This treatment is used to destroy cells by freezing tissue. Original attempts to treat prostate cancer with cryotherapy involved inserting a probe into the prostate through the skin between the rectum and the scrotum (perineum). Using a rectal microwave probe to monitor the procedure, the prostate was frozen in an attempt to destroy cancer cells. Poor precision in monitoring the extent of the freezing process often resulted in damage to tissue around the bladder and long-term complications such as injury to the rectum or the muscles that control urination.

More recently, smaller probes and more precise methods of monitoring the temperature in and around the prostate have been developed. These advances may decrease the complications associated with cryotherapy, making it a more effective treatment for prostate cancer. Although progress continues, more time is needed to determine how successful cryotherapy may be as a treatment for prostate cancer.

Cryoablation Comparable to Radiation Therapy for Prostate Cancer

WESTPORT, CT (Reuters Health) Mar 21 - Cryoablation appears to be at least as effective as radiation therapy in the treatment of prostate cancer, according to the results of a multicenter study.

Dr. John P. Long, of Tufts-New England Medical Center in Boston, and associates performed an outcomes analysis of 975 patients who underwent cryosurgical ablation of the prostate as primary therapy between 1993 and 1998. They report 24-month followup data in the March issue of Urology.

Using a prostate-specific antigen threshold of <1.0 ng/mL, the investigators found the 5-year actuarial biochemical-free survival rate to be 76% for patients at low risk of progression. For those at medium risk and at high risk, survival rates were 67% and 41%, respectively.

According to the authors, "these results are very comparable to those noted after conformal radiotherapy techniques and appear to be superior to those reported for brachytherapy."

The therapeutic equivalency of cryoablation was observed despite the fact that many physicians may use cryosurgical technologies that "are dated and have been shown to be less effective than current state-of-the-art methods and tools," Dr. Long said in a statement released by Endocarp, a manufacturer of cryoablation equipment.

The cryotherapy resulted in lower rates of rectal problems, slightly higher rates of voiding dysfunction, and higher rates of impotency than those reported for radiation therapy. Dr. Long's team suggests that institution of uniformly effective techniques may result in lower incidence of post-ablation voiding dysfunction "and even more reliable total prostatic ablation."

Urology 2001;57:518-523.

MY COMMENTS Note that using a threshold of 1.0 at five years low risk patients had 76%, medium risk at 67% and high risk at 41% (actually the 41% should of been 45%). The author states that these seem to be comparable to conformal radiotherapy and better than brachytherapy. Now we need to know the definition of low, medium and high and if it is mono brachytherapy. It would also help to know who he is comparing it against. I am yet to see a paper with a threshold of 1.0 with conformal radiotherapy show a 76% rate.

Lets now look at the abstract:

FIVE-YEAR RETROSPECTIVE, MULTI-INSTITUTIONAL POOLED ANALYSIS OF CANCER-RELATED OUTCOMES AFTER CRYOSURGICAL ABLATION OF THE PROSTATE

JOHN P. LONG, DUKE BAHN, FRED LEE, KATSUTO SHINOHARA, DOUGLAS O. CHINN, AND JOSEPH N. MACALUSO, JR

ABSTRACTR

Objectives. To define the potential role of cryosurgical ablation of the prostate (CSAP) as a treatment option for patients with localized prostate carcinoma (PCA), we performed a retrospective outcomes analysis of a large database of patients undergoing CSAP constructed from five institutions and compared this with matching outcomes from contemporary reports of patient outcomes after radiotherapy.

Methods. A total of 975 patients who underwent CSAP as primary therapy from January 1993 to January 1998 with sufficient outcomes data available were identified. Patients were stratified into three groups on the basis of their clinical features. Biochemical-free survival (BFS), post-CSAP biopsy results, and post-CSAP morbidities were calculated and recorded.

Results. The median follow-up for all patients was 24 months. The percentages of patients in the low, medium, and high-risk groups were 25%, 34%, and 41%, respectively. For prostate-specific antigen thresholds of less than 0.5 and less than 1.0 ng/mL, the 5-year actuarial BFS ranged from 36% to 61% and 45% to 76%, respectively, depending on the risk category. Overall, the positive biopsy rate was 18%. Morbidities included impotence in 93%, incontinence in 7.5%, rectourethral fistula in 0.5%, and transure-thral resection of the prostate in 13% of patients (10% approved warming catheters versus 40% nonap-proved).

Conclusions. For each risk group, the 5-year BFS and positive biopsy rate after CSAP was comparable to matching outcomes reported after radiotherapy. Morbidities also seemed comparable, with impotence rates higher and rectal injury rates lower after CSAP than after radiotherapy. These data indicate that CSAP can be performed with low morbidity and can produce cancer-related results comparable to those reported for patients undergoing radiotherapy. UROLOGY 57: 518–523, 2001. © 2001, Elsevier Science Inc.

MY COMMENTS

Now we can compare the 0.5 threshold to the 1.0. We find that at 0.5 the range is 36% to 61% and the range at 1.0 is 45 - 76%. I wonder why the press release only used the better one . Now we note that the medium follow up was only 24 months. Very short for a medium when measuring prostate cancer figures.

Some may be interested in the morbidities "Morbidities included impotence in 93%, incontinence in 7.5%, rectourethral fistula in 0.5%, and transure-thral resection of the prostate in 13% of patients. . ." Wonder why that important information was left out of the news release.

But even the Abstract does not tell us how they classified the low medium and high disease. Lets nest go to the paper itself.

The first thing that strikes me is that the study was a combined affair from 5 institutions. New England Medical Center, UCSF, Crittenton, Urologic institute in New Orlenes and Alhambra Hospital. Pretty impressive group.

Low risk was defined as T2a or lower, PSA of 10or less, Gleason 6 or less (25% of patients)

Medium risk was defined as patients with any ONE of the following. Stage T2b or greater, PSA over 10, Gleason 7 or greater. (34% of patients)

High was having two of the above three criteria. (41% of patients.

Now lets look at that.

We could have high defined as:

T1a or lower, Gleason 7 or more and a PSA of 10.1

T2b or greater, Gleason 6 or less and a PSA 0f 10.1

T2b or greater, Gleason of 7 or greater and a PSA of under 10.

Medium could be:

T2a or lower, Gleason 6 or less and a PSA under 10.

T2a or lower, Gleason 6 or less and a PSA of 10.1

T2b or higher, Gleason 6 or less and a PSA of under 10.

Low would be:

T2a or lower, Gleason of 6 or less, Gleason of 6 or less

This curve tends to send the patients toward a more high risk. If we look at the amount of T1/T2 patients which many clinics use we find that the breakdown is as follows.

T1 - 10.7%, T2 - 64%, T3 - 24%, T4 - 1.6% (Yes they treated T4 patients.)

Now we have T1T2 patients for a total of 74.7%. If we assume that all of the low and medium risk patients were in the T1/T2 category ( a few would of been out side) we could arrive at a T1T2 5 year disease free (median of 2 year follow-up) By the way some of these patients received 8 months of HT (Hormonal ablation Therapy) that would make some of those patients included with a followup of less than the two year medium with their PSA's still being influenced by the HT.

We had 101 T1 and 604 T2 total of 705 patients. Low risk had 25% (244 patients) and medium risk at 34% (331 patients) or 59% of 975 patients or a total of 575 patients. They don't match because some of the study patients who would of been classified in the high risk group would of been T1 or T2. The advantage here would probably be to the study group in this comparison. Using the figure given in the study we can now calculate the overall Low and Medium grade 5 years disease freedom rate which would of been 71%.

I than looked at the References they used to compare Brachytherapy. They were all of 1998 or earlier. Here are the names used. D'Amico, Ragde, Stock, Beyer. No Critz, Blasko, Grado, Grim. The Ragde study used was 10 years - hardly comparable at 5 years. Interesting they gave him a 87% at five years that was never reported in his studies at all. He had an overall 66% at ten years. Five years I would estimate to be around 8 points better. So at five years we might guess that Ragde would of had a 74% of all of his patients. A little better than the 71% low and medium risk figure of this study and Ragde included T1-T3 and a more conservative definition of failure of a PSA nadir of 0.5. He could been credited a few more points for those differences..

SUMMARY

We have an overall low and medium grade cancer projected 5 year disease freedom score of 71% with a two year followup using a definition of failure as anything over 1.0 to compare with T1T2 patients (no limit of Gleason or PSA) at a projected 5 year score of 88%

By the way the overall projected disease freedom at five years for this study with a medium of two year follow up would be 60%.

Now I have been known to have made mistakes in calculations and other errors so, although I think they are correct, I could of missed something someplace. However I think the general idea is very clear. In addition I have done some estimating based on my knowledge of trials that are not directly proven but I think are very good.

At this point I do not believe based on this study, and others I have seen, that Cryotherapy will match the rates obtained by brachytherapy and EBRT. When you further consider the rates of being incontinent at basically 0% with SI/EBRT and with Cryo at 7.5% AND the chances of being impotent at 93$ with Cryo vs. 25 to 35% with SI/EBRT - it is difficult for me to see why one would make a decision for Cryo as a local treatment when better results can be found with other treatments..

Actually I believe that they have a better record then EBRT alone.

Here are a series of Abstracts on Cryo.

- - - - - - - - - - -

1: BJU Int 2000 Feb;85(3):281-6 Related Articles, Books, LinkOut

Cryoablation for clinically localized prostate cancer using an argon-based system: complication rates and biochemical recurrence.

De La Taille A, Benson MC, Bagiella E, Burchardt M, Shabsigh A, Olsson CA, Katz AE

Department of Urology and Department of Biostatistics, Columbia University College of Physicians and Surgeons, New York, USA.

OBJECTIVE: To determine the complication rates and biochemical recurrence after cryoablation of the prostate, using an argon gas-based system, in patients with localized prostate cancer. PATIENTS AND METHODS: Between October 1997 and June 1999, 35 patients underwent cryoablation of the prostate (19 after radiation therapy failure and 16 as a primary treatment for localized prostate cancer). All patients had biopsy-confirmed prostate cancer with no seminal vesicle invasion, negative bone scans and a negative lymph node dissection. Patients received 3 months of combined hormonal therapy before cryosurgery. One surgeon performed all the procedures. Biochemical recurrence was defined by an increase in prostate specific antigen (PSA) of >/= 0.2 ng/mL above the PSA nadir. RESULTS: The complications were rectal pain (26%), urinary infection (3%), scrotal oedema (12%), haematuria (6%) and incontinence (6%). Complication rates were higher in those patients who failed after radiation therapy than in those who did not receive radiation (incontinence 11% vs 0%, rectal pain 37% vs 12%) but the difference was not statistically significant. Twenty-two patients (63%) had an undetectable serum PSA nadir (< 0.1 ng/mL) after cryotherapy and 30 (84%) patients had a PSA value of < 1.0 ng/mL. After a mean follow-up of 8.3 months (range 0.2-18), nine patients had biochemical recurrence. The biochemical recurrence-free survival (BRFS) was 70% at 9 months. Patients who had an undetectable PSA nadir had a statistically higher BRSF at 9 months than did patients who had a detectable PSA nadir (89% vs 55%, respectively, P = 0.03). Similarly, patients with a preoperative serum PSA level of < 10 ng/mL had a statistically higher BRFS than patients who had a PSA level of > 10 ng/mL (86% vs 42% at 9 months, P < 0.001). CONCLUSION: A PSA level before cryotherapy of < 10 ng/mL and an undetectable PSA nadir after cryotherapy were associated with the highest BRFS. Cryoablation of the prostate, with low morbidity, seems to be a viable option in managing patients by salvage therapy after radiation therapy and for the primary treatment of clinically localized prostate cancer.

PMID: 10671882, UI: 20138598

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2 : Urology 2000 Jan;55(1):79-84 Related Articles, Books, LinkOut

Salvage cryotherapy for recurrent prostate cancer after radiation therapy: the Columbia experience.

de la Taille A, Hayek O, Benson MC, Bagiella E, Olsson CA, Fatal M, Katz AE

Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York, USA.

OBJECTIVES: Cryotherapy of the prostate represents a potential treatment for localized recurrent prostate cancer after radiation therapy. We report our experience and evaluate the predictive factors for prostate-specific antigen (PSA) recurrence. METHODS: Between October 1994 and April 1999, 43 patients underwent salvage cryoablation. All patients had biopsy-proven recurrent prostate cancer without seminal vesicle invasion, negative bone scans, and negative lymph node dissection. Patients had received 3 months of combined hormonal therapy before cryosurgery. Biochemical recurrence-free survival (bRFS) was defined as a PSA value less than 0.1 ng/mL. RESULTS: Complications included incontinence (9%), obstruction (5%), urethral stricture (5%), rectal pain (26%), urinary infection (9%), scrotal edema (12%), and hematuria (5%). The mean follow-up was 21.9 months (range 1.2 to 54). Twenty-six patients (60%) reached a serum PSA nadir less than 0.1 ng/mL, 16 (37%) had a PSA less than 4 ng/mL, and 1 (3%) had a PSA less than 10 ng/mL. The bRFS rate was 79% at 6 months and 66% at 12 months. The bRFS rate was higher for patients who had an undetectable postcryotherapy PSA than for patients who did not reach a PSA less than 0. 1 ng/mL (73% versus 30%, P = 0.0076). Using multivariate analysis, a PSA nadir greater than 0.1 ng/mL was an independent predictor of PSA recurrence. CONCLUSIONS: Current salvage cryotherapy of the prostate can result in undetectable serum PSA levels with low morbidity. Our data support the current safety and efficacy profile. We believe that cryotherapy is a viable option in the treatment of patients who have biopsy-proven local failure after radiation therapy for prostate cancer. Further refinements in technique and equipment may enhance cryosurgical results.

PMID: 10654899, UI: 20119060

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3 : Semin Surg Oncol 2000 Jan-Feb;18(1):37-44 Related Articles, Books, LinkOut

Treatment of prostate cancer: watchful waiting, radical prostatectomy, and cryoablation.

Drachenberg DE

Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada. ddrachen@is2.dal.ca

Current advances in diagnostic modalities and screening has lead to diagnosis of prostate cancer at an earlier stage (the so-called "stage shift" phenomenon), making primary treatments of localized disease of extreme importance in management. Therapeutic modalities include conservative management, radical prostatectomy, external beam radiotherapy, and newer techniques such as cryoablation surgery and brachytherapy. This review will focus on the non-radiation, non-hormonal primary treatment of localized prostate cancer and discuss the popularity and success of "watchful waiting," radical surgery, and cryoablation along with their advantages and disadvantages. These treatments will be compared to the qualities of an ideal treatment, which include cost effectiveness, efficacy, convenience of administration, tolerance by patients, low morbidity and mortality, and minimal impact on quality of life. Copyright 2000 Wiley-Liss, Inc.

PMID: 10617895, UI: 20085322

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4 : Cancer 1999 Nov 1;86(9):1793-801 Related Articles, Books, LinkOut

Quality-of-life outcomes for men treated with cryosurgery for localized prostate carcinoma.

Robinson JW, Saliken JC, Donnelly BJ, Barnes P, Guyn L

Department of Oncology and Program in Clinical Psychology, University of Calgary, and Department of Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Alberta, Canada.

BACKGROUND: Cryosurgery was introduced as an alternative to radiotherapy or radical prostatectomy in the mid-1960s. Although it met the primary objective of achieving local control, it was largely abandoned due to a high incidence of complications. Technologic advances in the areas of imaging and urethral warming have renewed interest in this treatment methodology. The aim of the current study was to determine the quality of life of men enrolled in a Phase II clinical trial of cryosurgery for the treatment of localized prostate carcinoma. METHODS: Men were administered the Functional Assessment of Cancer Treatment-Prostate (FACT-P) prior to their treatment and at 6 weeks and 3, 6, and 12 months posttreatment. RESULTS: By 12 months after cryosurgery, most of the FACT-P subscales had returned to pretreatment levels, following a decline in well-being immediately after cryosurgery. There were two exceptions to this general trend: At 12 months, impairments in social/family well-being and sexual function still remained. The average time to return to work after therapy was 3 weeks. Stay in hospital after treatment was limited to 1 day for 94% of the participants. Compared with men who received the standard treatments of radical prostatectomy and radical radiotherapy, men treated with cryosurgery appeared to have a similar quality of life, with perhaps the exception of decreased sexual function. CONCLUSIONS: The quality-of-life outcomes of this study support the current renewed interest in cryosurgery. The severe impairments reported in other studies were not seen in this sample. In fact, it appeared that all aspects of the participants' well-being had returned to pretreatment levels by 12 months, with the exception of sexual function. Copyright 1999 American Cancer Society.

Publication Types: Clinical trial

PMID: 10547553, UI: 20016308

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5 : J Urol 1999 Nov;162(5):1653-7 Related Articles, Books, LinkOut

Total cryosurgery of the prostate versus standard cryosurgery versus radical prostatectomy: comparison of early results and the role of transurethral resection in cryosurgery.

Gould RS

Department of Urology, University of Massachusetts/Memorial Health Systems Hospital, Marlborough, USA.

PURPOSE: Results of standard cryosurgery of the prostate for prostate cancer in 49 patients were compared to those of destruction of the urethra during or after cryosurgery with subsequent transurethral resection or total freezing of the prostate (total cryosurgery) in 27. These results were compared to those of radical surgery in 83 patients with similar age, stage and grade of disease, and prostate specific antigen (PSA). MATERIALS AND METHODS: The 76 cryosurgery cases included all of those treated by 1 surgeon (R. S. G.) for localized prostate cancer after July 1, 1995. The 83 radical perineal prostatectomy cases consisted of all of those treated by another surgeon during the study period and by R. S. G. before cryosurgery use. Success was defined as a PSA of 0.2 or less 6 months after the procedure and a stricter standard, 0.0 PSA, was also assessed. RESULTS: The success rate was 96% for total cryosurgery, 48.9% for standard cryosurgery and 73.4% for radical surgery. Using 0.0 PSA as a criterion, 66.7% of total cryosurgery, 16.3% of standard cryosurgery and 48.2% of radical surgery cases were successfully treated. CONCLUSIONS: Total cryosurgical destruction of the prostate may offer new opportunities for cancer treatment heretofore unrecognized and should undergo more investigational analysis.

PMID: 10524891, UI: 99452522

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6 : Urology 1999 Aug;54(2):295-300 Related Articles, Books, LinkOut

Patient-reported complications after cryoablation therapy for prostate cancer.

Badalament RA, Bahn DK, Kim H, Kumar A, Bahn JM, Lee F

Department of Surgery, Crittenton Hospital, Rochester Hills, Michigan, USA.

OBJECTIVES: To define the patient-reported complications after cryoablation therapy for prostate cancer and to compare these results to previously published patient-reported complications for radical prostatectomy and external beam irradiation. METHODS: A questionnaire similar to previously published patient-reported complication studies was sent to the first 290 patients treated by cryoablation therapy at our institution. The questionnaire was returned by 267 patients. Forty-four patients were excluded from analysis because of prior irradiation, transurethral prostatectomy, or cryoablation, resulting in a study group of 223 patients. RESULTS: Of the 208 patients with good urinary control preoperatively, 9 (4.3%) patients used incontinence pads after cryoablation. Seven of the 8 patients who used one pad daily reported leakage of only a few drops. Impotency, defined as an inability to obtain erections adequate for vaginal penetration, occurred in 85% of men who were potent preoperatively. Urethrorectal fistula occurred in 1 patient (0.4%). Bladder outlet obstruction caused by stricture or sloughed necrotic prostatic tissue required dilation or transurethral resection in 10% of patients. Scrotal swelling, penile tingling, and pelvic pain occurred in 18%, 15%, and 12% of patients, respectively; typically, these resolved spontaneously within 3 months. CONCLUSIONS: Patient-reported complications for cryoablation compared favorably to those reported for radical prostatectomy and external beam irradiation. Patient satisfaction was high; 96% of patients reported that they would choose cryosurgery as a treatment option again.

7 : Urology 1999 Aug;54(2):295-300 Related Articles, Books, LinkOut

Patient-reported complications after cryoablation therapy for prostate cancer.

Badalament RA, Bahn DK, Kim H, Kumar A, Bahn JM, Lee F

Department of Surgery, Crittenton Hospital, Rochester Hills, Michigan, USA.

OBJECTIVES: To define the patient-reported complications after cryoablation therapy for prostate cancer and to compare these results to previously published patient-reported complications for radical prostatectomy and external beam irradiation. METHODS: A questionnaire similar to previously published patient-reported complication studies was sent to the first 290 patients treated by cryoablation therapy at our institution. The questionnaire was returned by 267 patients. Forty-four patients were excluded from analysis because of prior irradiation, transurethral prostatectomy, or cryoablation, resulting in a study group of 223 patients. RESULTS: Of the 208 patients with good urinary control preoperatively, 9 (4.3%) patients used incontinence pads after cryoablation. Seven of the 8 patients who used one pad daily reported leakage of only a few drops. Impotency, defined as an inability to obtain erections adequate for vaginal penetration, occurred in 85% of men who were potent preoperatively. Urethrorectal fistula occurred in 1 patient (0.4%). Bladder outlet obstruction caused by stricture or sloughed necrotic prostatic tissue required dilation or transurethral resection in 10% of patients. Scrotal swelling, penile tingling, and pelvic pain occurred in 18%, 15%, and 12% of patients, respectively; typically, these resolved spontaneously within 3 months. CONCLUSIONS: Patient-reported complications for cryoablation compared favorably to those reported for radical prostatectomy and external beam irradiation. Patient satisfaction was high; 96% of patients reported that they would choose cryosurgery as a treatment option again.

PMID: 10443728, UI: 99371328

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8 : J Urol 1999 Aug;162(2):427-32 Related Articles, Books, LinkOut

The efficacy of cryosurgical ablation of prostate cancer: the University of California, San Francisco experience.

Koppie TM, Shinohara K, Grossfeld GD, Presti JC Jr, Carroll PR

Department of Urology and University of California, San Francisco/Mt. Zion Cancer Center, USA.

PURPOSE: We analyze biopsy and prostate specific antigen (PSA) results following cryosurgery for patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 176 patients underwent 207 cryosurgical procedures for clinically localized (stages T1 to T4) prostate cancer using a multiprobe cryosurgical device. Cancer stage was T1 in 8.7%, T2 in 30%, T3 in 59% and T4 in 2.3% of the 176 patients. Neoadjuvant androgen deprivation was delivered to 101 patients (57%). End points used to determine efficacy of the procedure included analysis of posttreatment serum PSA characteristics (nadir and nonrising status) and biopsy results (absence of cancer). Cryosurgery was considered successful if PSA reached a nadir of less than 0.5 ng./ml. and did not increase by more than 0.2 ng./ml. on 2 consecutive occasions. Mean followup for the entire group was 30.8 months, with 122 patients (60%) followed for 24 or more months and 75 (36%) followed for 36 or more months. RESULTS: Serial PSA data was available after 181 initial and repeat procedures. Nadir PSA was undetectable in 88 patients (49%), between 0.1 and 0.4 ng./ml. in 39 (21%) and 0.5 ng./ml. or greater in 54 (30%) following cryosurgery. After 78 of these procedures (43%) serum PSA reached a nadir of less than 0.5 ng./ml. and failed to increase greater than 0.2 ng./ml. on at least 2 occasions. Prostate biopsy was performed following 167 procedures and was positive after 64 (38%). CONCLUSIONS: Cryosurgery was associated with favorable serum PSA characteristics in 49% of patients 3 years after treatment. Undetectable PSA nadir and pretreatment PSA 10 ng./ml. or less were associated with a favorable outcome, with a biochemical disease-free survival of 77% and 61% 3 years after treatment, respectively.

PMID: 10411051, UI: 99336832

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9 : Eur Urol 1998 Sep;34(3):181-7 Related Articles, Books, LinkOut

Cryoablation of localized prostate cancer. Experience in 48 cases, PSA and biopsy results.

Derakhshani P, Neubauer S, Braun M, Zumbe J, Heidenreich A, Engelmann U

Department of Urology, University of Cologne, Germany. p.derakhshani@uni-koeln.de

OBJECTIVES: As the first German center to perform perineal cryoablation of localized prostate cancer, we present our experience in a series of 48 consecutive patients. METHODS: 7 patients staged T1, 21 with T2 disease and 20 patients with T3 tumor were treated. 62.5% of the patients received neoadjuvant hormonal downsizing. Follow-up ranged from 4 to 27 months with a median of 15 +/- 5.7 months. RESULTS: Positive control biopsies after 6 months were obtained in 0% of T1 tumors, 16.7% of T2 tumors and 26.7% of T3 tumors. Prostate-specific antigen persistence above 1 ng/ml was diagnosed in 14.3, 33.3, and 40%, respectively. Complications were acceptable. 22.9% of the patients had prolonged urinary retention, requiring transurethral resection in 5 patients (10.4%) to relieve obstruction. In 5 cases (10.4%) incontinence was found, in 2 of these patients mild urge incontinence declined over time, in 3 cases moderate to severe stress incontinence developed. Two of these patients were pretreated with radiotherapy. No fistulae were noted. CONCLUSIONS: Cryoablation of the prostate is not a substitution for radical prostatectomy but enables the surgeon to perform a radical curative procedure in patients unfit for other radical forms of treatment or unwilling to undergo these. Long-term follow-up and prospective studies are necessary to define the clinical significance of this procedure.

PMID: 9732189, UI: 98402461

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10 : Br J Urol 1997 Dec;80(6):918-22 Related Articles, Books, LinkOut

The effect of cryosurgical ablation of the prostate on erectile function.

Aboseif S, Shinohara K, Borirakchanyavat S, Deirmenjian J, Carroll PR

Department of Urology, University of California School of Medicine, San Francisco, USA.

OBJECTIVE: To investigate the incidence and identify the possible cause of erectile dysfunction after cryoablation of the prostate. PATIENTS AND METHODS: Erectile function was examined prospectively in 15 sexually active men (aged 59-72 years) who underwent cryoablation of the prostate for clinically localized prostate cancer. Erectile function was assessed before and 6 months after treatment; after intracavernosal injection with 10 micrograms of prostaglandin E1 (PGE1), the degree and duration of erection, the size of the cavernosal arteries, the penile arterial blood flow velocity, and the time to achieve peak flow were evaluated using high-resolution ultrasonography and colour pulsed-Doppler spectral analysis. RESULTS: Post-operatively, all patients initially reported an inability to achieve an erection sufficient for vaginal intercourse. At 6 months' follow-up, erectile dysfunction persisted in nine, with minimal or no response to the intracavernosal PGE1 injections, there was a significant decrease in the peak velocity of blood flow within cavernosal arteries and a significant increase in the time to achieve peak arterial flow. CONCLUSION: Although many factors may contribute to erectile dysfunction after cryoablation of the prostate, vascular injury plays a major role.

PMID: 9439410, UI: 98102520

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11 : Semin Urol Oncol 1997 Nov;15(4):244-9 Related Articles, Books, LinkOut

Cryosurgery for locally advanced (T3) prostate cancer.

Connolly JA, Shinohara K, Carroll PR

Department of Urology, UCSF/Mt. Zion Cancer Center, University of California School of Medicine, San Francisco 94109-0738, USA.

Cryosurgery of prostate cancer results in epithelial destruction. An undetectable serum prostate-specific antigen and absence of cancer by biopsy is related to cancer stage. The best results are seen in patients with low stage disease. Recurrence is more common in those patients with seminal vesicle invasion or apical involvement by cancer. Morbidity is not insignificant. The risk of urinary retention can be minimized by the use of an effective urethral warming device and more prolonged urethral catheterization after the procedure. Impotence is common in patients who undergo complete cryoablation of the prostate.

PMID: 9421452, UI: 98081805

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12 : Chang Keng I Hsueh Tsa Chih 1997 Sep;20(3):201-6 Related Articles, Books, LinkOut

Application of cryoablation in the management of prostate cancer.

Chuang CK, Chu SH, Chen HW, Chiang YJ, Chou CC

Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan, R.O.C.

BACKGROUND: Radical prostatectomy is the most common and effective therapy for localized prostate cancer. But in addition to its surgical complications, even highly selected series carry a positive margin rate of 35 to 50%. Radiotherapy is another alternative for prostate cancer, but following radiotherapy there have been high positive biopsies reported. Cryosurgery, defined as in situ freezing and hence, devitalization of neoplastic tissues, has currently raised the interest of urologists in the management of localized prostate cancer or failed radiotherapy. MATERIAL: Five patients underwent transperineal cryosurgery of prostate in Chang Gung Memorial Hospital. Among them, three cases were stage D, one stage B and another failed radiotherapy of stage C prostate cancer. All patients received hormone therapy too. RESULTS: PSA declined in 3 patients and biopsies showed intraductal neoplasia. All 5 patients suffered from urine incontinence and one persisted. No mortality has been reported. CONCLUSION: Cryoablation of the prostate is an alternative for treatment of prostate cancer.

PMID: 9397611, UI: 98060002

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13 : Anticancer Res 1997 May-Jun;17(3A):1511-5 Related Articles, Books, LinkOut

Cryosurgery of prostate cancer. Use of adjuvant hormonal therapy and temperature monitoring--A one year follow-up.

Lee F, Bahn DK, McHugh TA, Kumar AA, Badalament RA

Department of Radiology and Surgery, Rochester, MI 48307, USA.

OBJECTIVE: To determine the clinical outcomes at one year of Stages T2-T3 prostate cancer by cryosurgery utilizing pretreatment with total androgen ablation therapy and temperature monitoring to control the freezing process. Study Group To date, 347 patients have had 356 cryosurgical procedures, 280 have reached one year post treatment. Of these 131 had re-evaluation with prostatic biopsy and serum PSA. METHODS: Transrectal ultrasound (TRUS) measurement of tumor size and biopsy of extraprostatic space was used to stage patients into two main groups: confined (66.6%) versus nonconfined (19.3%). Radiation failures (14.1%) formed a separate group. Failure rates for the 131 men include all cancer diagnosed during the one year period following cryosurgery. RESULTS: The one year failure rate for the study group was 19.8% (26/131). For stages T2a, T2h C, T3 and radiation failures, the rates of positive biopsies were 13.9%, 12.9%, 33.3% and 35%, respectively. For those with local control of cancer (negative biopsy), 80% had prostate specific antigen (PSA) levels of < 0.5 ng/ml. The statistical variables for persistent cancer with prostate specific antigen > 0.5 ng/ml were: sensitivity of 66.7%, PPV of 16.7%, NPV of 98% and specificity of 83.7%. A statistically significant difference exist between stages T2 vs T3 and radiation failures (p = < 0.5). Major complications of rectal fistula and total incontinence for previously non-treated cancer versus radiation failures were 0.33% and 8.7% respectively, a 26 times greater risk. CONCLUSION: Results of cryosurgery for all stages of prostate cancer at one year are encouraging, being 80% free of disease (biopsy and prostate specific antigen). The morbidity of the previously non-treated cancers from this procedure for us was minimal with high patient acceptance. For radiation failures a local control rate of 65% was achieved. However, early in our experience significant morbidity did occur and our enthusiasm for attempted salvage was initially tempered.

PMID: 9179188, UI: 97322698

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14 : J Urol 1996 Jul;156(1):115-20; discussion 120-1 Related Articles, Books, LinkOut

Cryosurgical treatment of localized prostate cancer (stages T1 to T4): preliminary results.

Shinohara K, Connolly JA, Presti JC Jr, Carroll PR

Department of Urology, University of California at San Francisco 94109-0738, USA.

PURPOSE: We determined the posttreatment biopsy results, prostate specific antigen (PSA) levels and complications associated with cryosurgical ablation of the prostate performed for localized prostate cancer. MATERIALS AND METHODS: Within 18 months 102 patients underwent cryosurgery as definitive therapy for localized prostate cancer. Mean patient age was 68 years and 57% had advanced local disease (stage T3 or T4). Mean preoperative PSA was 21.8 ng./ml. RESULTS: PSA was undetectable at 6 months in 48% of patients who received no androgen deprivation therapy following cryosurgery. Of 91 patients with postoperative biopsies 77% had no evidence of cancer but 71% had benign epithelial a elements. The complication rate (excluding impotence) was 51%. Biopsy and PSA results improved with experience and changes in technique, that is double freezing, more lateral placement of cryoprobes and more aggressive freezing beyond the prostatic capsule. The most recent cohort of 77 patients had a detectable PSA rate of 23% and a positive post-cryosurgical biopsy rate of 11%. The most common serious complication encountered was bladder outflow obstruction requiring transurethral resection in 23% of the patients. Impotence occurred in 84% of patients potent preoperatively. CONCLUSIONS: Cryosurgical ablation of the prostate can result in negative posttreatment biopsies and undetectable serum PSA levels. However, it is associated with significant side effects and the long-term durability of the procedure is unknown.

PMID: 8648771, UI: 96237710

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