Elsevier

European Urology

Volume 55, Issue 1, January 2009, Pages 76-86
European Urology

Review – Prostate Cancer
Cryosurgery for Prostate Cancer: an Update on Clinical Results of Modern Cryotechnology

https://doi.org/10.1016/j.eururo.2008.08.063Get rights and content

Abstract

Context

Cryosurgery is an evolving treatment for localized prostate cancer in European centers. Modern cryotechnology is associated with a low complication rate, but its definitive role in the spectrum of different treatment modalities remains to be determined.

Objective

The primary objective of this review is to analyze the oncological results and complication rates of modern cryosurgery for prostate cancer. Secondarily, the impact of patient selection and the criteria for treatment success are discussed.

Evidence acquisition

A structured literature review was performed by an online Pubmed search for data of primary and salvage cryosurgery of the prostate. Papers with relevant information on clinical outcome and complication rates were selected.

Evidence synthesis

The introduction of gas-based third-generation cryotechnology has significantly decreased side effects with similar oncological results compared to older techniques. The occurrence of severe complications like rectourethral fistulas (<1%) has almost been eradicated, but the rates of erectile dysfunction remain high (90%). With salvage cryosurgery more side effects can be expected with an average incontinence rate of 8% and fistulas up to 3.4%. Nevertheless, this minimal invasive treatment remains an option for radiorecurrent prostate cancer. Focal cryosurgery is considered experimental, but is an interesting new development in cryosurgery. The intermediate-term biochemical disease free survival rates of 60%–90% are comparable to the results of other treatment modalities. However, the current data of cryosurgery in literature are of low-level evidence which should be discussed when counselling patients.

Conclusions

Modern cryosurgery is reliable and results are promising with minimal morbidity. Focal cryosurgery in selected patients aims to reduce side effects, but is currently experimental treatment. Randomized trials comparing the outcomes of the different treatment modalities and long-term follow-up data are needed to define the ultimate role of cryosurgery in the treatment of localized prostate cancer.

Introduction

Cryosurgery for prostate cancer was first applied in 1964 by Gonder et al. using liquid nitrogen [1]. The technique encompassed transurethral freezing of the prostate with the inability to position the cryoneedles precisely and to monitor the extent of freezing. This resulted in severe and frequent complications such as incontinence, urethral sloughing and rectourethral fistulas. Therefore, cryosurgery of the prostate was abandoned until the late 1980s, when Onik et al. [2] refined the technique by using interventional radiologic procedures and transrectal ultrasound (TRUS). The accurate TRUS-guided transperineal placement of cryoprobes with real-time monitoring and control of the freezing process has significantly decreased the number of complications [3], [4]. The use of a urethral-warming catheter decreased the sloughing rate of the urethral mucosa and subsequently the risk of obstructive problems [5], [6]. Consequently, cryosurgery was recognized by the American Urological Association (AUA) as a therapeutic option for localized prostate cancer in 1996.

Since the use of thermosensors in Denonvilliers’ fascia and nearby the neurovascular bundles [7] and the application of gas-based cryosurgery [8], complication rates have further decreased. The introduction of argon gas for freezing and helium gas for thawing, permitted a dramatic reduction in the diameter of the cryoprobes. The ultrathin 17-gauge (1.47 mm) cryoneedles have a very sharp tip, that allows for a direct transperineal placement into the prostate [9]. The cryoneedles are inserted through a brachytherapy-like template and because of the smaller diameter more needles can be placed. This enables a precise contouring of the ice ball, subsequently resulting in a more effective ablation of the gland. The track dilatation and insertion kit, that were needed for older generation cryoprobes (3.5-5.5 mm), are no longer necessary [9], [10], [11]. This development has significantly minimized the scrotal swelling and perineal ecchymosis occurring after the procedure [12]. By active instead of passive warming the procedure can be performed much quicker which is advantageous for the patient's recovery. Most patients are discharged from the hospital either the same day or the following day after treatment [13].

These technical improvements have made modern cryosurgery a minimal invasive procedure. Most reports in the literature are from the USA and Canada, but cryosurgery is evolving in European centers [13], [14]. Therefore, an update is provided of the latest results of modern cryosurgery as a primary treatment option or as a salvage procedure for radiorecurrent prostate cancer. We specifically discuss the impact of patient selection and criteria of treatment success on the oncological results. Also, developments such as focal- and nerve-sparing cryosurgery are discussed.

Section snippets

Evidence acquisition

The aim of this review is to put the results of third-generation cryosurgery in perspective with older techniques. Therefore, a structured literature review was performed by an electronic Pubmed search from January 1960 until June 2008. Data of primary- and salvage cryosurgery of the prostate with the following search terms: “cryosurgery and prostate cancer” (rendering 426 articles), “cryotherapy of the prostate and prostate cancer” (rendering 83 articles) and “cryoablation and prostate cancer”

Primary cryosurgery of the prostate

In most studies with intermediate-term follow-up both liquid nitrogen- and gas-based cryosurgery techniques have been used. In general, these show an actuarial biochemical disease-free survival (bDFS) of 60%–90% at 7 years [15], [16]. Long-term overall survival data have not been published yet and one report shows a 5-year overall survival of 89% [17]. The bDFS for gas-based third-generation cryosurgery is comparable to the results in previous reports of older techniques [12], [14], [18]. Table

Conclusions

There are increasing numbers of European centers applying cryosurgery for prostate cancer. The long learning curve has declined with new computer planning programs and guidance systems which greatly facilitate the procedure. Modern cryotechnology is therefore highly reliable and results are promising. The introduction of gas-based third-generation cryosurgery has decreased the complication rates significantly with similar clinical outcome when compared to older techniques. Salvage cryosurgery

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