SUMMARY

Cryosurgery is peformed for the cure of prostate cancer by inserting thin needles , called cryoprobes, through the skin of the perineum (between  scrotus and anum) under ultrasound guide. The procedure is similar to a prostatic biopsy. The surgery lasts sixty minutes. Anesthesia can be local, spinal or general. The iceballs formed around the cryoprobes cause a controlled nechrosis of the cancer tissues. At the end of the procedure the patient is dismessed after few hours or rarely the day after.  

GENERAL INFORMATION

The prostate is a fibromuscular gland shaped like a pyramid in the male genital apparatus. It usually does not weight more than 20 grams and its sides do not go beyond 3-4 cms. Its main role is producing seminal fluid, which is vital for constituting sperm and its efficacy. 

It is currently the organ that is most stricken by serious pathologies such as carcinomas, which we discuss in this section, and by less serious ones such as Benign Prostatic Hyperplasia (Prostatic Adenomatosis or BPH) and infections arising from the urinary pathways, which we deal with in the section on Urology. Fortunately however, it is located about 5 cms from the anus, between the rectum and the bladder and thus can be easily investigated. 

Diagnosis

Prostate Specific Antigen has been the sole indicator of prostate cancer for years: at high levels it used to follow a relatively long diagnostic journey that usually ended in the surgical removal of the prostate, or part of it (radical or partial prostatectomy). This kind of operation usually involved high levels of impotence, erectile dysfunction and urinary disorders.  It is known today that the production of the antigen can also be caused by other factors, such as a benign enlargement that does not need removal, (See: internal link to the article by prof. Ablin), prostatitis, or recent sexual activity, just like by certain recent diagnostic activities a (cystoscopy, biopsy, or colonoscopy).

From recent estimates, around 180,000 Americans were diagnosed with prostate cancer in 2016 and more than 3,300,000 men are living with the same disease in the USA. The need to improve diagnostic capabilities had brought about the introduction of multi-parameter magnetic resonance imaging (MP MRI), for a more accurate classification of the degrees of risk (Gleason Score, PSA, Tumour Stage) and to image fusion biopsies1. The latter are performed using special outpatient equipment that merges Magnetic Resonance images (MR or MRI) with ultrasound scan images sampled at the time of the biopsy, with the aim of creating a faithful 3D model of the patient’s organ.  Studying the resonance images enables the Regions of Diagnostic Interest (ROI) to be identified, and then recreated in the 3D model and, thanks to an electromagnetic pointing system, to direct the biopsy needle exactly to the ROI2,3.

Therapy

Prostate Cancer (PC) is the most commonly diagnosed disease in men and turns out to be the second largest cause of death connected with cancer in industrial nations with about a 20-30% relapse rate5. Both annual urological examinations and blood samples to detect PSA are the main weapons we have in order to become aware of the disease in time, and thus have a very high chance of a cure.

Both the tumour and the adenomatosis (BPH) are subject to removal by traditional surgery, but they can be, and should be5,6, treated using other minimally invasive systems amongst which is  cryoablation 4, above all when traditional surgical techniques (open air and laparoscopic surgery) besides robot-assisted techniques, are deemed to be comparable. The latter technique has been improved over the years since it was considered promising 17 in order to enable focalised therapies 8,29, and so much so as to compete with or surpass, other techniques in various situations. All this is to the advantage of patients who can benefit in this way from several valid medical techniques, which have been consolidated and come close to their requirements. 

Cryosurgical technique provides for the insertion into the prostate of fine needles called cryoprobes. Thus is performed by the transperineal route (between the scrotum and the anus) guided by an ultrasound scan, following a pathway that is similar to any prostate biopsy. The duration of an operation varies from case to case but in general, following anaesthesia, which can be local, spinal or general, it lasts less than 40 minutes. The ice that forms round the cryoprobe triggers apoptotic and controlled necrotic mechanisms in the diseased tissues causing them to die irreversibly. At the end of the procedure, the patient undergoes a brief stay in hospital (a few hours or one night at most). A catheter is inserted for a few days to facilitate the discharge of urine from the bladder. 

General Experience and Indications:

  • This is the most effective approach for replacing failed radiotherapy19,21,23,24,25,26,28;
  • It guarantees sensitive results in cases with high levels of concurrent disorders that do not make a patient eligible for other approaches21;
  • It is the first choice for tumours considered to be low risk, and that thus do not need immediate removal, but which are to be monitored over time by traditional medicine, if an approach by operation is preferred;22
  • In certain cases it can delay the need for therapy by androgen deprivation both in patients that have chosen cryoablation as the main therapy, and in patients in whom radiotherapy has failed24,27;

Our experience has also revealed several other aspects of the technique such as for example: 

  • Haemostatic cryotherapy as a palliative approach for locally advanced prostate cancer could represent a valid treatment option whose use should be considered more often18;
  • The technique has considerable effectiveness in reducing the symptoms of urinating difficulties with large and obstructive prostates; 
  • We have now more than 20 years of experience and follow up. That experience confirms the good acceptance on the part of patients and its high therapeutic effectiveness. The low impact that the technique presents to the patient and the potential preservation of the gland and the related functions make cryoablation the main method chosen in several medical centres across the whole world.  
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  10. Focal cryotherapy for clinically unilateral, low-intermediate risk prostate cancer in 73 men with a median follow-up of 3.7 years.
    Bahn D1, de Castro Abreu ALGill ISHung AJSilverman PGross MELieskovsky GUkimura O.
    Eur Urol. 2012 Jul;62(1):55-63. doi: 10.1016/j.eururo.2012.03.006. Epub 2012 Mar 21.
  11. Cryoablation for locally advanced clinical stage T3 prostate cancer: a report from the Cryo-On-Line Database (COLD) Registry.
    Ward JF1, DiBlasio CJWilliams CGiven RJones JS.
    BJU Int. 2014 May;113(5):714-8. doi: 10.1111/bju.12476. Epub 2014 Jan 22.
  12. Cryoablation of prostate cancer
    Witzsch UK1, Becht E.
    Urologe A. 2015 Feb;54(2):191-201. doi: 10.1007/s00120-014-3667-1.
  13. Cryosurgery as primary treatment for localized prostate cancer.
    Lian H1, Guo HGan WLi XYan XWang WYang RQu FJi C.
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  14. Cryosurgery would be An Effective Option for Clinically Localized Prostate Cancer: A Meta-analysis and Systematic Review.
    Gao L1,2, Yang L2, Qian S1,2, Tang Z1,2, Qin F1, Wei Q2, Han P2, Yuan J1,2.
    Sci Rep. 2016 Jun 7;6:27490. doi: 10.1038/srep27490.
  15. Focal cryoablation for unilateral low-intermediate-risk prostate cancer: 63-month mean follow-up results of 41 patients.
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  17. Focal therapy in prostate cancer: the current situation.
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  19. Long-Term Oncologic Outcomes of Salvage Cryoablation for Radio-Recurrent Prostate Cancer.
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    Guo Z1, Si T1, Yang X1, Xu Y1.
    BJU Int. 2015 Jul;116(1):79-84. doi: 10.1111/bju.12914. Epub 2015 Jan 21.
  21. The role of cryosurgery of the prostate for nonsurgical candidates.
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  24. Salvage focal cryosurgery may delay use of androgen deprivation therapy in cryotherapy and radiation recurrent prostate cancer patients.
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  29. Propensity Score-Matched Comparison of Partial to Whole-Gland Cryotherapy for Intermediate-Risk Prostate Cancer: An Analysis of the Cryo On-Line Data Registry Data.
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