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Cryotherapy in Prostate Cancer Periprocedural Care

  • Author: Matthew R Cooperberg, MD, MPH; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 04, 2014
 

Preprocedural Evaluation

A preprocedure prostate-specific antigen (PSA) test is important for assessing risk and establishing a baseline from which the PSA level can be tracked after treatment. Other preprocedure laboratory studies include the following:

  • Urine culture
  • Complete blood count (CBC) with platelet count
  • Coagulation tests (ie, prothrombin time [PT] and activated partial thromboplastin time [aPTT])

Cryoablation is performed under the guidance of transrectal ultrasonography (TRUS). In addition, a TRUS scan is required before the cryoablation procedure, for the following reasons:

  • To plan treatment
  • To assist in clinical staging by identifying any hypoechoic or hypervascular lesions (as well as extracapsular extension or seminal vesical involvement)
  • To estimate the prostate volume
  • To identify any large transurethral resection defect

In most cases, TRUS has already been performed to obtain the prostate biopsy specimen by which the disease was diagnosed.

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Equipment

Modern third-generation cryotherapy systems such as Galil (Galil Medical USA, Woburn, MA), and CRYOcare (Endocare, Irvine, CA) use small, needle-shaped probes, which can be placed percutaneously, under TRUS guidance, directly into the prostate.

Older systems used relatively large cannulas, which necessitated a more complex technique: 6 hollow, diamond-tipped, 18-gauge needles were placed transperineally under TRUS guidance in the anteromedial, posterolateral, and posteromedial regions of the prostate. A 0.038 J-tip guide wire was passed through each needle; the needle was removed, the tract was dilated over the wire, a 12-French cannula was placed, and the wire was removed.

Computer software systems are under development that are likely to facilitate both preoperative planning and real-time monitoring of progression of therapy.[67]

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Monitoring and Follow-up

Cryotherapy is usually performed in an outpatient setting. A urethral catheter is left in place for 3 weeks after treatment to minimize the likelihood of tissue sloughing and urinary retention. Urinary retention after cryotherapy commonly develops as a consequence of local urethral edema. Some investigators have left the urethral warming catheter in place for several hours after the procedure in an attempt to minimize injury to the urethra,[8] but this maneuver has not been well studied.

After cryotherapy, routinely evaluate the patient to assess for the development of late complications and to look for symptoms or signs of clinical recurrence. Monitor the PSA level at regular intervals.

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Contributor Information and Disclosures
Author

Matthew R Cooperberg, MD, MPH Assistant Professor, Department of Urology, University of California, San Francisco, School of Medicine

Matthew R Cooperberg, MD, MPH is a member of the following medical societies: American Medical Association, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Peter Carroll, MD, FACS Chair, Professor, Department of Urology, University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Katsuto Shinohara, MD Professor, Department of Urology, University of California, San Francisco, School of Medicine

Katsuto Shinohara, MD is a member of the following medical societies: American Institute of Ultrasound in Medicine, American Society for Radiation Oncology, American Urological Association, Society of Urologic Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Acknowledgements

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

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Diagram illustrating dimensions of a typical ice ball as seen end-on (left) and from the side (right).
Example of third-generation prostate cryotherapy setup, illustrating urethral warming catheter, 2 percutaneous temperature probes, and 3 cryotherapy probes. (This case was a salvage case of focal treatment for an ultrasonographically visible lesion, so only 3 cryoprobes were required.)
Transrectal sonogram of the prostate illustrating placement of the cryoprobes and urethral-warming catheter.
Transrectal sonogram of the prostate during cryoablation. The leading edge of the ice ball, growing posteriorly, is echodense and casts a dark acoustic shadow anteriorly.
Transrectal sonogram illustrating the ice ball now extending posteriorly to the muscularis propria of the rectum. All prostate tissue is now included within the margin of the ice ball.
Table. Risk-Stratified Outcomes of Studies of Cryotherapy for Prostate Cancer
Study No. of Patients Residual Cancer, % Median Follow-up Period bDFS Criterion bDFS, %
Onik et al[6] 23173 mo. . .. . .
Miller et al[43] 62213 mo. . .. . .
Bahn et al[28] 1308. . .. . .. . .
Coogan et al[44] 87171 y≤0.2 ng/mL33
Wieder et al[45] 61133 mo< 0.5 ng/mL57
Bales et al[32] 23141 y< 0.3 ng/mL14
Shinohara et al[31] 102233 mo< 0.1 ng/mL48
Wake et al[29] 63253 mo< 0.1 ng/mL25
Cohen et al[46] 383182 y< 0.4 ng/mL55
Pisters et al[15] 15018. . .< 0.2 ng/mL46
Lee et al[35] 813. . .. . .. . .
Gould[47] 27. . .6 mo< 0.2 ng/mL96
Long et al[12] 9751824 mo< 0.5 ng/mL60 (low risk), 45 (intermediate risk), 36 (high risk)
Bahn et al[11] 590135.4 y< 0.5 ng/mL61 (low risk), 68 (intermediate risk), 61 (high risk)
Han et al[48] 106. . .1 y< 0.4 ng/mL75 (78 low risk, 71 high risk)
Prepelica et al[40] 65 (all high-risk). . .35 moASTRO



< 1 ng/mL



83



35



Cresswell et al[49] 51. . .9 mo< 0.5 ng/mL79
Jones et al[41] 119814.5/38.42 yASTRO/Phoenix85 (low risk), 73 (intermediate risk), 75 (high risk)
bDFS = biochemical disease-free survival.
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