rare.
  • Some patients may experience constipation or bowel upset shortly after treatment, usually resolving quickly.
  • Very rare (1 in 1000 – 0,1 %) risk of recto-urethral fistula (a hole connecting the rectum and urinary tract).
  • If a fistula occurs, long-term catheter drainage is required for healing; surgery may be necessary if healing does not occur.
    
    
• Urethral Narrowing (Stricture):
  • Occurs in about 0,1-1 % of patients.
  • May require surgical removal of necrotic tissue or scar tissue through a cystoscopic procedure under general anesthesia.
    
    

After cryotherapy for prostate cancer

You’ll likely be able to go home the day of your procedure, or you may spend the night in the hospital. The catheter may need to remain in place for about two weeks to allow for healing. You might also be given an antibiotic to prevent infection.

After the procedure, you may experience:

• Soreness and bruising for several days where the probes or needles were placed
• Blood in your urine for several days
• Problems emptying your bladder and bowels, which usually resolve over time
  
  

How is follow-up after the treatment?

PSA levels should be checked every 3 months.

In order to check if your prostate cancer is cured or not, you will have prostate MR in specific periods after treatment.

In case of any clinical necessity prostate biopsy might be used to confirm.

If cancer cells are existent, a second cryotherapy treatment or other focal therapy procedures can be used.