What is cryotherapy?
Cryotherapy is a way of treating prostate cancer that uses freezing and thawing to kill the cancer cells in the prostate gland. It is also sometimes known as cryosurgery and cryoablation. It is done using a number of thin needles (cryoneedles) which are inserted into the prostate gland under anaesthetic. This process kills both normal cells and cancer cells within the gland.
The treatment involves getting the right balance between freezing the whole prostate gland, to kill all the cancer cells, and protecting healthy parts of the gland and surrounding tissues to avoid damaging them.
There have been improvements in cryotherapy in recent years, which have reduced the risk of side effects and improved the success of the treatment. However, we need more research to show whether cryotherapy improves quality of life or is as effective in the long term compared to other treatments..
Who can have cryotherapy?
Cryotherapy can be used to treat prostate cancer that has not spread outside the prostate gland (localised prostate cancer). It is also sometimes used to treat cancer that is breaking through the capsule of the prostate. It is not suitable for cancer that has spread to other parts of the body (advanced prostate cancer).
It is most commonly an option for men whose prostate cancer has come back after treatment with radiotherapy or brachytherapy. It is less commonly offered as a first treatment for prostate cancer. However, it may be an option for men who are unable to have surgery to treat prostate cancer, for example because they have heart problems (cardiovascular problems) which can make surgery more risky.
Men with severe urinary symptoms may not be suitable for cryotherapy as it may make these problems worse. If you have difficulty passing urine or have to pass urine frequently you may wish to discuss this with your specialist team.
What are the advantages and disadvantages?
The advantages and disadvantages of cryotherapy may depend on whether you are having it as a first treatment for prostate cancer, or because the cancer has come back after another treatment. There is a higher risk of side effects if you have already had treatment for prostate cancer.
• It involves less invasive surgery with little blood loss.
• You will only be in hospital for a short time and recovery time is quick.
• If you have cryotherapy as a first treatment, you may still be able to have radiotherapy or surgery if your cancer starts to grow again.
• It may be a treatment option if your cancer has come back after radiotherapy or brachytherapy.
• There is a high risk of erectile dysfunction.
• Not as much is known about long term survival and impact on everyday life after cryotherapy.
cancer, or because the cancer has come back after another treatment. There is a higher risk of side effects if you have already had treatment for prostate cancer.
your doctor, at length.
Before having treatment
You may need to take laxatives before treatment to make sure that your back passage (rectum) is empty. This will give your specialist team a good view of the prostate gland during the procedure.
Cryotherapy is carried out under either general or local anaesthetic. Sometimes, a tube to drain urine is passed into your bladder through a small cut in your tummy. This is called a suprapubic catheter.
An ultrasound probe is inserted into your back passage. This allows your specialist team to make sure the needles are in the right place so that the whole prostate gland can be treated.
Several very thin needles are then inserted into the gland through the skin between thetesticles and back passage (perineum), using the ultrasound probe to guide them into place. Probes to monitor temperature are also inserted into and around the prostate gland.
A tube is passed through your penis into your bladder (urethral catheter). Warm liquid is circulated through this catheter during the procedure. This helps to prevent the tube which you pass urine through (urethra) from freezing and being damaged during treatment.
Freezing gases are passed down the needles, causing the temperature to drop to about –40°C. The prostate gland is then allowed to warm up, either naturally, or a different gas is passed through the needles which warms the gland more quickly. This is called a freeze-thaw cycle. The process of freezing and thawing is repeated. There are often two freeze-thaw cycles, but there may be more if you have a large prostate gland.
After the last cycle, the needles and probes are removed. The catheter in your penis will be left in for at least 20 minutes after the procedure. If you have had a catheter placed through your tummy this will be left in for up to two weeks in case you have any problems passing urine normally. If you only had a catheter in your penis, then this will be left in for up to two weeks.
The whole process usually takes around two hours. You will be given antibiotics to reduce the risk of infection which you will need to take for a few days after you go home.
Most people can go home on the same day or the following day. It is normal to have some discomfort, and your specialist team will tell you which painkillers you can take.
You may have some problems passing urine for a few days after having cryotherapy. The catheter is left in until you are able to pass urine normally. Your specialist team will show you how to care for the catheter before you leave the hospital. Some treatment centres may also give you medication called alpha-blockers to relax the muscle in and around the prostate to help you pass urine. You may see some blood in your urine, both while the catheter is in and after it has come out. This is normal, and you should drink plenty of fluids to help clear the blood. If you are worried about it at all you should contact your specialist team for advice. The catheter will be removed about two weeks after the procedure at the hospital. This may be uncomfortable, but should not be painful. You will need to stay for a few hours after the catheter has come out to check that you can pass urine without difficulty. You may wish to take some spare underwear with you.
Bruising and swelling of the skin around the testicles (scrotum), buttocks and inner thigh are common in the few weeks after the procedure. Avoid long periods of standing for the first few weeks. You should be able to go back to your day-to-day activities as soon as you feel able to, although it may take a few weeks or months before you feel back to normal.
You will have follow up appointments with your specialist team at the hospital to check your recovery and monitor your response to the treatment. Your prostate specific antigen (PSA) will be monitored on a regular basis to measure how well the treatment has worked. How often your PSA level is measured will vary depending on the treatment centre, but should be about every three months for at least the first year, and every six months after that. You can ask your specialist team how often you will have a PSA test.
What are the side effects?
• Bruising and swelling of the penis, skin around the testicles (scrotum), inner thigh and the area between your testicles and back passage (perineum)
• Pain and/or bleeding where the needles were inserted
You should be given antibiotics to help stop an infection after the procedure. Contact your specialist team if your urine becomes strong smelling or if you have a temperature. These could be signs of an infection and you may need more antibiotics.
Mid or long term side effects
The most common long term side effect is problems getting or keeping an erection (erectile dysfunction). More than three quarters of men (over 75 per cent) will be unable to get an erection for some time following cryotherapy. However, many men already have some problems with erectile dysfunction before they have cryotherapy. This may be because of previous treatment for prostate cancer or for other reasons, such as age or other health problems.
Cryotherapy can cause a variety of urinary problems. Up to one in six men will leak urine following treatment (urinary incontinence). You are at greater risk of leaking urine if you have had cryotherapy after another treatment. For some men this may improve with time but this does not always happen. You may have to wear pads in your underwear either temporarily or permanently. Pelvic floor exercises can also help by strengthening the muscles that control urination.
Some men find that they have a weak or slow flow of urine after treatment or may need to pass urine more frequently. This may be caused by swelling of the prostate gland. Some men will have some discomfort when passing urine which may take some weeks or months to stop.
Cryotherapy can sometimes cause damage to the tube that carries urine out through the penis (urethra). This can include small pieces of dead tissue being passed through the urethra (urethral sloughing). This will usually pass, but in some cases may cause blockage. There is also a risk that the urethra may become narrowed (stricture) after treatment. In some cases these side effects may need to be corrected with a simple operation. The warming catheter placed through the penis during cryotherapy treatment helps to reduce the chance of these side effects.
Problems with the anus
A small number of men may get a complication where a hole forms between the anus (rectum) and the tube which carries urine through the penis (urethra). This is known as a fistula, and is uncommon. We do not know how many men get fistulas, but different studies have shown that it may affect up to two out of every 100 men (up to 2 per cent). It is more likely if you have had an earlier treatment for prostate cancer which may have damaged the wall of the back passage.
Fistulas can develop up to several weeks after cryotherapy. Sometimes pain and infections of the urethra can be early signs of fistulas, although these may also be caused by something else. Contact your doctor if your urine is strong smelling or you have a temperature, which could be signs of an infection. If you develop a fistula, you will need to have an operation to repair the hole.
This information has been reproduced from the fact sheet Cryotherapy produced by and with permission of the The Prostate Cancer Charity www.prostate-cancer.org.uk April, 2012