Treatment Gives Cancer the Cold Shoulder

Filberto Rodriguez was first diagnosed with prostate cancer back in 2000.

"It was kind of a shock to me," he said of the news.

Even more shocking was when, after seemingly successful treatment, it came back. This time, his doctor recommended cryoablation.

Dr. Mark Bransted of Urology Associates of Topeka says the procedure essentially freezes the prostate. He's been doing cryosurgery in Topeka for about a year.

Using ultrasound and computer technology, the prostate is mapped and areas are pinpointed on a grid to insert four to eight cryoprobes. Additional thermal probes are put in place to protect surrounding structures. Then, freezing begins.

"The prostate will get anywhere from -40 to -80 degrees Celsius," Dr. Bransted said.

Once frozen, the area is thawed, and the process repeated a second time. Dr. Bransted says the process of freezing the cancer cells causes them to burst, killing them.

The entire procedure takes about 45 minutes, and patients are typically out of the hospital within 24 hours, instead of the three to five day hospital stay traditional surgery requires.

Dr. Bransted says a less invasive procedure has advantages. He says it can be used on older men who may have other conditions that preclude them from having surgery. Plus, it can be repeated, unlike radiation.

That means for second-time patients like Filberto, there's finally an option.

"I'm here to tell people the challenges are there, but if you want to live, you have to take them," Filberto said.

The American Cancer Society says one in six men will get prostate cancer in his lifetime. Filberto wants his experience to remind all men to get a yearly prostate check after age fifty, earlier if you're African-American or have a family history of prostate cancer.

More about Cryoablation
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Cryoablation for Prostate Cancer

Prostate cancer is one of the most common forms of cancer in men and some of its traditional treatments can result in serious complications. However, cryoablation is an emerging alternative that shows great promise. What does this new treatment entail? What are its advantages and disadvantages? The following information should help answer those questions and more.

What is cryoablation?

Cryoablation is a form of cryotherapy for the prostate that involves the controlled freezing of the prostate gland in order to destroy cancerous cells. The damage caused by freezing occurs at several levels: molecular, cellular and whole tissue structure. Important factors influencing freezing injury are the rate of temperature reduction after the initiation of freezing, the time cells remain frozen and the subsequent heating rate during thawing.

The cells are not the only structures damaged during freezing. During cryoablation of the prostate, the surrounding connective tissue (stroma) and the smallest blood vessels (capillaries) are damaged and subsequently have an inadequate blood supply that is believed to slow the growth of cancer.

Who are the most suitable candidates for cryoablation of the prostate?

Suitable candidates for this procedure are patients who have organ-confined prostate cancer or those who have minimal spreading beyond the prostate.

How is the procedure performed?

Under anesthesia, an ultrasound probe is guided into the rectum. The prostate is imaged and its dimensions measured. An aiming grid software program is then activated and images of the prostate are projected on a screen. Under continuous monitoring with ultrasound imaging, cryoablation probes are placed at predetermined sites within the prostate. The freezing starts at the front part of the prostate by activating the front probes, followed by the middle and finally the back probes. This sequence allows continuous monitoring (by visualizing the freezing process through the transrectal ultrasound). Two freezing cycles are usually done. Between them, the prostate is allowed to thaw either passively or actively by using helium gas. If the prostate is more than 26 to 27 mm. long, an apical pullback maneuver is usually done to freeze the lower part of the prostate. Double freezing is performed again. Each of the commercially available cryosurgical systems has a different type of probe and placement strategy, but all aim to freeze the prostate, tumor(s) and surrounding tissue — except the urethral area. By keeping the urethra warm during prostate freezing, the urethral wall remains viable. This is important, as it minimizes the risk of urethral damage, obstruction and urinary incontinence. Using a flexible cystoscope, the bladder and urethra are examined meticulously for evidence of injury. If a probe is found piercing the urethra it is repositioned. A suprapubic catheter (a small catheter that is pierced into the bladder through a small opening in the lower abdomen) is inserted and secured in place by a suture. The urethral warming catheter is introduced through the urethra with its end in the bladder. During the procedure, the bladder is kept nearly full by keeping the open suprapubic catheter at a slightly higher level than the bladder. The urethral warming catheter keeps the urethra warm throughout the procedure and is kept active for about 20 minutes after complete thawing to prevent the urethra from freezing.

What can be expected after treatment?

The patient is usually kept overnight, allowed some food and encouraged to walk. The patient is usually discharged the next morning with a catheter in place for drainage.

The patient can attempt to urinate at first desire. Most patients are able to urinate in about 10 to 15 days but some may require longer recovery periods. When the patient is able to urinate well and empty the bladder satisfactorily, the suprapubic catheter is removed. Some surgeons use a urethral catheter instead of the suprapubic catheter. In that case, the urethral catheter is removed seven to ten days and trial unination is attempted. If the patient is unable to urinate, the catheter is reinserted for a few more days. Oral antibiotics are usually given for 10 to 14 days. Other symptoms and signs the patient may experience are generalized fatigue that usually persists for seven to 10 days, urethral discharge, scrotal swelling, numbness at the tip of the penis, passage of flecks of tissue, pain or burning sensation during urination and increased urinary frequency and/or urgency.

A PSA test is usually done at three months. Also, a prostatic biopsy may be done at three to six months to assess for prostate destruction and absence of viable cancer cells especially if PSA level is detectable. If the biopsy proves negative, PSA measurements are obtained monthly for one to two years, then every six months for the next one to three years and every year thereafter.

What type of results can be expected?

Five U.S. institutions reported their experience with the use of cryoablation. The results were compared to those of conformal radiotherapy and brachytherapy. Patients with a previous history of failed radiotherapy were excluded and androgen deprivation was determined and categorized separately. Patients were classified as low risk, moderate risk or high risk according to the cancer characteristics (stage of the disease, Gleason grade and PSA level). The procedure was not consistent at all institutions. Differences included the number of probes used, number of freeze cycles per patient, length of apical pullback maneuver, real-time monitoring during freezing and the system used for freezing. A total of 975 patients were studied, of whom 238 were low risk, 321 were moderate risk and 385 were high risk; risk was not determined in 38 patients. The five-year rate for non-rising postoperative PSA levels for low and medium risk patients ranged between 60 and 76 percent and for high-risk patients it was 41 percent. Only about 18 percent of the patients were found to have a positive biopsy following the procedure. These results are encouraging and may place cryoablation therapy between radical prostatectomy and radiotherapy in effectiveness.

What are the risks associated with this procedure?

New technological advances have resulted in a significant reduction of the rate of complications. Improved urethral warming devices have minimized urethral complications. Better spacing of the probes now contributes to the effectiveness and safety of the procedure. Improved monitoring of the freezing with transrectal ultrasound is also helpful. However, some risks still exist. Perhaps one of the most critical is the risk of urinary rectal fistula, which creates a channel between the prostate or the bladder and the rectum and may cause diarrhea due to urine in the rectum and possibly severe infection due to bacteria in the bladder. There is also a high incidence of erectile dysfunction. Other complications, although uncommon given technological advances, include urinary incontinence, urinary retention requiring transurethral resection of the prostate (TURP) and inflammation of the testicle. Almost all patients have a temporary need for a catheter to empty the bladder for an average of 15 days. Permanent, severe incontinence is rare (approximately 1 percent) and other rare complications include prostatic abscess and permanent penile numbness.

Frequently asked questions:

What are the advantages and disadvantages of cryoablation of the prostate?

Cryoablation therapy offers:

  • a minimally invasive procedure
  • favorable success rate and complication rates
  • a short recuperation period
  • procedure can be repeated if the first cryoablation has failed
  • radiation therapy or radical prostatectomy is still an option if the procedure fails
  • less than half the cost of the traditional treatment

The disadvantages are:

  • insurance may not cover this procedure
  • extensive experience and training by the surgeon are required

Is cryoablation therapy ever used after other prostate cancer treatments have been tried?

Yes. An important use of cryoablation therapy is for patients who fail or develop recurrence after radiation therapy.

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