Q. What is prostate cryosurgery?
A. Prostate cryosurgery, also called cryoablation, cryotherapy or cryo, is a surgical technique that involves the controlled freezing of the prostate gland to destroy cancerous cells. This is a minimally invasive procedure. It is done by inserting specialized needles called “cryoprobes” into the prostate through the perineum, the area between the scrotum and the anus without making incisions. After the cryoprobes are inserted, freezing of the prostate gland is performed by using Argon gas. The process is monitored accurately with the help of a computer. Temperature sensors are also used to monitor the process. The procedure is done under general or spinal anesthesia. It takes about one and a half hours. Patients usually are discharged from the hospital after an overnight stay. This is a one-time procedure with no additional procedures or treatments needed.
Q. How does cryosurgery treat cancer?
A. It has been well known to physicians that extreme temperatures, either hot or cold, can destroy biological tissues. Cryosurgery has been used experimentally to treat various cancers since the 1960’s. The idea behind using cryo is that rapid cooling of body tissues to a temperature of -60C or lower causes ice crystals to form, disrupting the cell structure and, ultimately, killing the cell. In addition to the cells, surrounding connective tissue and blood vessels are damaged as well leading to more complete tissue destruction. There is also mounting evidence that by-products of the dead cells, like intracellular proteins, trigger an immune response attracting natural antibodies, thus adding to the efficacy of the procedure.
Today, cryosurgery is increasingly used in various medical fields like dermatology, gynecology, general surgery and urology. The main indications for the use of cryosurgery in urology are localized prostate cancer and small kidney tumors up to 4 cm in diameter.
Q. How is the decision to have cryosurgery made?
A. Your medical records, imaging studies and laboratory tests are reviewed with your physician at the time of your consultation. The doctor also examines your prostate gland. Next, he covers the various options available for treating localized prostate cancer, which include active surveillance, surgery, radiation therapy and cryosurgery. You will be informed about the risks and benefits of those treatment modalities. After considering your options, you will need to make your own decision regarding treatment. If you decide to proceed with cryosurgery, further instructions regarding scheduling of the procedure, pre-operative testing, etc., will be given to you. The cryosurgery procedure is performed at St. Joseph Hospital in Orange, California.
Q. What are the risks, benefits and potential complications of cryosurgery?
A. The main benefit of cryosurgery is its truly minimally invasive yet very effective nature. Recovery is quick and with no serious complications.
With considerable technical improvements in the cryosurgical equipment and the use of computers making the procedure safer, there has been a significant decrease in the number of complications associated with the procedure. Incontinence occurs in less than 2% of patients treated. The risk is slightly higher in patients who have had previous radiation to the prostate. Damage to the bladder or rectum resulting in fistula formation is rare and occurs in less than 1% of cases.
Erectile dysfunction (ED) is the main complication resulting from cryosurgery (incidence of 70-80%). New treatment protocols are being developed to reduce ED (focal or partial gland cryosurgery). With penile rehabilitation techniques and passage of time, about one third to half of the patients recover satisfactory erectile function. Patients with persistent ED can be treated with medication, injections or surgery with satisfactory recovery of erectile function.
Q. How long will I be in the hospital?
A. The average length of stay is one day (overnight stay). After the procedure, the patient is taken to the recovery room and monitored. Once stable, he is taken to a regular hospital room. Most of the patients can take a regular diet after the procedure and are able to move around. Patients are discharged the next morning with the urethral catheter attached to a leg bag. Antibiotics and pain medications are prescribed for one week. After cryosurgery, patients need to have a urethral catheter to secure urine drainage. The catheter is removed in the office 5-7 days after the procedure.
Q. Are there any immediate or late post-procedure complications?
A. About 50% of the time, there will be some swelling of the penis and scrotum that will subside within 1-2 weeks. Some patients report a sensation of lower abdominal tightness due to fluid retention. Patients can also experience temporary urinary irritative symptoms like frequency, urgency and slow stream and occasional blood in the urine. Often, there will be some bruising in the genital and perineal (the space between the scrotum and anus) areas. All these problems are temporary and usually resolve within a couple of weeks after the procedure.
Q. How will I be followed? Will I need additional testing?
A. The response to the treatment is monitored by obtaining a PSA blood test every three months after cryosurgery for the first two years, and every six months after that. In certain situations, a follow-up prostate biopsy can be recommended. Other tests like bone scan and CT scan can be performed as needed.
Q. How successful is cryosurgery?
A. Prostate cryosurgery has long-term results comparable to surgery and radiation therapy. Recent 10-year results of cryosurgery from Allegheny General Hospital and Columbia University compare very favorably with those achieved by surgery and radiation therapy.
According to their published results, the odds of being cancer-free 10 years after cryosurgery appear to be 80 to 89% for low-risk patients, 74 to 84% for medium-risk patients, and 46 to 80% for high-risk patients.
Q. What type of patient is a good candidate for cryosurgery?
A. This procedure works well in all patients with localized prostate cancer. In particular, it works very well in patients who are at high risk of failing more conventional treatments. Such patients include those with locally advanced tumors (Stage T3), patients with high-grade tumors (Gleason score 8 to 10), and patients with a high initial PSA greater than 15 ng/ml. Cryosurgery is often used in combination with other treatment modalities for high-risk patients to improve odds of success. Cryosurgery is considered to be the treatment of choice for patients who have failed radiation therapy.
Because of its safety profile, older patients who are high-risk for other treatments can safely undergo cryosurgery with minimal risk for morbidity, thus minimizing their risk of developing advanced local or metastatic disease.
Q. Does my insurance cover cryosurgery?
A. Most insurance companies, including Medicare, Blue Cross, Aetna and other major insurance companies cover cryosurgery as a treatment modality for both primary prostate cancer and as a salvage procedure after failure of radiation therapy. Before scheduling your procedure, the physician’s office staff will check your benefits with your insurance company and make sure that cryosurgery is a covered benefit.