Cryotherapy for Prostate Conditions

(Also known as: Cryosurgery and Cryoablation)

Procedure overview

What is cryotherapy?

Cryotherapy is a procedure that involves killing cancer cells by freezing them and surrounding them with ice crystals. Tiny needles are placed directly into the tumor then argon gases are passed through the needles and exchanged with helium gases. This causes a freezing and warming cycle. A urethral warming catheter keeps the urethra warm throughout the procedure to prevent the urethra from freezing.

For prostate treatment, the needles are often inserted using transrectal ultrasound (TRUS) guided technology.

What is the prostate gland?

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The prostate gland is about the size of a walnut and surrounds the neck of a man's bladder and urethra—the tube that carries urine from the bladder. It's partly muscular and partly glandular, with ducts opening into the prostatic portion of the urethra. It's made up of three lobes, a center lobe with one lobe on each side.

As part of the male reproductive system, the prostate gland's primary function is to secrete a slightly alkaline fluid that forms part of the seminal fluid (semen), a fluid that carries sperm. During male climax (orgasm), the muscular glands of the prostate help to propel the prostate fluid, in addition to sperm that was produced in the testicles, into the urethra. The semen then travels through the tip of the penis during ejaculation.

Researchers don't know all the functions of the prostate gland. However, the prostate gland plays an important role in both sexual and urinary function. It's common for the prostate gland to become enlarged as a man ages, and it's also likely for a man to encounter some type of prostate problem in his lifetime.

Many common problems are associated with the prostate gland. These problems may occur in men of all ages and include:

• Benign prostatic hyperplasia (BPH). An age-related condition of the prostate that isn't malignant. BPH is the most common noncancerous prostate problem, occurring in most men by the time they reach their 60s. Symptoms are slow, interrupted, or weak urinary stream; urgency with leaking or dribbling; and frequent urination, especially at night. Although it isn't cancer, BPH symptoms are often similar to those of prostate cancer.
• Prostatism. The symptom of prostatism is decreased urinary force due to obstruction of flow through the prostate gland. The most common cause of prostatism is BPH.
• Prostatitis. This inflammation or infection of the prostate gland is characterized by discomfort, pain, frequent or infrequent urination, and sometimes fever.
• Prostatalgia. This is pain in the prostate gland, also called prostatodynia. It's frequently a symptom of prostatitis.

Cancer of the prostate is a common and serious health concern. According to the American Cancer Society (ACS), prostate cancer is the most common form of cancer in men older than age 50, and the third leading cause of death from cancer.

There are two other types of treatments that can be used for either BPH or prostatectomy. However, there hasn't yet been enough research done to prove their long-term effects.

• High intensity focused ultrasound (HIFU). This procedure uses high-energy sound waves delivered to tissue. The energy that's targeted to tissue causes a heating effect, which then destroys or ablates prostate tissue. This treatment has been used more widely in Europe, and is being studied now in the U.S. Preliminary outcomes appear to indicate that this treatment is safe and fairly comfortable. However, it isn't the best approach for a very large prostate gland and can cause urinary retention.
• Laser prostatectomy or laser ablation. This is a newer procedure, but it can be performed on prostate glands that are larger. A laser works by releasing concentrated light energy in bursts lasting 30 to 60 seconds. It cuts through tissue with a minimum of blood loss. It's also precise enough to dissect away the prostatic lobes (on each side of the prostate gland) from the prostatic capsule. Any dead tissue remaining behind dissolves and eventually passes out through the urine. While laser prostatectomy appears to be safe and effective, it has some drawbacks. Only trained practitioners are able to perform the procedure appropriately. There is, however, a relatively long post-operative recovery, which lasts several weeks before there's any significant improvement in urinary symptoms. Also, dead tissue can't be examined for signs of cancer cells once it is destroyed.

Why is cryotherapy used?

Cryotherapy may be used in patients with low-risk tumor factors, such as an original prostate specific antigen (PSA) level less than 10 ng/mL, Gleason score lower than 6, and less advanced clinical stage (for example, T1c or T2a, and some say, even up to T3a). A Gleason score is a way of grading prostate cancer cells on a scale of 2 to 10. The higher the number, the faster the cancer will likely grow and the more chance it will to spread beyond the prostate. Men who aren't as concerned about their erectile function after surgery may consider cryosurgery as an option, as the risk for temporary or permanent impotence after the procedure is high.

When the intent is not to cure, cryosurgery may be useful for patients who have disease that has spread beyond the prostate gland and need treatment for symptoms. Sometimes cryoablation may be used as an alternative for patients who have had unsuccessful results with radiation therapy. Some experts believe cryotherapy can be helpful when the prostate cancer cells aren't as sensitive to radiation.

Cryotherapy may not be recommended for men who have a very large prostate gland.

Cryosurgery is also used because it's less invasive than radical prostatectomy, and subsequently, there's generally less blood loss, a shorter hospital stay (or even no hospital stay), shorter period of recovery, and less pain.

Cryosurgery has only been used since the late 1990s. Because there are no long-term studies of cryosurgery available, it may not be among the first options presented to many prostate cancer patients. However, initial studies indicate that cryotherapy is a safe and effective treatment.

There may be other reasons for your physician to recommend cryotherapy.

What are the risks of the procedure?

As with any procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• Bleeding or blood in the urine
• Soreness or swelling in the region where the needles are placed
• Swelling around the penis or scrotum
• Freezing may affect the bladder and intestines, which can lead to pain and burning sensations
• Urge to empty the bladder and recover bowels more often (most men recover normal function in several weeks)
• Erectile dysfunction (impotence) for around 80 percent of men, which is usually permanent
• Urinary incontinence is rare; however, this may be more common if the man has had prior radiation therapy
• Fistula (an abnormal opening) between the rectum and bladder is a rare complication

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the procedure

Here are some things you can expect:

• Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You'll be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something isn't clear.
• In addition to a complete medical history, your physician may perform a physical examination to ensure you're in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.
• You'll be asked to fast for eight hours before the procedure, generally after midnight.
• Notify your physician if you're sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).
• Notify your physician of all medications (prescribed and over the counter) and herbal supplements that you're taking.
• Notify your physician if you have a history of bleeding disorders or if you're taking any anticoagulant (blood-thinning) medications, aspirin, or any other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure
• If you smoke, you should stop smoking as soon as possible prior to the procedure, in order to improve your chances for a successful recovery from surgery and to improve your overall health status.
• You'll be asked to undergo a bowel regimen to empty your colon the night before surgery.
• You may receive a sedative prior to the procedure to help you relax.

Based upon your medical condition, your physician may request other specific preparation.

During the procedure

Cryosurgery may require a one-day stay in the hospital. It may also be done as an outpatient procedure. Procedures may vary depending on your condition and your physician's practices.

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Generally, cryotherapy follows this process:

1. You'll be asked to remove any jewelry or other objects that may interfere with the procedure.
2. You'll be asked to remove your clothing and will be given a gown to wear.
3. You'll be asked to empty your bladder prior to the procedure. An intravenous (IV) line will be started in your arm or hand.
4. The surgeon will first place a catheter into the bladder to drain urine from it. The catheter will be placed through the urethra and the bladder will be filled with saline solution. This will help to keep urine draining even if the prostate gland swells after the treatment. The catheter will also be used for the circulation of a warm liquid to protect the urethra from the cold temperatures used during the procedure.
5. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you're sedated, a breathing tube may be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.
6. The surgeon may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medication delivered through an epidural catheter (in the back) to numb the area to be operated on. You'll receive medication to help you relax and analgesic medication for pain relief. The surgeon will be able to talk to you during the procedure. The surgeon will determine which type of anesthesia is appropriate.
7. You'll be placed on your back on the operating table with your legs up in stirrups.
8. The surgeon will insert the cryoprobes (needles) into the preselected areas between the scrotum and anus. A liquid cooling agent (usually argon) will be placed into the needles, which eventually freezes the entire prostate gland. The frozen area will stay frozen for only a few minutes then will be thawed by inserting helium through the needle probes. This cycle may be repeated once.
9. The surgeon will view ultrasound images to assess the freezing process to ensure only the affected tissue is being treated.
10. The needles will be extracted and the urinary catheter will remain in the bladder.
11. A sterile bandage/dressing will be applied.
12. You'll be transferred from the operating table to a bed then taken to the recovery room.

After the procedure

After the procedure, you may be taken to the recovery room before being taken to a hospital room. You'll be connected to monitors that will constantly display your heart rate (electrocardiogram tracing, ECG or EKG), blood pressure, other pressure readings, breathing rate, and your oxygen level.

Once your blood pressure, breathing, and pulse are stable and you're alert, you'll be taken to your hospital room.

You may receive pain medication as needed, either by a nurse, or by administering it yourself through a device connected to your intravenous line.

Once your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as you're able to tolerate them.

Your recovery will continue to progress. You'll probably have some bruising and swelling in the perineum where the probes were inserted. You should be allowed to walk the same day and you may be able to go home the same or the next day.

You may notice some blood in your urine for a day or two after the surgery. Swelling in the penis or scrotum is common. You may also experience pain in the abdomen and burning sensations, which may make you feel an urge to go to the bathroom more often.

The catheter will stay in for a couple of weeks to help urine drain while your prostate gland heals.

Due to nerve damage caused by the freezing process, impotence (erectile dysfunction) will occur in most men who have this treatment.

Urinary incontinence may also result from cryosurgery. Your physician will give you suggestions for how to manage this side effect.

Arrangements will be made for a follow-up visit with your physician.

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.

At home

Once you're home, it'll be important to keep the surgical area clean and dry. Your physician will give you specific bathing instructions.

The needle insertion sites and the catheter incision may be tender or sore for several days after cryosurgery. Take a pain reliever for soreness as recommended by your physician.

You shouldn't drive until your physician tells you to. Other activity restrictions may apply.

Notify your physician to report any of the following:

• Fever and/or chills
• Redness, swelling, or bleeding or other drainage from any incision sites
• Increase in pain around the incision sites

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.